management of postoperative atrial fibrillation stephen d. cassivi, md msc frcsc facs professor of...
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Management of Postoperative Atrial FibrillationStephen D. Cassivi, MD MSc FRCSC FACS
Professor of Surgery
Vice Chair – Department of Surgery
cassivi.stephen@mayo.edu
Financial Relationship / Conflict of Interest Disclosure
Statement
I have NO financial relationships or
potential conflicts of interest to report
Take Home Messages
Take Home Messages
1. Frequent
2. Mostly Self-Limited
3. Difficult to Prevent
4. Hemodynamic stability defines Treatment Goals
• Unstable Patient Restore HD stability
• Stable Patient Rate Control
5. Anticoagulation – based on individual patient risk
Key References: JTCVS 2014;148:772-791.JACS 2013;219:831-841.
Postoperative Atrial Fibrillation - POAF
Most common sustained arrhythmia after pulmonary and esophageal surgery.
Postoperative Atrial Fibrillation – POAFImpact
• Major, potentially preventable adverse outcome
ICU length of stay
ICU readmission
Hospital length of stay
Morbidity – stroke, bleeding
Mortality (RR 1.7-3.4)
Resource utilization
Postoperative Atrial Fibrillation – POAFTimecourse
• POAF occurrence peaks on POD 2-4
• 90-98% of new onset POAF resolves within 4-6 weeks
Ann Thorac Surg 2011;92:421–7
Postoperative Atrial Fibrillation – POAFMechanisms
Requires BOTH:
• “Triggers”• Rapidly firing ectopic focus
• Reentrant circuit of short cycle length
• Multiple reentrant ‘wavelets’
• “Vulnerable Substrate”• Sympathetic or parasympathetic
stimulation
• Atrial dilation or acute atrial stretch
• Pericarditis
• Fibrosis
• Conduction abnormalities
• Inflammation or oxidative stress
Postoperative Atrial Fibrillation – POAFIncidence
• Incidence varies• Incidence Intensity of surgical procedure
Postoperative Atrial Fibrillation – POAFIncidence
• Incidence varies• Incidence Intensity of surgical procedure
Low Riskof POAF
Bronchoscopy
VATS biopsy
Laparoscopic Nissen
Postoperative Atrial Fibrillation – POAFIncidence
• Incidence varies• Incidence Intensity of surgical procedure
Low Riskof POAF
Bronchoscopy
VATS biopsy
Laparoscopic Nissen
VATS Lobectomy
Open Lobectomy
Thymectomy
Intermediate Riskof POAF
Postoperative Atrial Fibrillation – POAFIncidence
• Incidence varies• Incidence Intensity of surgical procedure
Low Riskof POAF
High Riskof POAF
Bronchoscopy
VATS biopsy
Laparoscopic Nissen
Extrapleural Pneumonectomy
Esophagectomy
VATS Lobectomy
Open Lobectomy
Thymectomy
Intermediate Riskof POAF
Postoperative Atrial Fibrillation – POAFIncidence
Ann Thorac Surg 2008;86:927–33
Postoperative Atrial Fibrillation – POAFIncidence
Ann Thorac Surg 2008;86:927–33
New onset atrial fibrillation with rapid ventricular response
44/606 (7.3%)
Postoperative Atrial Fibrillation – POAFIncidence – Patient Factors
• Modifiable Factors
• Hypertension
• Valvular Heart
Disease
• Obesity
• Obstr. Sleep Apnea
• Hyperthyroidism
• Smoking
• Nonmodifiable Factors
• Age
• Race
• Male
• History of arrhythmias
Postoperative Atrial Fibrillation – POAFGuidelines
JTCVS 2014;148:772-791.
Thromboembolic Stroke
CHA2DS2-VASc
Chest 2010;137:263-72.
Postoperative Atrial Fibrillation – POAFAATS Guidelines
Monitoring / Telemetry• No monitoring necessary – if:
• Low Risk procedure• No prior history of arrhythmias/HF/CVA• CHA2DS2-VASc < 2
• 48-72 hours of Monitoring / Telemetry – if:• Intermed or High Risk procedure• CHA2DS2-VASc ≥ 2
• Hx of pre-existing or periodic recurrent AF
Postoperative Atrial Fibrillation – POAFAATS Guidelines
Prevention
• Avoidance of β-blockade withdrawal
• Correction of abnormal serum Mg++ levels
Postoperative Atrial Fibrillation – POAFAATS Guidelines
Treatment
• Depends on Hemodynamic Stability
UNSTABLE:Restore Sinus Rhythm
STABLE:Rate Control
Postoperative Atrial Fibrillation – POAFAATS Guidelines
Treatment• For ALL patients:
• Reduce or stop catecholaminergic inotropic agents
(if hemodynamics allow)
• Optimize fluid balance
• Correct electrolyte abnormalities
• Treat/correct possible triggering factors
• Bleeding, PE, Pneumothorax, Ischemia/MI, Infection/Sepsis
Postoperative Atrial Fibrillation – POAFAATS Guidelines
Treatment - UNSTABLE• Primary Goal = Restore Sinus Rhythm
1. Cardioversion
2. If Cardioversion unsuccessful or unstable POAF recurs:• Initiate IV Esmolol / Digoxin / Diltiazem /
Amiodarone• Prepare to Cardiovert again
Postoperative Atrial Fibrillation – POAFAATS Guidelines
Treatment - STABLE• Primary Goal = Rate Control
1. Β-blocker (esmolol/metoprolol) or Ca++ channel blocker (diltiazem, verapamil) to achieve HR ≤ 110 bpm
2. For pts with HF, LV dysfnx, or unresponsive to above tx Amiodarone
Caveat: WPW syndrome
Postoperative Atrial Fibrillation – POAFAATS Guidelines
Treatment• Cardiology consultation if:
• Recurrent or refractory POAF
• Persistent hemodynamic instability
• CHAD-VASc score high
• Require second-line anti-arrhythmic agent
• Develop acute renal injury/failure
Postoperative Atrial Fibrillation – POAFAATS Guidelines
Follow-up
• Cardiology follow-up if:
• EF ≤ 45%
• Dx of Systolic HF or Cardiomyopathy
• Started NEW rhythm control agent
• POAF last > 6 weeks
Postoperative Atrial Fibrillation – POAFAATS Guidelines
Anticoagulation Treatment
• During first 48h from onset
• Anticoagulation decision based on TE risk
(CHADS-VASc)
• Stable POAF >48 hours duration
• Anticoagulation is recommended
Anticoagulation
Ann Thorac Surg 2011;92:421–7
Results
January 1994 – December 2009
527 232
759 Patients
Median Age – 71 years (Range 31 – 92)
ResultsStrokes
8 (1.1%) patients developed a stroke
• Not anticoagulated - 3 (0.6%) pts.• Anticoagulated - 5 (2.2%) pts.
(p=0.057)
ResultsBleeding
49 (6.5%) patients developed a bleeding complication
Not anticoagulated - 27 (5.1%)* pts.
Anticoagulated - 22 (9.6%)* pts.
*statistically different p=0.009
Conclusions
• Anticoagulation did not lower the risk of stroke or TIA
• Anticoagulation was associated with an increase in postoperative bleeding
• Routine anticoagulation for POAF should be avoided
Postoperative Atrial Fibrillation – POAFGuidelines
Anticoagulation Treatment
• Anticoagulation decision based on TE risk
(CHADS-VASc)
• Both within and beyond 48 hours
JACS 2013;219:831-841.
JACS 2013;219:831-841.
JACS 2013;219:831-841.
JACS 2013;219:831-841.
JACS 2013;219:831-841.
JACS 2013;219:831-841.
JACS 2013;219:831-841.
Take Home Messages
1. Frequent
2. Mostly Self-Limited
3. Difficult to Prevent
4. Hemodynamic stability defines Treatment Goals
• Unstable Patient Restore HD stability
• Stable Patient Rate Control
5. Anticoagulation – based on individual patient risk
Key References: JTCVS 2014;148:772-791.JACS 2013;219:831-841.
cassivi.stephen@mayo.edu
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