Treatment of postoperative atrial fibrillation: The long road ahead Dawn S. Hui, MD, a and Richard Lee, MD, MBA b During the past few decades, there have been numerous ad- vances in the surgical treatment of atrial fibrillation (AF), with well-established, evidence-based recommendations. 1 Contrast this with the treatment of postoperative AF (POAF) following cardiac surgery: The 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society guideline, 2 which included input from a thoracic surgery representative, has a few brief statements on POAF for cardiac and thoracic surgery: beta-blockade and calcium channel blockers are Class I recommendations, whereas prophylactic amiodarone, ibutilide, or direct cur- rent cardioversion; maintenance with antiarrhythmic medi- cations; antithrombotic medications; and rate control/ anticoagulation/cardioversion are all Class II recommenda- tions described as reasonable therapies. These did not mark- edly differ from the 2006 guidelines. Regarding patients undergoing cardiac surgery, the recently published 2019 guideline update, 3 endorsed by the Society of Thoracic Sur- geons (STS), adds only that apixaban and edoxaban may be equitable alternatives to warfarin in patients with AF and remote bioprosthetic valve implantations, and that further study is needed before recommending use of the Congestive heart failure, Hypertension, Age, Diabetes, and Stroke/ Transient Ischemic Attack Vascular Disease (CHA 2 DS 2 - VASc) score in this population. On POAF, no new recom- mendations have come forth. A natural question is why there is such disparity between advancements in the moni- toring and treatment after surgical treatment of AF, but not of AF after surgical treatment of other cardiac lesions. There are several potential etiologies of this discrepancy. First, POAF has historically been characterized as low in incidence, transient in nature, and benign in course. Howev- er, one should consider the context in which it is assessed. Because POAF falls in the bucket of postoperative compli- cations, data on its true prevalence may be limited with reportable postoperative metrics typically limited to a 30- day period. This problem may be compounded by the limits of detection. With increasing scrutiny of hospital stay as quality metric, shorter postoperative stays mean shorter monitoring periods and the possibility of underestimating POAF. One cannot see that for which one does not look. There is also a perception that in-hospital–detected POAF that converts to sinus rhythm is transient in nature. A few studies using contemporary monitoring modalities during the postdischarge period suggest that this perception might benefit from re-examination. A small study by Funk and colleagues, 4 utilizing ambulatory symptom-linked event re- corders plus daily transmitted electrocardiograms, found the in-hospital rate of AF to be 28% but the overall postop- erative rate to be 42%. After hospital discharge, 14% of pa- tient had AF episodes, with the first episode occurring after postoperative day 5 in > 10% of patients. Another study us- ing continuous ambulatory monitoring for 80 hours postop- eratively found sustained (ie, lasting> 10 minutes) POAF in 40% of postcoronary artery bypass grafting (CABG) pa- tients. 5 These hypothesis-generating findings have not translated into more extensive study nor use of longer- term monitoring in contemporary studies. The idea that POAF is benign in course is reflected in the following sentence from a 2003 study: ‘‘Although postoperative AF usually does not result in long-term sequelae, it often increases length and cost of hospital stay due to hemodynamic compromise or thromboembolic From the a Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex; and b Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Georgia, Augusta University, Augusta, Ga. Received for publication April 5, 2019; revisions received May 14, 2019; accepted for publication May 16, 2019; available ahead of print July 26, 2019. Address for reprints: Richard Lee, MD, MBA, Department of Surgery, Medical College of Georgia, 1120 15th St, BA-4300, Augusta, GA 30912 (E-mail: [email protected]). J Thorac Cardiovasc Surg 2020;159:1840-3 0022-5223/$36.00 Copyright Ó 2019 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2019.05.066 Richard Lee, MD, MBA, and Dawn S. Hui, MD Central Message Historically, POAF has been considered tran- sient and relatively benign. Growing evidence suggests otherwise—particularly in the long term. Opportunities to improve the evidence base and treatment exist. The Invited Expert Opinion provides a perspec- tive on this topic based on the following paper: J of the American College of Cardiology, Vol- ume 72, Issue 2, 2018, pp. 141-153. https:// doi.org/10.1016/j.jacc.2019.01.011. 1840 The Journal of Thoracic and Cardiovascular Surgery c May 2020 ADULT: ARRHYTHMIAS: INVITED EXPERT OPINION ADULT
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