Incidence of atrial fibrillation after off-pump versus on-pump coronary artery bypass grafting: A meta-analysis of randomized clinical trials and propensity score matching trials

Atrial Fibrillation and Perioperative Inflammation (FIBRILLAMMED Study): A Retrospective Analysis of the Predictive Role of Preoperative Albumin-Adjusted Platelet-Leukocytic Indices in OPCABG

Objective

New-onset atrial fibrillation (NOAF), an important postoperative complication, has pertinent inflammatory links. Motivated by the encouraging literature on the prognostic role of hypoalbuminemia, leukocytic indices [LIs: neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR)], systemic inflammation response index (SIRI=NLR×monocyte) and platelet-leukocytic indices [PLIs: platelet-to-lymphocyte ratio (PLR)], systemic immune inflammation index (SII=NLR×platelet), aggregate index of systemic inflammation (AISI=NLR×platelet×monocyte), we sought to investigate the NOAF-predictive value of preoperative albumin-adjusted indices (aa-LIs and aa-PLIs) in an off-pump coronary artery bypass grafting (OPCABG) setting.

Methods

Of 899 patients, 151 patients (16.79%) developed the primary outcome i.e. NOAF that was analyzed further retrospectively for its predictors instead of the highlighted text perioperative data of 899 patients undergoing elective OPCABG, were retrospectively analyzed. The study participants were categorized into non-NOAF and NOAF groups (defined as new-onset atrial arrhythmia with irregular RR interval with indistinct P wave in the first week postoperatively).

Results

One hundred and fifty-one patients (16.79%) developed NOAF. On univariate analysis: age, smoker status, The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, systemic hypertension, diabetes mellitus, prior congestive heart failure (CHF), and a higher preoperative NLR, PLR, SII, and albumin were significant predictors of NOAF. While age, CHF, and EuroSCORE II retained predictive significance in multivariate analysis, LI-PLIs and albumin did not emerge as independent NOAF predictors. Notably, aa-NLR, aa-PLR, and aa-SII independently predicted NOAF on the computation of model-estimates in the regression analysis (Odds ratio; 95% confidence interval: 31.05;15.75-70.61, 1.04;1.02-1.05, 1.12;1.10-1.14, respectively, P < 0.001). aa-NLR ≥1.32, aa-PLR ≥52.64, and aa-SII ≥344.38 predicted NOAF with the respective AUC;sensitivity;specificity of 0.66;63.6%;73.3%, 0.63;66.2%;59.0%, and 0.65;58.3%;78.2%. Preoperative aa-NLR, aa-PLR and aa-SII also positively correlated with CHA2DS2-VASc score (R=0.40, 0.45 and 0.42; P < 0.001).

Conclusion

The independent NOAF predictive value of aa-NLR, aa-PLR, and aa-SII reiterates the inflammatory relationship of the arrhythmic complication following OPCABG.

Incidence, predictors, and outcome for post-operative atrial fibrillation in Indian patients undergoing off-pump coronary artery bypass grafting-a prospective observational study

Purpose

Indian patients who undergo surgical revascularization are relatively younger than their Western counterparts and are predominantly revascularized using off-pump coronary artery bypass grafting (OPCAB) technique. They may therefore be at a reduced risk of developing post-operative atrial fibrillation (POAF). The aim of this study was to assess the incidence of POAF, measure its impact on outcomes, and identify the predictors for POAF in the Indian patients undergoing OPCAB. Besides, the ability of European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Society of Thoracic Surgeons (STS) scores in predicting POAF was also assessed.

Methods

In this prospective observational study, all patients undergoing isolated OPCAB in a single institution over a 12-month period were included. Patients undergoing re-operative surgery, emergency procedure, concomitant surgery, or those with history of previously diagnosed or treated atrial fibrillation were excluded. Logistic regression was performed to identify the predictors of POAF. The receiver operating characteristic (ROC) curve was used to determine the ability of EuroSCORE and STS scores to assess risk of developing POAF.

Results

We recruited 1108 patients in the study of which 88 (7.94%) patients developed POAF. Age (OR = 1.082, p < 0.001, 95%CI: 1.050-1.114), unstable angina (OR = 16.32, p = 0.036, 95%CI: 1.2-221.4), presence of diabetes mellitus (OR 1.781, p = 0.025, 95%CI: 1.074-2.955), left atrial size (OR 2.506, p = 0.001, 95%CI: 1.478-4.251), and presence of chronic renal failure (OR 8.7, p = 0.001, 95%CI: 2.4-31.53) were significant predictors of POAF. Both the EuroSCORE (p = 0.035) and the STS score (p = 0.001) were significantly higher in patients developing POAF. The area under the ROC curve for the EuroSCORE II was 0.62 and for the STS score was 0.64 suggesting satisfactory and similar discriminatory power of both the scores to predict POAF in these patients. POAF was associated with significantly increased adverse outcomes like stroke and prolonged hospital stay.

Conclusions

In our study, the incidence of POAF was much lower (7.94%) than that reported previously. POAF significantly increased adverse outcomes and length of hospital stay. Both EuroSCORE II and STS scores had similar discriminating power in predicting POAF.

Incidence and risk factors for new-onset atrial fibrillation following coronary artery bypass grafting: A systematic review and meta-analysis

OBJECTIVES

To estimate the incidence of new-onset post-operative atrial fibrillation after isolated coronary artery bypass surgery and summarise the evidence on risk factors that predispose people to developing the complication.

STUDY DESIGN/METHODS

A systematic review was conducted to identify studies from the CINAHL, MEDLINE and Cochrane databases. A title and abstract review was conducted by one reviewer. Full text review and quality assessment processes were conducted by two reviewers. Incidence data was combined in meta-analysis using the 'metaprop' routine in Stata and risk factor data were synthesised in narrative and table format.

RESULTS

Ten studies, including 6173 participants, were included in the review. The estimated pooled incidence of post-operative atrial fibrillation was 25% (CI 0.19-0.30). In a secondary meta-analysis including studies that only included first time bypass surgery recipients the estimated pooled incidence was 26% (CI 0.14-0.41). Due to high levels of heterogeneity these results should be interpreted with caution. Risk factors with the strongest associations to post-operative atrial fibrillation were chronic obstructive pulmonary disease, decreased partial pressure of oxygen on air, congestive heart failure, right coronary artery disease, male gender, prolonged cross clamp time and port-operative inotropic exposure.

CONCLUSION

Further prospective studies are needed to strengthen the current evidence base.