Atrial fibrillation following aortic valve replacement: impact of perioperative use of intravenous β-blocker

Adverse Outcomes Associated With Delaying or Withholding β-Blockers After Cardiac Surgery: A Retrospective Single-Center Cohort Study

BACKGROUND

Ideal timing of postoperative β-blockers is unclear. We hypothesized that patients who do not receive β-blockers immediately after cardiac surgery would have increased in-hospital mortality (primary outcome) and postoperative hemodynamic, pulmonary, neurologic, or respiratory complications (secondary outcomes).

METHODS

We performed a retrospective cohort study evaluating patients who underwent cardiac surgery at our institution from January 1, 2013 to September 30, 2017. We compared outcomes between patients who received β-blockers by postoperative day (POD) 5 with outcomes in patients who did not receive β-blockers at any time or received them after POD 5. Inverse probability of treatment weighting was used to minimize confounding. Univariate logistic regression analyses were performed on the weighted sets using absent or delayed β-blockers as the independent variable and each outcome as dependent variables in separate analyses. A secondary analysis was performed in patients prescribed preoperative β-blockers. E-values were calculated for significant outcomes.

RESULTS

All results were confounder adjusted. Among patients presenting for cardiac surgery, not receiving β-blockers by POD 5 or at any time was not associated with the primary outcome in-hospital mortality, estimated odds ratio (OR; 99.5% confidence interval [CI]) of 1.6 (0.49-5.1), P = .28. Not receiving β-blockers by POD 5 or at any time was associated with postoperative atrial fibrillation, estimated OR (99.5% CI) of 1.5 (1.1-2.1), P < .001, and pulmonary complications, estimated OR (99.5% CI) of 3.0 (1.8-5.2), P < .001. E-values were 2.4 for postoperative atrial fibrillation and 5.6 for pulmonary complications. Among patients presenting for cardiac surgery taking preoperative β-blockers, not receiving β-blockers by POD 5 or at any time was not associated with the primary outcome mortality, with estimated OR (99.5% CI) of 1.3 (0.43-4.1), P = .63. In this subset, not receiving β-blockers by POD 5 or at any time was associated with increased adjusted ORs of postoperative atrial fibrillation (OR = 1.6; 99.5% CI, 1.1-2.4; P < .001) and postoperative pulmonary complications (OR = 2.8; 99.5% CI, 1.6-5.2; P < .001). Here, e-values were 2.7 for postoperative atrial fibrillation and 5.1 for pulmonary complications. For the sensitivity analyses for secondary outcomes, exposure and outcome periods overlap. Outcomes may have occurred before or after postoperative β-blocker administration.

CONCLUSIONS

Among patients who undergo cardiac surgery, not receiving postoperative β-blockers within the first 5 days after cardiac surgery or at any time is not associated with in-hospital mortality and is associated with, but may not necessarily cause, postoperative atrial fibrillation and pulmonary complications.

The role of surgery type in postoperative atrial fibrillation and in-hospital mortality in esophageal cancer patients with preserved left ventricular ejection fraction

BACKGROUND

Postoperative atrial fibrillation (POAF) is one of the most common complications of esophagectomy, which may extend the inpatient hospital stay. Minimally invasive esophagectomy (MIE) has been increasingly used in clinical practice; however, its POAF risk and short-term mortality remain unclear. This study aimed to examine the POAF risk and in-hospital mortality rate between patients receiving MIE and open esophagectomy (OE).

METHODS

Esophageal cancer patients who underwent MIE or OE from a retrospective cohort study were evaluated. A multivariate logistic regression model was built to assess the associations between esophagectomy (MIE vs. OE) and various outcomes (POAF, in-hospital mortality). Covariates included age, sex, body mass index, neoadjuvant therapy, tumor stage, surgery incision type, comorbidities, cardia conditions, peri-operative medication, and complications.

RESULTS

Of the 484 patients with esophageal cancer, 63 received MIE. A total of 53 patients developed POAF. Compared to patients receiving OE, MIE patients had 81% reduced odds of POAF (adjusted odds ratio [aOR] 0.185, 95% CI 0.039-0.887, P = 0.035). No statistically significant association was found for in-hospital mortality (aOR 0.709, 95% CI 0.114-4.409, P = 0.712).

CONCLUSIONS

MIE is associated with a lower risk of POAF, compared to traditional surgery. No significant short-term survival benefit was found for MIE.

The impact of beta-blocker use on postoperative atrial fibrillation after aortic valve replacement

Background

Current guidelines recommend perioperative use of beta-blocker (BB) in patients undergoing cardiac surgery to prevent postoperative atrial fibrillation (POAF). However, this recommendation is mainly based on studies those exclusively enrolled patients undergoing coronary artery bypass grafting. This study was conducted to evaluate the impact of perioperative BB use on the occurrence of POAF after aortic valve replacement (AVR).

Methods

From January 2015 to June 2018, 296 patients (male: female = 163:133) who underwent AVR at our institution were retrospectively reviewed. Patients who underwent concomitant valve surgery other than AVR or patients with preoperative arrhythmia were excluded. Mean age at the operation was 67±12 years. All patients were continuously tele-monitored for the occurrence of AF until discharge. Occurrence of any short runs of AF during the hospital stay was treated as POAF. Early outcomes were evaluated and perioperative factors associated with POAF were analyzed using a multivariable logistic regression model.

Results

Early mortality rate was 3.7% (11 of 296 patients). The POAF occurred in 154 patients (52.0%). Univariate analyses demonstrated that postoperative use of BB as well as age, type of prosthesis, history of stroke, body surface area, and chronic kidney disease were associated with the occurrence of POAF. The multivariable model showed that postoperative use of BB within 24 hours after AVR was a preventive factor of POAF (odds ratio, 0.354; 95% CI, 0.163 to 0.770; P=0.009).

Conclusions

Postoperative use of BB within 24 hours after AVR rather than preoperative use might be effective in prevention of POAF.

New Onset Atrial Fibrillation Following Transcatheter and Surgical Aortic Valve Replacement: A Systematic Review and Meta-Analysis

BACKGROUND

New-onset atrial fibrillation (NOAF) is a well-recognised, although variably reported complication following surgical aortic valve replacement (SAVR). Rates of NOAF following transcatheter aortic valve implantation (TAVI) seem to be notably less than SAVR, even though this population is typically older and of higher risk. The aim of this study was to determine the prevalence of NOAF in both these populations and associated postoperative outcomes.

METHODS

We conducted a systematic review and meta-analysis of studies reporting rates of NOAF post SAVR or TAVI, along with early postoperative outcomes. Twenty-five (25) studies with a total of 13,010 patients were included in the final analysis.

RESULTS

The prevalence of NOAF post SAVR was 0.4 (95% CI 0.36-0.44) and post TAVI 0.15 (95% CI 0.11-0.18). NOAF was associated with an increased risk of postoperative cerebrovascular accident (CVA) for SAVR and TAVI (RR 1.44 95% CI 1.01-2.06 and RR 2.24 95% CI 1.46-3.45 respectively). NOAF was associated with increased mortality in the TAVI group (RR 3.02 95% CI 1.55-5.9) but not the SAVR group (RR 1.00, 95% CI 0.54-1.84). Hospital length of stay was increased for both TAVI and SAVR patients with NOAF (MD 2.54 days, 95% CI 2.0-3.00) and (MD 1.64 days, 95% CI 0.04-3.24 respectively).

CONCLUSIONS

The prevalence of NOAF is significantly less following TAVI, as compared to SAVR. While NOAF is associated with increased risk of postoperative stroke for both groups, for TAVI alone NOAF confers increased risk of early mortality.

Perioperative Beta-Blocker for Atrial Fibrillation after Cardiac Surgery: A Meta-Analysis

Background This meta-analysis was conducted to evaluate the impact of perioperative use of beta-blocker (BB) on postoperative atrial fibrillation (POAF) after cardiac surgery other than isolated coronary artery bypass grafting (CABG).

Methods Five online databases were searched. Studies were included if they (1) enrolled patients who underwent cardiac surgery other than isolated CABG and (2) demonstrated the impact of perioperative use of BB on POAF based on the randomized controlled trial or adjusted analysis. The primary outcome was the occurrence rates of POAF after cardiac surgery. A meta-regression and subgroup analysis were performed according to the proportion of patients with cardiac surgery other than isolated CABG and the timing of BB use, respectively.

Results Thirteen articles (5 randomized and 8 nonrandomized studies: n = 25,496) were selected. Proportion of enrolled patients undergoing cardiac surgery other than isolated CABG ranged from 7 to 100%. The BBs were used in preoperative, postoperative, and both periods in 5, 5, and 3 studies, respectively. The pooled analyses showed that the risk of POAF was significantly lower in patients with perioperative BB than those without (odds ratio, 95% confidence interval = 0.56, 0.35–0.91 and 0.70, 0.55–0.91 in randomized and nonrandomized studies, respectively). The risk of POAF was lower in the BB group irrespective of the proportion of nonisolated CABG. Benefit regarding in-hospital mortality was inconclusive. Perioperative stroke and length of stay were not significantly different between BB and non-BB groups.

Conclusions Perioperative use of BB is effective in preventing POAF even in patients undergoing cardiac surgery other than isolated CABG, although it did not translate into improved clinical outcomes.

Incidence of postoperative atrial fibrillation in transdermal β-blocker patch users is lower than that in oral β-blocker users after cardiac and/or thoracic aortic surgery

OBJECTIVE

Postoperative atrial fibrillation (POAF) after open heart surgery is associated with a high risk of mortality and morbidity. Although oral β-blockers are usually recommended to prevent POAF, the efficacy of a transdermal β-blocker patch in preventing POAF is unclear. We compared the incidence of POAF between users of oral and transdermal bisoprolol.

METHODS

We investigated 108 patients who underwent cardiac and/or thoracic aortic surgery between April 2016 and February 2018. We compared perioperative clinical and hemodynamic variables between 49 patients treated with a transdermal bisoprolol patch and 59 patients treated with an oral bisoprolol fumarate.

RESULTS

POAF occurred in 24% of patients in the transdermal and in 46% of patients in the oral bisoprolol groups (p = 0.027). No intergroup difference was observed in in-hospital mortality, perioperative blood pressures and heart rates, and other morbidities. Multivariable logistic regression analysis revealed that the use of transdermal bisoprolol was independently associated with a lower rate of POAF (odds ratio 0.21, 95% confidence interval 0.05-0.84, p = 0.027).

CONCLUSIONS

A transdermal bisoprolol patch is an effective and safe β-blocker drug delivery system. The incidence of POAF in this group was lower than that in users of oral bisoprolol.

Landiolol for managing atrial fibrillation in post-cardiac surgery

Landiolol is an intravenous ultra-short acting beta-blocker which has been used in Japan for many years to prevent and/or to treat post-operative atrial fibrillation following cardiac surgery. The drug is now available in Europe. This article is a systematic review of literature regarding the use of landiolol in that specific surgical setting.