Long Term Outcome Of Postoperative Atrial Fibrillation After Cardiac Surgerya Propensity Score
- 1Division of Cardiology, Department of Internal Medicine, Camillian Saint Mary’s Hospital Luodong, Yilan, Taiwan
- 2Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- 3Division of Cardiology, Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
- 4Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
- 5Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- 6Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
- 7Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- 8Division of Electrophysiology, Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
Background: Postoperative atrial fibrillation results in a longer hospital stay and excess mortality. However, whether POAF would increase stroke rate has been debated for years. When and how long should anticoagulation be used to prevent stroke are unknown. In the study, we planned to investigate the clinical demographics and long-term outcomes of POAF after cardiac surgery in a single-center cohort.
When Is Surgery Necessary
It is possible to treat A-fib using electrical cardioversion or surgery. Surgery is generally a last-line treatment, but health professionals have started to recommend it earlier in the course of A-fib treatment, especially to those with a reduced pumping function of the heart.
Researchers are now investigating whether or not early catheter ablation could change the trajectory of A-fib.
The success of cardioversion depends on the cause and duration of a persons A-fib symptoms. For most people, cardiac rhythm returns to normal. However, cardioversion is not a guaranteed cure for A-fib, as it can reoccur.
If A-fib symptoms return, a doctor may suggest another cardioversion procedure . When a person combines cardioversion with medications, the heart rhythm can remain regular for up to a year or longer.
A-fib treatment involves preventing blood clots and reducing the risk of stroke. Other goals include controlling heart rate and rhythm, as well as treating underlying health conditions.
A doctor will often suggest making lifestyle changes as a first-line treatment. These may include:
Approaches To Treating Underlying Causes And Reducing Risk Factors
Your doctor also may recommend other treatments for an underlying condition that may be causing AF or to reduce AF risk factors. For example, he or she may prescribe medicines to treat an overactive thyroid or reduce blood pressure.
Your doctor also may recommend lifestyle changes, such as following a healthy diet, cutting back salt intake , quitting smoking, and reducing stress.
Limiting or avoiding stress and alcohol, caffeine, or other stimulants that may increase your heart rate also may help reduce the risk of AF.
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What Can Be Done To Prevent It
As you prepare to have heart surgery, you may be looking for ways to reduce the chances of complications. Managing your overall risk factors for AFib is the best way to reduce your risk for post-operative atrial fibrillation as well. Although some risk factors are impossible to eliminate, keeping your body as healthy as possible before surgery will reduce the likelihood of post-operative AFib and other complications from surgery.
- Manage your chronic conditions. Thyroid problems, anemia, diabetes, and high blood pressure are among the risk factors for AFib. If you have any of these or other chronic conditions, treating them prior to surgery may reduce your risk for complications. This includes taking any prescribed medications and following your doctors advice on managing these conditions.
- Eat healthy foods and exercise. The healthier you are going into surgery, the healthier you are coming out of surgery. Eat a heart healthy diet and make exercise part of your daily routine. Aim for 30 minutes a day of moderate exercise at least five days a week.
- Limit stress. Stress can be a trigger for atrial fibrillation, and we know that having surgery can be a stressful event. Managing stress includes physical stress on your body as well as mental or emotional stress in your life. After surgery, managing your pain reduces stress on your body, and having the right support systems in place can help manage mental and emotional stress.
How Else Can I Improve The Success Rate Of An Afib Ablation
Another reason why some people exeprience AFib after an ablation is what I would call: missing pieces of the puzzle. There are many factors that are outside of the ablation itself which have been found to improve the success rate of the ablation procedure as well. Most of these are involved in the category of lifestyle modifications or managing other health conditions. Probably one of the most studied lifestyle modification that can also improve AFib ablation is weight loss. Weight loss had been found to significantly improve AFib, but it has also been found to improve AFib in the setting of a catheter ablation, to improve the success rate of the ablation itself.
When patients are overweight they are also at increased risk for high blood pressure and diabetes, which can also contribute AFib, as well as increasing the scar tissue in the left atrium. However, the fat molecules themselves, whether thats fat molecules around the waist or even fat molecules that develop around the heart tissue, can all secrete hormones which increase inflammation, which can then in turn continue to lead to progressions of AFib. That is a reason why weight loss has been shown to have significant improvement in AFib. And one of the biggest diet studies to date called the LEGACY trial.
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What Is The Experience Of Anesthesia Like For The Patient With Atrial Fibrillation
When a patient with atrial fibrillation has been prepared for surgery, doctors put in several routine monitors. In addition, they use an arterial line, which is a special catheter that is inserted into an artery in the wrist that allows for continuous blood pressure measurement and for sampling blood for analysis.
Not long after that, doctors give the patient sedation drugs. Thats the last thing a patient should feel until he or she wakes up in the intensive care unit or in a post-anesthesia recovery unit.
Effectiveness Of Pulmonary Vein Isolation In Prevention Of Atrial Fibrillation Following Heart Bypass Surgery
|The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
|First Posted : June 20, 2006Last Update Posted : February 8, 2011
Atrial fibrillation is an irregular heart rhythm that occurs in 30% to 40% of patients following heart surgery. This irregular heart rhythm, although often self-limiting, can be cause for concern. AF is associated with a two-fold increase in patient complications and mortality after heart surgery. During AF, the heart muscle does not contract properly causing the blood flow through the heart to slow down potentially forming clots. A clot may then enter the blood stream and be carried to the brain, possibly causing a stroke. Patients in persistent AF require blood thinners to prevent strokes, and this carries its own bleeding risks especially in elderly patients.
Recently, Medtronic has developed the Cardioblate® BP and BP 2 Surgical Ablation System devices to perform pulmonary vein isolation to treat AF. Vichol et al have demonstrated a mean ablation time of 15.2 seconds per lesion with the use of this device.
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What Are The Dangers Of Afib
It is important to identify afib after heart surgery and treat it if necessary. Because the blood isnt pumped efficiently during afib, it increases your risk of blood clots, which can cause a stroke. If it continues over time, it can weaken your heart, potentially causing heart failure.
Talk to your physician before and after surgery about your potential risks of afib and what you may do to .
What Happens During A Maze Procedure
Talk with your doctor about what to expect about your Maze procedure. The following is a general description of the traditional Maze surgery, but your doctor may plan a less invasive procedure. Because the Maze procedure is commonly done in people needing heart surgery for another reason, the surgical process will vary. During a typical open-heart Maze procedure:
- A doctor will give you anesthesia before the surgery starts. This will cause you to sleep deeply and painlessly during the operation. Afterwards, you wont remember the operation.
- The operation will take several hours. Your doctor will make an incision down the middle of your chest and separate your breastbone.
- The surgery team will connect you to a heart-lung machine. This machine will act as your heart and lungs during the procedure.
- Your surgeon will make several cuts through the atria and then sew them back together. Alternatively, your doctor might use radiofrequency energy or another energy source to destroy small areas of tissue.
- Once complete, the surgery team will remove the heart-lung machine.
- The team will wire your breastbone back together.
- The team will then sew or staple the incision on your skin.
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Electrolyte Supplementation And Repletion
Current clinical practice often includes intraoperative and postoperative repletion of magnesium and potassium, although its effects remain controversial . Additionally, intraoperative and postoperative electrolyte supplementation has been proposed as a means of POAF prophylaxis, but this has also not been definitively shown to prevent POAF . Our recent single-institution retrospective observational study of over 2000 patients undergoing CABG and/or valve surgery found that, contrary to clinical dogma, magnesium supplementation was associated with an increased risk of POAF, while potassium supplementation was not protective against POAF and hypokalemia was not associated with POAF .
Systemic Inflammation And Oxidative Stress
Surgical trauma, ischaemia from the initiation and prolonged use of CPB, and reperfusion lead to oxidative stress and the production of pro-inflammatory molecules, resulting in endothelial and leucocyte activation, the release of NADPH oxidases, nitrous oxide production and reactive oxygen species generation . Human studies have demonstrated an association between systemic inflammation and oxidative stress and the development of POAF . This association is supported by a demonstrated decrease in POAF from anti-inflammatory prophylaxis using corticosteroids .
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What Is A Maze Procedure
The Maze procedure is a type of heart surgery used to treat atrial fibrillation.
The heart has 4 chambers. There are 2 upper chambers called atria and 2 lower chambers called ventricles. Normally, a specialized group of cells called the sinoatrial node in the upper right chamber of your heart, or the right atrium, provide the signal to start your heartbeat. With atrial fibrillation, the signal to start the heartbeat doesnt begin in the sinoatrial node the way it should. Instead, the signal begins somewhere else in the atria. This causes the atria to quiver or fibrillate. The atria cant contract normally to move blood to the ventricles. The disorganized signal spreads to the ventricles, causing them to contract irregularly and sometimes more quickly than they normally would. The contraction of the atria and the ventricles is no longer coordinated, and the ventricles may not be able to pump enough blood to the body.
In a traditional Maze procedure, the surgeon makes a number of small cuts in the atrium and then sews them back together. The hearts electrical signal is not able to cross these cuts. The cut area now stops conducting the abnormal signals that caused the atrial fibrillation. The heart rhythm can therefore return to normal, and the heart can stop fibrillating. Traditionally, the Maze procedure is done as part of an open-heart surgery assisted with a heart-lung machine .
Anterior Fat Pad Preservation Vs Dissection Or Removal
Dissecting the epicardial fat pad to reveal an aortopulmonary window for aortic cannulation and cross-clamp placement is a routine step in cardiac surgery. Some authors have hypothesized that the disruption or removal of the anterior fat pad might be useful in decreasing AFACS. However, in a study of 55 patients undergoing CABG, the incidence of AFACS was significantly lower in the group randomized to anterior fat pad preservation than the group with anterior fat pad dissection . Contradictory results from a study of 180 patients concluded that preserving the anterior fat pad did not reduce AFACS . A 2015 meta-analysis that included 7 RCTs concluded that the removal of the anterior fat pad did not lead to a decreased risk of AFACS, but did not examine the question of whether the converse was truethat is, whether preserving the fat pad would influence AFACS risk . Further studies are required before a recommendation can be made about how surgical manipulation of the anterior fat pad might affect AFACS.
How Do You Fix Afib After Bypass Surgery
Some treatments used for afib after open heart surgery include:
Local Inflammation And Oxidative Stress
Pericardial disruption causes local inflammation around the heart and an increase in pericardial fluid volume . Postoperative PCF is highly oxidative and contains blood, haemolyzed blood cells, haemoglobin and high levels of inflammatory markers that reflect leucocyte and platelet activation . The myocardium itself also produces pro-inflammatory molecules which contribute to local inflammation and directly alter cardiac function .
A Pericardial fluid bathes the normal heart including the right and left atria. Green arrows represent atrial conduction. B Surgery disrupts the pericardium and blood and inflammatory cells enter the pericardial space . C Pericardial fluid composition now includes inflammatory cells, cytokines, and highly oxidative proteins, causing atrial fibrillation .
Inflammation within the pericardial space results in cardiomyocyte apoptosis and altered electrical activity, which allows heterogenous action potentials and arrhythmias to form and propagate . Animal models have shown that the degree of atrial inflammation directly corresponds to the incidence of POAF . Contact between inflammatory cells and cardiac tissue likely plays a role in the pathogenesis of POAF, although the exact mechanisms have not yet been elucidated .
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Areas For Further Investigation
As described above, there is a paucity of definitive data in the form of appropriately powered randomized controlled trials to determine whether a successful reduction in AFACS burden by means of the above prevention and treatment strategies translates into a meaningful decrease in adverse outcomes, such as cerebrovascular events or other thromboembolic events, morbidity from anticoagulation, mortality, critical care or hospital lengths-of-stays, or quality of life. Unfortunately, as eloquently noted by Sessler in his recent call to action , this lack of adequately sized trials providing clinically actionable results is not limited to AFACS investigations but is widespread across many disciplines.
It remains uncertain whether prophylactic interventions to prevent AFACS should be limited only to high-risk patients or whether all patients should receive at least some of these interventions.
How Do Anesthesiologists Approach Atrial Fibrillation Procedures
Atrial fibrillation is a complicated disease that cardiologists manage in a variety of ways, depending on the symptoms and wishes of each patient, as well as the patient’s medical history.
When surgery is recommended, the anesthesiologist must come up with a plan that will be influenced by how a particular patient’s current medications affect body function.
One key consideration for atrial fibrillation patients is that cardiologists almost universally prescribe them blood thinnersa treatment that substantially reduces their risk of stroke. However, during surgery, blood thinners put patients at risk for bleeding.
Patients with atrial fibrillation often have a procedure known as ablation. This is performed by a cardiologist with training in electrophysiology, a procedure that uses either very cold or very hot probes to damage the parts of the muscle that are causing the hearts arrhythmia.
While the electrophysiologist pokes around for as long as six hours, stimulating the necessary muscles to find the ones causing the atrial fibrillation, the anesthesiologist is responsible for monitoring the patient’s vital signs.
Sometimes the doctor will use general anesthesia, and sometimes monitored anesthesia , all the while closely watching heart and lung functions.
Why Might I Need A Maze Procedure
Some people have unpleasant symptoms from atrial fibrillation, like shortness of breath. Atrial fibrillation also greatly increases the risk of stroke. Blood thinners used for preventing stroke pose their own risks, and some medicines require extra blood tests for monitoring.
Many people with atrial fibrillation take medicines to help control their heart rate or their heart rhythm. Although some people respond well to these medicines, others do not.
There are other surgical procedures as well as less invasive procedures, such as ablation, that are also options to control atrial fibrillation. Depending on your medical history, you may be a better fit for a particular procedure over another. Your doctor can review what options are best for you. He or she may recommend the Maze procedure if you already need open heart surgery to correct another problem, such as coronary artery disease or a heart valve problem.
Some, but not all people, may be able to stop taking anticoagulation medicine after the Maze procedure. Ask your doctor about the pros and cons of the procedure in your situation.
After Your Maze Procedure:
- When you wake up, you might feel confused at first. You might wake up a couple of hours after the surgery, or a little later.
- The team will carefully monitor your vital signs, such as your heart rate. They will hook you up to several machines so that you are continuously monitored.
- You may have a tube in your throat to help you breathe. This may be uncomfortable, and you wont be able to talk. Someone will usually remove the tube within 24 hours.
- You may have a chest tube to drain excess fluid from your chest.
- You will feel some soreness, but you shouldnt feel severe pain. If you need it, you can ask for pain medicine.
- In a day or two, you should be able to sit in a chair and walk with help.
- You may do breathing therapy to help remove fluids that collect in your lungs during surgery.
- You will probably be able to drink liquids the day after surgery. You can have regular foods as soon as you can tolerate them.
- You will probably need to stay in the hospital around 5 days. It might be less than that if you had less invasive surgery.
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