Postoperative Atrial Fibrillation: Prophylaxis and Treatment Ralph J. Damiano Jr. John Shoenberg Professor of Surgery Chief, Cardiac Surgery Postoperative Atrial Fibrillation: Prophylaxis and Treatment Ralph J. Damiano Jr. John Shoenberg Professor of Surgery Chief, Cardiac Surgery Chief, Cardiac Surgery Vice Chairman, Department of Surgery Barnes Jewish Hospital Washington University School of Medicine St. Louis, Missouri USA Chief, Cardiac Surgery Vice Chairman, Department of Surgery Barnes Jewish Hospital Washington University School of Medicine St. Louis, Missouri USA Allied Health Professional Symposium Allied Health Professional Symposium AATS Annual Meting AATS Annual Meting April 28, 2012 April 28, 2012
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Postoperative Atrial Fibrillation:
Prophylaxis and Treatment
Ralph J. Damiano Jr.
John Shoenberg Professor of Surgery
Chief, Cardiac Surgery
Postoperative Atrial Fibrillation:
Prophylaxis and Treatment
Ralph J. Damiano Jr.
John Shoenberg Professor of Surgery
Chief, Cardiac SurgeryChief, Cardiac Surgery
Vice Chairman, Department of Surgery
Barnes Jewish Hospital
Washington University School of MedicineSt. Louis, Missouri USA
Chief, Cardiac Surgery
Vice Chairman, Department of Surgery
Barnes Jewish Hospital
Washington University School of MedicineSt. Louis, Missouri USA
Allied Health Professional SymposiumAllied Health Professional SymposiumAATS Annual MetingAATS Annual Meting
April 28, 2012April 28, 2012
DisclosureDisclosure
�� Consultant for AtriCure, MedtronicConsultant for AtriCure, Medtronic
�� Research and educational grants over the last 2 years:Research and educational grants over the last 2 years:
�� Remains the most common complication following Remains the most common complication following
cardiac surgery, the incidence is unchanged despite cardiac surgery, the incidence is unchanged despite
decades of basic and clinical researchdecades of basic and clinical research
�� Significant cause of morbidity leading to increased Significant cause of morbidity leading to increased
utilization of healthcare resourcesutilization of healthcare resources�� ArankiAranki SF, SF, ShaweShawe DP, Adams DH et al. Circulation 1996; 94: 390DP, Adams DH et al. Circulation 1996; 94: 390--397.397.
�� Lauer MS, Eagle KA, Buckley MJ, Lauer MS, Eagle KA, Buckley MJ, SanctisSanctis RW. Pro RW. Pro CardiovascCardiovasc DisDis 1989; 5:3671989; 5:367--368.368.
IncidenceIncidence
�� MetaMeta--analysis of 24 randomized controlled trials found an analysis of 24 randomized controlled trials found an
incidence of 26%incidence of 26%�� Andrews TC, Andrews TC, ReimoldReimold SC, Berlin JA, SC, Berlin JA, AntmanAntman EM. Circulation 1991; 81: III236EM. Circulation 1991; 81: III236--III244.III244.
�� Higher incidence after valve surgery and combined valve Higher incidence after valve surgery and combined valve
surgery and coronary artery bypass graftingsurgery and coronary artery bypass graftingsurgery and coronary artery bypass graftingsurgery and coronary artery bypass grafting
�� Lowest rates seen after transplantationLowest rates seen after transplantation�� Creswell LL, Creswell LL, SchuesslerSchuessler RB, RB, RosenbloomRosenbloom M, Cox JL. Ann M, Cox JL. Ann ThoracThorac SurgSurg 1993; 56:5391993; 56:539--549.549.
�� The incidence at Washington University has been 30% over The incidence at Washington University has been 30% over
the last 20 years.the last 20 years.
�� No change in incidence despite widespread use of beta No change in incidence despite widespread use of beta
�� Various factors have been implicated.Various factors have been implicated.�� Various factors have been implicated.Various factors have been implicated.
�� InflammationInflammation
�� Autonomic dysfunctionAutonomic dysfunction
�� Ventricular dysfunctionVentricular dysfunction
�� CardioplegiaCardioplegia
�� Atrial swelling or stretchAtrial swelling or stretch
�� ReninRenin--angiotensinangiotensin--aldosterone systemaldosterone system
InflammationInflammation
�� The degree of atrial inflammation has been shown by our The degree of atrial inflammation has been shown by our
group to be associated with a proportional increase in the group to be associated with a proportional increase in the
inhomogeneity of atrial conduction and AF duration in an inhomogeneity of atrial conduction and AF duration in an
animal model.animal model.
�� This may be a factor in the pathogenesis of early This may be a factor in the pathogenesis of early
postoperative AF. postoperative AF.
�� AntiAnti--inflammatory therapy may have the potential to inflammatory therapy may have the potential to
decrease the incidence of AF after cardiac surgery.decrease the incidence of AF after cardiac surgery.
Postoperative Predictors of AFPostoperative Predictors of AF
�� In addition to preoperative risk factors, complications In addition to preoperative risk factors, complications following cardiac surgery have been shown to following cardiac surgery have been shown to increase the risk of postoperative AF.increase the risk of postoperative AF.�� Myocardial infarctionMyocardial infarction
�� Often thought of as a benign arrhythmia, however, this is not Often thought of as a benign arrhythmia, however, this is not
true.true.
�� Studies have shown increased early and late mortality, Studies have shown increased early and late mortality,
stroke, and prolonged hospital length of stay.stroke, and prolonged hospital length of stay.�� AlmassiAlmassi GH, GH, SchowalterSchowalter T, T, NicolosiNicolosi AC et al. Ann AC et al. Ann SurgSurg 1997; 226: 5011997; 226: 501--513.513.AlmassiAlmassi GH, GH, SchowalterSchowalter T, T, NicolosiNicolosi AC et al. Ann AC et al. Ann SurgSurg 1997; 226: 5011997; 226: 501--513.513.
�� LikoskyLikosky DS, Leavitt BJ, DS, Leavitt BJ, MarrinMarrin CA et al. Ann CA et al. Ann ThoracThorac SurgSurg 2003; 76:4282003; 76:428--435.435.
�� VillarealVillareal RP, RP, HariharanHariharan R, Liu BC et al. J Am R, Liu BC et al. J Am CollColl CardiolCardiol 2004; 43: 7422004; 43: 742--748.748.
�� BorzakBorzak S, Tisdale JE, S, Tisdale JE, AminAmin NB et al. Chest 1999; 113: 1489NB et al. Chest 1999; 113: 1489--1491.1491.
�� Increased hospital and healthcare costsIncreased hospital and healthcare costs�� LikoskyLikosky DS, Leavitt BJ, DS, Leavitt BJ, MarrinMarrin CA et al. Ann CA et al. Ann ThoracThorac SurgSurg 2003; 76:4282003; 76:428--435.435.
�� Auer J, Weber T, Auer J, Weber T, BerentBerent R et al. J R et al. J CardiovascCardiovasc SurgSurg 2005; 46:5832005; 46:583--588.588.
�� InIn--hospital mortality was increased in hospital mortality was increased in ptspts. with . with
POAF from 3.4 to 7.4% (p=.0007)POAF from 3.4 to 7.4% (p=.0007)
�� POAF was an independent predictor of late POAF was an independent predictor of late �� POAF was an independent predictor of late POAF was an independent predictor of late
�� Stroke was increased in Stroke was increased in ptspts. with POAF from 1.7 to . with POAF from 1.7 to
5.2% (p<.0001)5.2% (p<.0001)
Villareal et. al.
J Am Coll Cardiol 2004;43:742-48
Preventing Postoperative AFPreventing Postoperative AF
�� Many studies have been conducted examining Many studies have been conducted examining
effective preventative strategies for AF.effective preventative strategies for AF.
�� A metaA meta--analysis demonstrated that prophylactic treatment analysis demonstrated that prophylactic treatment
to decrease postoperative AF reduced hospital stay and to decrease postoperative AF reduced hospital stay and
cost, but had no effect on stroke or mortality.cost, but had no effect on stroke or mortality.cost, but had no effect on stroke or mortality.cost, but had no effect on stroke or mortality.�� Zimmer J, Zimmer J, PezzulloPezzullo J, J, ChoucairChoucair W et al. Am J W et al. Am J CardiolCardiol 2003; 91: 11372003; 91: 1137--1140.1140.
�� MetaMeta--analyses have shown positive effect.analyses have shown positive effect.�� Reduced the incidence of postoperative AF from 33% to 19%.Reduced the incidence of postoperative AF from 33% to 19%.
�� Crystal E, Crystal E, ConolloyConolloy SJ, SJ, SleikSleik K et al. Circulation 2002; 106: 75K et al. Circulation 2002; 106: 75--80.80.
Benefit of combined oral and intravenous Benefit of combined oral and intravenous amiodaroneamiodarone versus versus �� Benefit of combined oral and intravenous Benefit of combined oral and intravenous amiodaroneamiodarone versus versus
placebo alone (22% vs. 39% of patients) demonstrated in placebo alone (22% vs. 39% of patients) demonstrated in
AFIST II trialAFIST II trial�� White CM, Caron MF, White CM, Caron MF, KalusKalus JS et al. Circulation 2003; 108: II200JS et al. Circulation 2003; 108: II200--II206.II206.
�� Only drug shown to have effect on reducing incidence of Only drug shown to have effect on reducing incidence of
�� Crystal E, Connolly SJ, Crystal E, Connolly SJ, SleikSleik K et al. Circulation 2002; 106:75K et al. Circulation 2002; 106:75--80.80.Crystal E, Connolly SJ, Crystal E, Connolly SJ, SleikSleik K et al. Circulation 2002; 106:75K et al. Circulation 2002; 106:75--80.80.
�� No significant difference found between high and low No significant difference found between high and low
dose regiments, or between preoperative and dose regiments, or between preoperative and
postoperative initiation of treatmentpostoperative initiation of treatment�� Buckley MS, Nolan PE Jr., Slack MK et al. Pharmacotherapy 2007; 27: 360Buckley MS, Nolan PE Jr., Slack MK et al. Pharmacotherapy 2007; 27: 360--368.368.
Other TreatmentsOther Treatments
�� Numerous other treatments have been tested for the Numerous other treatments have been tested for the
prevention of postoperative AFprevention of postoperative AF
�� Diagnosis of atrial flutter is best made by Diagnosis of atrial flutter is best made by
obtaining an atrial electrogram.obtaining an atrial electrogram.
Atrial epicardial pacing wires
Atrial Flutter
Atrial FlutterAtrial Flutter
�� In patients that have atrial flutter, consider In patients that have atrial flutter, consider
rapid atrial pacing.rapid atrial pacing.
�� Begin burst pacing at twice diastolic threshold and a Begin burst pacing at twice diastolic threshold and a
rate 10% above the flutter cycle length. Increase in rate 10% above the flutter cycle length. Increase in rate 10% above the flutter cycle length. Increase in rate 10% above the flutter cycle length. Increase in
increments of 10% until flutter is terminated.increments of 10% until flutter is terminated.
�� If unsuccessful, treat according to atrial If unsuccessful, treat according to atrial
�� First goal is to control the heart rate.First goal is to control the heart rate.
�� Goal to decrease the heart rate below 100Goal to decrease the heart rate below 100
Atrial Fibrillation Rate ControlAtrial Fibrillation Rate Control
�� For patients with preserved EF (>30%)For patients with preserved EF (>30%)
�� DiltiazemDiltiazem 5mg IV test dose5mg IV test dose
�� If tolerated, give 0.25mg/kg IV over 3 minutesIf tolerated, give 0.25mg/kg IV over 3 minutes
�� If effective, begin 5If effective, begin 5--10mg/hr IV infusion10mg/hr IV infusion
��May increase in 5mg/hr increments up to 20mg/hrMay increase in 5mg/hr increments up to 20mg/hr��May increase in 5mg/hr increments up to 20mg/hrMay increase in 5mg/hr increments up to 20mg/hr
�� For patients with poor EF (<30%)For patients with poor EF (<30%)
�� DigoxinDigoxin loadload
�� 0.5mg IV, followed by 0.25mg IV q4h 0.5mg IV, followed by 0.25mg IV q4h xx 2 doses2 doses
�� Maintenance dose based on renal functionMaintenance dose based on renal function
�� Consider early cardioversionConsider early cardioversion
Rhythm ControlRhythm Control
�� For patients that persist in AF for greater than one hour despite For patients that persist in AF for greater than one hour despite
adequate rate control, consider initiation of rhythm control.adequate rate control, consider initiation of rhythm control.
�� AmiodaroneAmiodarone loadload
�� For patients able to take For patients able to take popo or absorb via NGor absorb via NG
�� 400mg 400mg popo t.i.dt.i.d loading dose x 5 daysloading dose x 5 days�� 400mg 400mg popo t.i.dt.i.d loading dose x 5 daysloading dose x 5 days
�� Reassess for maintenance doseReassess for maintenance dose
�� For patients unable to utilize their GI tractFor patients unable to utilize their GI tract
�� 150mg IV over 10 minutes, then 1mg/min infusion 150mg IV over 10 minutes, then 1mg/min infusion xx 6 hours, 6 hours,
followed by 0.5mg/minfollowed by 0.5mg/min
�� MonitoringMonitoring
�� Initial assessment of Initial assessment of LFT’sLFT’s, and , and TFT’sTFT’s
�� Follow QT intervalFollow QT interval
Contraindications to Contraindications to AmiodaroneAmiodarone
�� ContraindicationsContraindications
�� AllergyAllergy
�� History of toxicityHistory of toxicity
�� Severe pulmonary diseaseSevere pulmonary disease�� Severe pulmonary diseaseSevere pulmonary disease
�� 22ndnd degree Type 2 or 3rd degree heart blockdegree Type 2 or 3rd degree heart block
fibrillation requires both rate and rhythm control.
� Further research is needed to define the mechanism
� Successful treatment of postoperative atrial
fibrillation requires both rate and rhythm control.
� Further research is needed to define the mechanism � Further research is needed to define the mechanism
of postoperative atrial fibrillation to more effectively
prevent it.
� Further research is needed to define the mechanism
of postoperative atrial fibrillation to more effectively
prevent it.
Drug Trials to Prevent Postoperative AFDrug Trials to Prevent Postoperative AFDrug Trials to Prevent Postoperative AFDrug Trials to Prevent Postoperative AF