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Çiçek ÖF, Esenboğa K, Yalçın MU, Durdu MS, Altunkeser BB, Büyükateş M. Myocardial Blush Grade Predicts Postoperative Atrial Fibrillation following Mitral Valve Replacement: A Novel Perspective. J Cardiovasc Dev Dis 2023; 10:275. [PMID: 37504531 PMCID: PMC10380330 DOI: 10.3390/jcdd10070275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/18/2023] [Accepted: 06/28/2023] [Indexed: 07/29/2023] Open
Abstract
Background: Atrial fibrillation (AF) remains the most common arrhythmia following mitral valve surgery. Although numerous clinical and laboratory indicators and possible mechanisms of postoperative AF (PoAF) have been described, the role of microvascular dysfunction in pathogenesis has not been assessed. We aimed to evaluate the association between microvascular dysfunction and PoAF in patients undergoing isolated mitral valve replacement. Methods: 188 patients undergoing mitral valve replacement were included in this retrospective study. Demographic characteristics of the patients were recorded. Angiographic assessment of microvascular perfusion was performed using the myocardial blush grading technique for each patient. Univariate and multivariate logistic regression analyses were utilized to determine predictors of PoAF. Results: Of 188 patients (56.69 ± 8.9 years, 39.4% male) who underwent mitral valve replacement, 64 (34%) patients developed PoAF. In the PoAF group, a lower basal hemoglobin level (12.64 ± 0.89 vs. 14.46 ± 0.91 g/dL; p < 0.001), a higher left atrial diameter [5.9 (5.2-6.47) vs. 4.9 (4.5-5.8) cm; p < 0.001], and a lower total blush score (TBS) (8.33 ± 0.84 vs. 8.9 ± 0.31; p < 0.001) were detected. Multivariate logistic regression analysis revealed that preoperative LA diameter (OR:2.057; 95% CI: 1.166-3.63; p = 0.013), preoperative hemoglobin (OR:0.12; 95% CI: 0.058-0.245; p < 0.001), and abnormal TBS (OR:15.1; 95% CI: 1.602-142.339; p = 0.018) were independent predictors of PoAF. Conclusions: Our findings demonstrated that TBS at the preoperative period was an independent predictor of PoAF in patients undergoing isolated mitral valve replacement.
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Affiliation(s)
- Ömer Faruk Çiçek
- Department of Cardiovascular Surgery, Medical Faculty, Selçuk University, Konya 42250, Turkey
| | - Kerim Esenboğa
- Department of Cardiology, Medical Faculty, Ankara University, Ankara 06590, Turkey
| | - Muhammed Ulvi Yalçın
- Department of Cardiology, Medical Faculty, Selçuk University, Konya 42250, Turkey
| | - Mustafa Serkan Durdu
- Department of Cardiovascular Surgery, Medical Faculty, Ankara University, Ankara 06590, Turkey
| | | | - Mustafa Büyükateş
- Department of Cardiovascular Surgery, Medical Faculty, Selçuk University, Konya 42250, Turkey
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El-Gendy HA, Dabsha MH, Elewa GM, Ali AH. Predictors of postoperative atrial fibrillation after coronary artery bypass grafting: a prospective observational cohort study. AIN-SHAMS JOURNAL OF ANESTHESIOLOGY 2020. [DOI: doi.org/10.1186/s42077-020-00103-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Abstract
Background
This study was conducted to determine the effect of certain predictors on the incidence of postoperative atrial fibrillation (POAF) during ICU stay after coronary artery bypass graft (CABG) surgery.
Results
We enrolled 123 patients in this study. The mean age was 57.4 ± 8.7 years, and the mean left atrial diameter was 4.1 ± 0.52 cm with male preponderance (76.4%). The incidence of POAF following CABG was 33.3%. There was no statistically significant association between POAF and smoking (P = 0.123). However, POAF was significantly associated with higher CHA2DS2-VASc score (P = 0.002), valve replacement (P < 0.001), and inotropic support (P = 0.005). Moreover, patients with POAF had significantly higher mean age (P = 0.031) and left atrial (LA) diameter (P < 0.001). Logistic regression showed that LA diameter (P < 0.001), potassium level at 36 h (P = 0.016), and female gender (P = 0.001) were independent predictors of POAF.
Conclusions
We had several significant epidemiological, clinical, and operative variables that were significantly associated with post-CABG AF, including older age, female gender, large LA diameter, valve replacement, higher CHA2DS2-VASc score, and postoperative inotropic support. However, only LA diameter, female gender, and potassium level at 36 h were independent predictors of POAF. Nevertheless, further large-scale studies are needed to confirm our findings.
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Vural Ü, Ağlar AA. What is the role of metabolic syndrome and obesity for postoperative atrial fibrillation after coronary bypass grafting? BMC Cardiovasc Disord 2019; 19:147. [PMID: 31208345 PMCID: PMC6580605 DOI: 10.1186/s12872-019-1130-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 06/11/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Postoperative atrial fibrillation is the most common arrhythmia seen after cardiac surgery. We aimed to determine the effect of obesity and metabolic syndrome on postoperative atrial fibrillation, whether they are independent risk factors, and their effect level. We also analyzed the effect of atrial fibrillation on postoperative complications. METHODS In our clinic, 756 patients who underwent coronary artery bypass grafting between June 2010-September 2017 were evaluated retrospectively. Preoperatively, demographic characteristics, chronic diseases, body mass index, waist circumference measurements, and ejection fraction values of the cases were determined from file records. Perioperatively, cross-clamp and cardiopulmonary bypass times, intra-aortic balloon use, distal coronary bypass counts were determined. Postoperatively, complications, duration of intensive care unit and hospital stay, and mortality were evaluated. The patients were followed up with continuous 3-lead ECG monitorization on the postoperative first day and 12-lead ECG records once in a day on the remaining days. In the study, the first endpoint was the determination of atrial fibrillation and the second endpoint was the discharge time of the patient. RESULTS The rate of postoperative atrial fibrillation was 21.3%. Atrial fibrillation was seen in 33% of metabolic syndrome cases and in 38.5% of obese cases. Atrial fibrillation was seen in 23, 24 and 17% of cases using statin, ACE inhibitor and beta blocker, respectively. It was seen in 21% of smokers and 20% of the COPD cases. In the study, metabolic syndrome, diabetes mellitus, hypertension, and obesity, between the ages of 56-78 with Metabolic syndrome, were found to affect the development of postoperative atrial fibrillation (2.46), (2.3), (1.6), and (1.65) times, respectively. In cases with postoperative atrial fibrillation, infection and stroke were 1.45 and 8.85 times more frequent, respectively. Patients with metabolic syndrome were found to have 31% longer hospital stay, and 17% higher infection rate. In obese patients, hospitalization was 23.5% longer. CONCLUSIONS Metabolic syndrome and obesity were found to be two independent risk factors for postoperative atrial fibrillation. If causes and mechanisms of postoperative atrial fibrillation are identified in planned cardiovascular interventions, we believe that cost of hospitalization and morbidity will be reduced.
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Affiliation(s)
- Ünsal Vural
- Dr. Siyami Ersek Kalp ve Damar Cerrahisi Eğitim ve Araştırma Hastanesi Cardiovascular Surgery Clinic, Tıbbiye Cad. Haydarpasa Uskudar, 34668, Istanbul, Turkey.
| | - Ahmet Arif Ağlar
- Dr. Siyami Ersek Kalp ve Damar Cerrahisi Eğitim ve Araştırma Hastanesi Cardiovascular Surgery Clinic, Tıbbiye Cad. Haydarpasa Uskudar, 34668, Istanbul, Turkey
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Vural Ü, Balcı AY, Ağlar AA, Kızılay M. Which Method to Use for Surgical Ablation of Atrial Fibrillation Performed Concomitantly with Mitral Valve Surgery: Radiofrequency Ablation versus Cryoablation. Braz J Cardiovasc Surg 2019; 33:542-552. [PMID: 30652742 PMCID: PMC6326442 DOI: 10.21470/1678-9741-2018-0130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 07/08/2018] [Indexed: 11/24/2022] Open
Abstract
Objective The effects of energy source on the maintenance of sinus rhythm and the
contribution of demographic characteristics to the case selection in
patients submitted to ablation performed concurrently with mitral valve
surgery were analyzed. Methods Cryothermal (n=42; 43.8%) and radiofrequency (n=54; 56.3%) energy were
employed in 96 patients submitted to mitral valve replacement and Cox maze
IV procedure. Patients were called for control visits between 15 days and 12
months after discharge. The causal relationship between recurrence of atrial
fibrillation and factors such as left atrial diameter, C-reactive protein,
hypertension, left ventricular ejection fraction, chronic obstructive
pulmonary disease, and body mass index was determined. Results Maintenance rates of the sinus rhythm with radiofrequency and cryoablation
were 97.6% and 96.3%, respectively, in the first postoperative month,
whereas at the 12th postoperative month were 88.1% and 83.3%. No
significant difference was found between groups in relation to the energy
source. Sensitivity and specificity for left atrial diameter with a cut-off
value of 50.5 mm were 85.7% and 70.7%, respectively. Sensitivity and
specificity for C-reactive protein with a cut-off value of 12 mg/dL on the
15th postoperative day were 83.3% and 88.9%, respectively.
The effect of body mass index on atrial fibrillation recurrence was 3.2
times. Sensitivity and specificity for left ventricular ejection fraction
37% cut-off value were 96.3% and 11.4%, respectively. Atrial fibrillation in
hypertensive cases was 5.3 times more. In patients with chronic obstructive
pulmonary disease, recurrence of atrial fibrillation was 40%. The causal
relation between recurrence of atrial fibrillation and the studied factors
was established. Conclusion Demographic characteristics have a significant impact on ablation efficiency,
while the type of energy source does not.
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Affiliation(s)
- Ünsal Vural
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Yavuz Balcı
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Arif Ağlar
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Kızılay
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Yuan D, Zheng P, Tan C, Huang SH, Li D, Huang J. Influence of Continuous Training on Atrial Myocytes I K1 and I KAch and on Induction of Atrial Fibrillation in a Rabbit Model. Cardiol Res Pract 2018; 2018:3795608. [PMID: 30662768 PMCID: PMC6313976 DOI: 10.1155/2018/3795608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/01/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Elucidation of mechanisms underlying continuous training-related atrial fibrillation (AF) may inform formulation of novel therapeutic approaches and training method selection. This study was aimed at assessing mechanisms underlying continuous training-induced AF in an animal model. METHODS Healthy New Zealand rabbits were divided into three groups (n=8 each), namely, control (C), and moderate intensity (M), and high intensity (H) continuous training according to treadmill speed. Atrial size andintrinsic and resting heart rates were measured by transthoracic echocardiography before, and 8 and 12 weeks after training. Using a Langendorff perfusion system, AF was induced by S1S2 stimulation and the induction rate was recorded. Atrial IK1 and IKAch ion current densities were recorded using whole-cell patch-clamp technique in isolated atrial myocytes. Changes in atrial Kir2.1, Kir2.2, Kir3.1, and Kir3.4 mRNA expression were assessed by reverse transcriptase-coupled polymerase chain reaction. RESULTS After 8 and 12 weeks, Groups M and H vs. Group C had greater (all P < 0.05) atrial anteroposterior diameter; greater incidence of AF (60% and 90% vs. 45%, respectively; P < 0.05, also between Groups H and M); and greater atrial IKAch current density. In Group H, Kir2.1 and Kir2.2 mRNA expression in the left and right atria was increased (P < 0.05, vs. Groups C and M) as was left atrial Kir3.1 and Kir3.4 mRNA expression (P < 0.05, vs. Group C). CONCLUSION In a rabbit model, continuous training enlarges atrial diameter leading to atrial structural and electrical remodeling and increased AF incidence.
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Affiliation(s)
- Dou Yuan
- Department of Thoracic and Cardiovascular Surgery, Cheng Du Shang Jin Nan Fu Hospital, West China Hospital of Sichuan University, Chengdu, China
| | - Ping Zheng
- Clinical Department of Strategic Support Force Aerospace Systems in Beijing Space City, Beijing, China
| | - Chen Tan
- Department of Cardiology, HeBei Yan Da Hospital, Langfang, China
| | - Si Hui Huang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Dan Li
- Department of Ultrasound, PLA Army General Hopsital, Beijing, China
| | - Jian Huang
- Fuwai Heart Disease Hospital, CAMS and PUMC, Beijing, China
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Coronary artery anatomy and the occurrence of atrial fibrillation after coronary artery bypass surgery. Res Cardiovasc Med 2017. [DOI: 10.5812/cardiovascmed.40682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Phan K, Khuong JN, Xu J, Kanagaratnam A, Yan TD. Obesity and postoperative atrial fibrillation in patients undergoing cardiac surgery: Systematic review and meta-analysis. Int J Cardiol 2016; 217:49-57. [PMID: 27179208 DOI: 10.1016/j.ijcard.2016.05.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 04/18/2016] [Accepted: 05/01/2016] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Post-operative atrial fibrillation (POAF) is one of the most common complications following cardiac surgery. However, it is unclear whether there is a relationship between obesity and POAF. We thus assessed all available evidence investigating the association between obesity and POAF, also considering any link between POAF and other post-operative conditions such as mortality, stroke, myocardial infarctions and respiratory complications. METHODS Five electronic databases were searched and relevant studies were identified. Data was extracted and meta-analyzed from the identified studies. RESULTS We found that obese patients had significantly higher odds of POAF when compared with non-obese patients (P=0.006). There was also significant heterogeneity among the identified studies. POAF when compared with no-POAF was associated with an increased risk of stroke (P<0.0001), 30-day mortality (P=0.005) and respiratory complications (P<0.00001). However, we found no significant link between POAF and myocardial infarctions (P=0.79). CONCLUSIONS Our findings suggest that obesity is associated with a moderately higher risk of POAF. While POAF is also associated with an increased incidence of stroke, 30-day mortality and respiratory complications, further studies must be conducted before conclusions can be made about the long-term outcomes.
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Affiliation(s)
- Kevin Phan
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.
| | | | - Joshua Xu
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Aran Kanagaratnam
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Tristan D Yan
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
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9
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Abstract
Atrial fibrillation is the most commonly encountered arrhythmia after cardiac surgery. Although usually self-limiting, it represents an important predictor of increased patient morbidity, mortality, and health care costs. Numerous studies have attempted to determine the underlying mechanisms of postoperative atrial fibrillation (POAF) with varied success. A multifactorial pathophysiology is hypothesized, with inflammation and postoperative β-adrenergic activation recognized as important contributing factors. The management of POAF is complicated by a paucity of data relating to the outcomes of different therapeutic interventions in this population. This article reviews the literature on epidemiology, mechanisms, and risk factors of POAF, with a subsequent focus on the therapeutic interventions and guidelines regarding management.
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Impact of coronary collateral circulation and severity of coronary artery disease in the development of postoperative atrial fibrillation. Interact Cardiovasc Thorac Surg 2014; 19:394-7. [DOI: 10.1093/icvts/ivu158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Association Between Obesity and Postoperative Atrial Fibrillation in Patients Undergoing Cardiac Operations: A Systematic Review and Meta-Analysis. Ann Thorac Surg 2013; 96:1104-16. [DOI: 10.1016/j.athoracsur.2013.04.029] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/31/2013] [Accepted: 04/02/2013] [Indexed: 11/22/2022]
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Maesen B, Nijs J, Maessen J, Allessie M, Schotten U. Post-operative atrial fibrillation: a maze of mechanisms. Europace 2011; 14:159-74. [PMID: 21821851 PMCID: PMC3262403 DOI: 10.1093/europace/eur208] [Citation(s) in RCA: 285] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Post-operative atrial fibrillation (POAF) is one of the most frequent complications of cardiac surgery and an important predictor of patient morbidity as well as of prolonged hospitalization. It significantly increases costs for hospitalization. Insights into the pathophysiological factors causing POAF have been provided by both experimental and clinical investigations and show that POAF is ‘multi-factorial’. Facilitating factors in the mechanism of the arrhythmia can be classified as acute factors caused by the surgical intervention and chronic factors related to structural heart disease and ageing of the heart. Furthermore, some proarrhythmic mechanisms specifically occur in the setting of POAF. For example, inflammation and beta-adrenergic activation have been shown to play a prominent role in POAF, while these mechanisms are less important in non-surgical AF. More recently, it has been shown that atrial fibrosis and the presence of an electrophysiological substrate capable of maintaining AF also promote the arrhythmia, indicating that POAF has some proarrhythmic mechanisms in common with other forms of AF. The clinical setting of POAF offers numerous opportunities to study its mechanisms. During cardiac surgery, biopsies can be taken and detailed electrophysiological measurements can be performed. Furthermore, the specific time course of POAF, with the delayed onset and the transient character of the arrhythmia, also provides important insight into its mechanisms. This review discusses the mechanistic interaction between predisposing factors and the electrophysiological mechanisms resulting in POAF and their therapeutic implications.
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Affiliation(s)
- Bart Maesen
- Department of Cardiothoracic Surgery, University Hospital of Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands
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Abstract
Atrial fibrillation (AF) is the most common arrhythmia, with an incidence of 17-33%, after coronary artery bypass grafting (CABG) and it increases the cost of operative treatment. beta-Blocker therapy reduces markedly the incidence of postoperative AF. The more effective preventive methods, e.g. amiodarone therapy or atrial pacing, are not cost-effective for all the patients. Thus, identification of patients at high risk of AF after CABG would be helpful. This review summarizes the predictors of postoperative AF and the current methods for risk stratification. In summary, identification of the patients at high risk of postoperative AF remains a challenge. The clinical usefulness of most of the conventional factors, e.g. age or history of AF, is low. Even attempts to build logistic regression models based on the pre- and intraoperative variables have failed to provide powerful predictors for postoperative AF after CABG. From the new predictors, the P-wave duration in signal-averaged ECG looks promising. Sensitivity and negative predictive value are high, positive predictive value remains low, which limits its usefulness. Contrary, even detailed analysis of standard 12-lead ECG or measure of heart rate variability has failed to provide useful information for risk stratification. A new method for risk stratification has been developed in our centre. The diagnostic accuracy of high-rate atrial pacing seems to be sufficient to identify a group of patients to whom prophylactic treatment could be proactively targeted. Further experience is, however, warranted to verify significance of this method in everyday clinical practice.
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Affiliation(s)
- Tapio Hakala
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland.
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Oc M, Ucar HI, Pinar A, Akbulut B, Oc B, Akyon Y, Kanbak M, Dogan R. Heat Shock Protein70: A New Marker for Subsequent Atrial Fibrillation Development? Artif Organs 2008; 32:846-50. [DOI: 10.1111/j.1525-1594.2008.00640.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Canbaz S, Erbas H, Huseyin S, Duran E. The role of inflammation in atrial fibrillation following open heart surgery. J Int Med Res 2008; 36:1070-6. [PMID: 18831903 DOI: 10.1177/147323000803600526] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study investigated the role of systemic inflammation in the development of atrial fibrillation (AF) after coronary artery bypass grafting (CABG). CABG was performed using cardiopulmonary bypass in 77 patients. Pre-operative AF was present in six patients (7.8%) and postoperative AF developed in 13 (18.3%) of the 71 patients with pre-operative sinus rhythm. Post-operative mediastinal drainage was significantly increased in patients with post-operative AF compared with those with sinus rhythm. Plasma E-selectin, P-selectin and vascular cell adhesion molecule levels were not significantly different between patients with pre- and post-operative sinus rhythm, those with pre-operative sinus rhythm and post-operative AF, and those with pre- and post-operative AF. There were significant differences between pre- and post-operative C-reactive protein, interleukin (IL)-6 and IL-10 levels within all three groups, but no differences in these parameters between the groups. Thus, in all groups there were significant alterations in mediators indicative of systemic inflammation following CABG, but comparisons between the groups revealed no differences predictive of AF.
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Affiliation(s)
- S Canbaz
- Department of Cardiovascular Surgery, Medical Faculty, Trakya University, Edirne, Turkey.
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Turk T, Ata Y, Vural H, Ozkan H, Yavuz S, Ozyazicioglu A. Intravenous and oral amiodarone for the prevention of postoperative atrial fibrillation in patients undergoing off-pump coronary artery bypass surgery. Heart Surg Forum 2007; 10:E299-303. [PMID: 17599879 DOI: 10.1532/hsf98.20071060] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Atrial fibrillation is still a frequent complication that increases morbidity after coronary artery bypass grafting. This prospective randomized study is designed to define efficacy of postoperative amiodarone prophylaxis in preventing atrial fibrillation after off-pump coronary artery bypass grafting. METHODS One hundred forty-four patients who underwent elective off-pump coronary artery bypass grafting were enrolled for the study. Seventy-six patients (amiodarone group) received 5 mg/kg loading amiodarone infusion in the first postoperative hour, followed by 10 mg/kg for the first 24 hours. After 24 hours, patients received 600 mg/day amiodarone orally for 7 days and 200 mg/day until the end of the postoperative first month. Sixty-eight patients received placebo (control group). RESULTS Preoperative characteristics and operative variables of the patients were similar in both groups. Incidence of new-onset atrial fibrillation and maximal ventricular rate response were recorded. The incidence of new-onset atrial fibrillation (11.8% versus 26.5%) (P = .025) and maximal ventricular rate response (109 +/- 13.8 beats/min versus 124.5 +/- 13.9 beats/min) (P = .011) were significantly lower in the amiodarone group. Duration of atrial fibrillation was 17.5 +/- 8.1 hours for the amiodarone group compared with 32.7 +/- 12 hours for the control group (P = .002). CONCLUSION Postoperative intravenous amiodarone prophylaxis followed by oral amiodarone significantly reduces the incidence of atrial fibrillation after off-pump coronary artery bypass grafting and the ventricular rate during atrial fibrillation.
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Affiliation(s)
- Tamer Turk
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Education and Research Hospital, Bursa, Turkey.
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Ucar HI, Tok M, Atalar E, Dogan OF, Oc M, Farsak B, Guvener M, Yilmaz M, Dogan R, Demircin M, Pasaoglu I. Predictive Significance of Plasma Levels of Interleukin-6 and High-Sensitivity C-Reactive Protein in Atrial Fibrillation after Coronary Artery Bypass Surgery. Heart Surg Forum 2007; 10:E131-5. [PMID: 17597037 DOI: 10.1532/hsf98.20061175] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Postoperative atrial fibrillation (AF) plays a major role in the determination of hemodynamic deterioration and can be associated with cardiovascular events after coronary artery surgery. Elevated interleukin (IL)-6 and C-reactive protein (CRP) levels in patients with AF suggest a role of inflammation in the pathogenesis of AF. We conducted a study to investigate the correlation between postoperative AF and IL-6 and high-sensitivity CRP (hsCRP). MATERIALS AND METHODS Forty-nine patients with a mean age of 60.3 +/- 10.7 years were enrolled in this study. Preoperative and postoperative first day blood samples were collected to assess the IL-6 and hsCRP levels. IL-6 levels were measured by enzyme-linked immunosorbent assay, and hsCRP was measured by rate turbidimetry method. RESULTS Fourteen patients (28.5%) developed AF postoperatively. Patients who developed AF showed elevated serum concentrations of postoperative first day IL-6 (P < .001), preoperative hsCRP (P < .005), and postoperative first day hsCRP (P < 0.001). Preoperative hsCRP levels (P < .002) and postoperative first day IL-6 (P < .001) and hsCRP (P < 0.001) levels were associated with prolonged endotracheal intubation time. Prolonged intensive care unit stay showed significant correlations with elevated levels of preoperative hsCRP (P < 0.002) and postoperative first day IL-6 (P < 0.001) and hsCRP (P < 0.001). There was also statistical significance between the AF+ and AF- groups regarding intensive care unit stay and endotracheal intubation times (P < .001 and P < .001, respectively). Cut-off points for postoperative first day IL-6, preoperative hsCRP, and postoperative first day hsCRP were 46.4 pg/mL (sensitivity = 92.9% and specificity = 80%), 0.46 mg/L (sensitivity = 71% and specificity = 75%), and 17.9 mg/L (sensitivity = 92.9% and specificity = 78%), respectively. CONCLUSIONS Elevated IL-6 and hsCRP levels in patients with postoperative AF suggest inflammatory components have a role of in the pathogenesis of AF.
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Affiliation(s)
- Halil Ibrahim Ucar
- Department of Cardiovascular Surgery, Hacettepe University, Faculty of Medicine, Ankara, Turkey
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Caravelli P, De Carlo M, Musumeci G, Tartarini G, Gherarducci G, Bortolotti U, Mariani MA, Mariani M. P-wave signal-averaged electrocardiogram predicts atrial fibrillation after coronary artery bypass grafting. Ann Noninvasive Electrocardiol 2006; 7:198-203. [PMID: 12167179 PMCID: PMC7027619 DOI: 10.1111/j.1542-474x.2002.tb00163.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AF is one of the most common complications after CABG. The aim of the study was to identify the risk factors for postoperative AF. METHODS Between June and December 2000, 129 consecutive patients (72 men, 47 women; mean age 67 +/- 6 years) underwent preoperative signal-averaged electrocardiogram (SAECG) with assessment of filtered P-wave duration (fPWD) and of the root mean square voltage of the last 10 and 20 ms of atrial depolarization (RMSV10 and RMSV20, respectively) before CABG. RESULTS Fifty-six (43%) patients developed one episode of AF lasting > 30 seconds at a mean distance of 2.6 +/- 1.8 days after surgery (group A), while 73 patients remained in sinus rhythm (group B). No differences between the two groups were found in terms of age, sex, P-wave duration on the standard ECG, left atrial dimensions, and operative characteristics. In contrast, group A patients showed a significantly longer fPWD (138 +/- 10 vs 111 +/- 9 ms; P < 0.001) and smaller RMSV10 and RMSV20 (2.8 +/- 1.0 vs 4.3 +/- 1.1 microV, P < 0.001; 4.2 +/- 2.1 vs 6.2 +/- 2.0 microV, P < 0.001). Multivariate analysis indicated only fPWD as an independent predictor of AF (P = 0.009). With a cut-off value of 135 ms for fPWD, the occurrence of AF could be predicted with a sensitivity of 84%, a specificity of 73%, a negative predictive value of 85%, and a positive predictive value of 70%. CONCLUSION Preoperative SAECG is a simple exam that correctly identifies patients at higher risk of AF after CABG. A more widespread use of this technique can be suggested.
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Aerra V, Kuduvalli M, Moloto AN, Srinivasan AK, Grayson AD, Fabri BM, Oo AY. Does prophylactic sotalol and magnesium decrease the incidence of atrial fibrillation following coronary artery bypass surgery: a propensity-matched analysis. J Cardiothorac Surg 2006; 1:6. [PMID: 16722587 PMCID: PMC1440299 DOI: 10.1186/1749-8090-1-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Accepted: 03/03/2006] [Indexed: 11/30/2022] Open
Abstract
Background Atrial fibrillation can occur in up to 40% of patients undergoing coronary surgery. Methods We retrospectively analysed 103 consecutive coronary surgery patients under the care of one surgeon between April 2003 and September 2003. These patients received 40 mg of sotalol orally twice daily from the first post-operative day for 6 weeks and 2 g of magnesium intravenously immediately post surgery and on the first post-operative day. We developed a propensity score for the probability of receiving sotalol and magnesium after coronary surgery. 89 patients from the sotalol and magnesium group were successfully matched with 89 unique coronary surgery patients who did not receive either sotalol or magnesium with an identical propensity score. Results Preoperative characteristics were well matched between groups. There was no significant difference with respect to in-hospital mortality between groups (sotalol and magnesium 1.1% versus control 4.5%; p = 0.17). The incidence of atrial fibrillation in the sotalol and magnesium group was 13.5% compared to 27.0% in the controls (p = 0.025). Conclusion The combination of sotalol and magnesium can significantly reduce the incidence of post-operative atrial fibrillation following coronary surgery.
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Affiliation(s)
- V Aerra
- Department of Cardiothoracic Surgery. The Cardiothoracic Centre Liverpool, UK
| | - M Kuduvalli
- Department of Cardiothoracic Surgery. The Cardiothoracic Centre Liverpool, UK
| | - AN Moloto
- Department of Cardiothoracic Surgery. The Cardiothoracic Centre Liverpool, UK
| | - AK Srinivasan
- Department of Cardiothoracic Surgery. The Cardiothoracic Centre Liverpool, UK
| | - AD Grayson
- Department of Research and Development. The Cardiothoracic Centre Liverpool, UK
- Senior Clinical Information Analyst, Clinical Governance Department. The Cardiothoracic Centre-Liverpool, Thomas Drive, Liverpool, L14 3PE, UK
| | - BM Fabri
- Department of Cardiothoracic Surgery. The Cardiothoracic Centre Liverpool, UK
| | - AY Oo
- Department of Cardiothoracic Surgery. The Cardiothoracic Centre Liverpool, UK
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Sedrakyan A, Zhang H, Treasure T, Krumholz HM. Recursive partitioning-based preoperative risk stratification for atrial fibrillation after coronary artery bypass surgery. Am Heart J 2006; 151:720-4. [PMID: 16504639 DOI: 10.1016/j.ahj.2005.05.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2004] [Accepted: 05/09/2005] [Indexed: 11/16/2022]
Abstract
BACKGROUND Knowledge of the risk of atrial fibrillation (AF) for patients undergoing coronary artery bypass graft surgery (CABG) can guide decisions about prophylactic therapy. Accordingly, we sought to use tree-based methods to stratify patients into groups that will have similar risk of AF after CABG and informed decision making regarding aggressive prophylaxis of AF. METHODS We studied 1209 consecutive patients with isolated CABG performed in 1998-1999 at Yale-New Haven Hospital. Patients with preoperative AF were excluded. Tree-based analysis was carried out to stratify patients into similar groups regarding the risk of AF. Relative risks (RRs) and 95% CIs were calculated at each level of stratification. RESULTS Age was the most important variable. The importance of other risk factors seemed to be different for younger and older patients. Although in the younger age group (< or =60 years) severity of coronary artery disease (RR 2.19, 95% CI 1.12-3.34) followed by hypertension (RR 1.82, 95% CI 1.23-2.68) were important predictors, in the older age subgroups (61-69 and > or =70 years), nothing or only ejection fraction <40% (RR 1.31, 95% CI 1.08-1.59) was important. In the highest-risk group, AF occurrence was 55% and, in the lowest-risk group, it was 10%. In the low-risk groups, aggressive prophylaxis may not be justified in light of the smaller number of events that would be prevented, possible adverse events, and costs. CONCLUSION Age and variables related to heart disease severity are predictors of AF. The tree-based method may be a useful tool for clinicians who seek to determine who is more or less likely to benefit from aggressive arrhythmia prophylaxis.
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Affiliation(s)
- Artyom Sedrakyan
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Wilhelm M, Kirste W, Kuly S, Amann K, Neuhuber W, Weyand M, Daniel WG, Garlichs C. Atrial distribution of connexin 40 and 43 in patients with intermittent, persistent, and postoperative atrial fibrillation. Heart Lung Circ 2006; 15:30-7. [PMID: 16473788 DOI: 10.1016/j.hlc.2005.06.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2004] [Revised: 03/08/2005] [Accepted: 06/13/2005] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sustained atrial fibrillation (AF) causes alterations in atrial electrical and structural properties. Conflicting data regarding the structural remodeling of the gap junction proteins connexin (Cx) 40 and 43 in human and animal studies exists. We investigated the amount and distribution of Cx40 and Cx43 in three subtypes of AF. METHODS In 50 patients undergoing coronary artery bypass graft and/or mitral or aortic valve surgery, right atrial appendages were taken and examined with immunoconfocal microscopy. Retrospectively, four groups were built: (1) sinus rhythm pre- and postoperative (SR, n=20), (2) intermittent AF, but SR prior to surgery (intAF, n=6), (3) postoperative AF (popAF, n=12), and (4) persistent AF, at least 3 month prior to surgery (persAF, n=12). We analyzed the amount of Cx40 and Cx43 and the degree of fibrosis in three randomly selected areas of each sample. RESULTS As compared with SR, the amount of Cx40 was significantly reduced by 53% in persAF. The distribution pattern of Cx40 was heterogeneous in patients with SR, intAF, and popAF, whereas patients with persAF showed similar densities of Cx40 in the three examined areas. We found no significant difference in the amount of Cx43 between the four groups. The distribution pattern of Cx43 was heterogeneous in all four groups. The Cx40/Cx43 ratio was significantly reduced in patients with popAF and persAF by 51% and 53%, respectively. No difference was seen in the degree of fibrosis between the four groups. CONCLUSIONS In this study, sustained AF leads to a reduction in the amount of Cx40. Together with a specific Cx40/Cx43 ratio, this may contribute to localized conduction abnormalities, facilitating the self-perpetuation of re-entry pathways in AF. In the time course of structural atrial remodeling these changes seem to be earlier than a concomitantly developing fibrosis.
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Affiliation(s)
- Matthias Wilhelm
- Department of Cardiology, University of Erlangen, Ulmenweg 18, D-91054 Erlangen, Germany.
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Mandal K, Torsney E, Poloniecki J, Camm AJ, Xu Q, Jahangiri M. Association of high intracellular, but not serum, heat shock protein 70 with postoperative atrial fibrillation. Ann Thorac Surg 2005; 79:865-71; discussion 871. [PMID: 15734396 DOI: 10.1016/j.athoracsur.2004.08.018] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2004] [Indexed: 11/17/2022]
Abstract
BACKGROUND Atrial fibrillation is a common arrhythmia, after cardiac surgery. Reperfusion injury and inflammation associated with cardiac surgery are thought to be involved in its pathogenesis. We hypothesized that cytoprotective effects associated with heat shock protein 70 (HSP70) could counteract these proarrhythmic insults. We therefore set out to examine the influence of heat shock protein 70 on the incidence of postoperative atrial fibrillation. METHODS We prospectively recruited 80 patients undergoing elective coronary artery bypass surgery. Blood samples were collected preoperatively. Right atrial tissue was obtained at surgery. Incidence of postoperative atrial fibrillation and its duration were noted. Using a nested case-control design, 15 patients who developed atrial fibrillation were matched for operative procedure, age, sex, and beta-blocker usage, with 15 controls from the remaining patients. Atrial heat shock protein 70 was subsequently quantified by immunohistochemistry. Serum heat shock protein was measured using enzyme-linked immunosorbent assay and high sensitivity C-reactive protein was determined by immunoturbidometric assay. RESULTS Intracellular HSP70 level was significantly higher in patients who did not develop atrial fibrillation (35 +/- 13 vs 19 +/- 15; p = 0.006). Atrial HSP70 level negatively correlated with atrial fibrillation; independent of other risk factors (odds ratio = 0.90; 95% confidence interval 0.84 to 0.99, p = 0.02). Serum HSP70 levels were similar in both groups (p = 0.81) and did not correlate with intracellular levels (p = 0.38). Preoperative C-reactive protein levels were similar in both groups (p = 0.93). CONCLUSIONS Intracellular, but not serum, HSP70 level is negatively correlated with postoperative atrial fibrillation. This suggests a cardioprotective and an antiarrhythmic role for intracellular HSP70.
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Affiliation(s)
- Kaushik Mandal
- Department of Cardiothoracic Surgery, St. George's Hospital and Medical School, London, United Kingdom
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Abstract
Atrial fibrillation (AF) is one of the most frequent complications of cardiac surgery, affecting more than one third of patients. The mechanism of this arrhythmia is believed to be reentry. The electrophysiologic substrate may be preexisting or may develop due to heterogeneity of refractoriness after surgery. Multiple perioperative factors have been proposed to contribute to the latter, including operative trauma, inflammation, elevations in atrial pressure (including that due to left ventricular diastolic dysfunction), autonomic nervous system imbalance, metabolic and electrolyte imbalances, or myocardial ischemic damage incurred during the operation. Whether ectopic beats originating in the pulmonary veins explain at least some episodes of postoperative AF, as has been shown for nonsurgical patients with the arrhythmia, is of current interest as such sites could easily be isolated at the time of surgery. The development of postoperative AF is associated with a higher risk of operative morbidity, prolonged hospitalization, and increased hospital cost compared with that in patients remaining in sinus rhythm. Many factors have been identified as being associated with postoperative AF, but the most consistent variable across studies is increasing patient age. It is speculated that age-related pathologic changes in the atrium contribute to arrhythmia susceptibility. An important modifiable risk factor for postoperative AF is the failure to resume therapy with beta-adrenergic receptor blockers after surgery. The stratification of patients who are at higher risk for AF would focus preventative strategies on patients who are most likely to benefit from such therapy. Nonetheless, since postoperative AF often develops in patients with comorbidities who are predisposed to other complications and prolonged hospitalization, it is presently unclear whether the prevention of postoperative AF will result in improved patient outcomes, particularly shorter hospitalizations.
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Affiliation(s)
- Charles W Hogue
- Department of Anesthesiology, Washington University School of Medicine, 660 South Euclid Ave, Box 8054, St. Louis, MO 63110, USA.
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Alex J, Guvendik L. Evaluation of Ventral Cardiac Denervation As a Prophylaxis Against Atrial Fibrillation After Coronary Artery Bypass Grafting. Ann Thorac Surg 2005; 79:517-20. [PMID: 15680826 DOI: 10.1016/j.athoracsur.2004.08.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2004] [Indexed: 11/28/2022]
Abstract
BACKGROUND To evaluate the efficacy of ventral cardiac denervation as a prophylaxis against post-coronary artery bypass grafting (CABG) atrial fibrillation (AF). METHODS Seventy consecutive patients who underwent CABG (group A) were compared to 70 consecutive subsequent patients who underwent CABG + ventral cardiac denervation (group B). Both groups were well-matched for age, gender, disease severity, LV function, Euro scores, Parsonnet scores, preoperative beta-blockers, Ca-channel blockers, digoxin, and angiotensin converting enzyme inhibitors. The same cardioplegia, bypass, and operation techniques were used in all cases. Denervation before initiating bypass increased operation time by approximately 5 minutes. Heart rate and rhythm were monitored by continuous telemetry until postoperative day 5 and then 4- hourly until discharge. RESULTS The cross-clamp time (p = 0.6), bypass time (p = 0.1), number of grafts (p = 0.9), inotrope usage (p = 0.4), reexploration rate (p = 1), postoperative myocardial infarction (none in either group), blood loss (p = 0.7), and length of stay (p = 0.8) were comparable in both groups. There was no significant difference in the incidence of AF; 34% in group A versus 29% in group B (p = 0.3). CONCLUSIONS Ventral cardiac denervation failed to significantly reduce the incidence of AF following coronary revascularization in our study.
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Affiliation(s)
- Joseph Alex
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull, United Kingdom.
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Mandal K, Jahangiri M, Mukhin M, Poloniecki J, Camm AJ, Xu Q. Association of anti-heat shock protein 65 antibodies with development of postoperative atrial fibrillation. Circulation 2004; 110:2588-90. [PMID: 15249499 DOI: 10.1161/01.cir.0000136825.96029.a5] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a frequently encountered arrhythmia after cardiac surgery, but its underlying mechanisms are still unclear. We hypothesize that autoimmune and inflammatory responses against heat shock protein 65 (HSP65) may be involved and hence examined the relationship between HSP65 autoantibodies and occurrence of postoperative AF. METHODS AND RESULTS A prospective study of 329 patients undergoing elective primary CABG was undertaken. Cardiovascular risk factors, ECG characteristics, medications, and intraoperative and postoperative features were documented. Anti-HSP65 antibodies and C-reactive protein levels were measured in all preoperative blood samples with ELISA. Postoperative AF was defined as the characteristic arrhythmia, lasting for at least 15 minutes and confirmed on 12-lead ECG and occurring within the first postoperative week. This occurred in 62 patients (19%). In univariate analysis, HSP65 antibodies were significantly higher in patients with postoperative AF (P=0.02). History of previous myocardial infarction, duration of bypass, number of distal anastomosis, and duration of ventilation were also associated with AF (P<0.05), but C-reactive protein levels were not (P=0.13). Multivariate analysis confirmed the positive association of HSP65 antibodies with postoperative AF (OR, 1.41; P=0.04) independent of age, sex, other cardiovascular risk factors, severity of coronary artery disease, duration of ventilation, duration of bypass, and left ventricular function. CONCLUSIONS We report a novel association between anti-HSP65 antibodies and occurrence of postoperative AF, indicating a possible role for antibody-mediated immune response in its pathogenesis.
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Affiliation(s)
- Kaushik Mandal
- Department of Cardiothoracic Surgery, St George's Hospital & Medical School, London, UK
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Abstract
Postoperative atrial fibrillation after heart surgery is frequent and may increase the length of hospital stay and costs of postoperative care of patients after heat surgery. Pharmacological and pacing interventions were evaluated in the large number of relatively small trials with often contradictory results. Conventional beta-blockers, sotalol, amiodarone and pacing were shown to be equally effective in the prevention of postoperative atrial fibrillation. Amiodarone and bi-atrial pacing were also effective in decreasing the length of hospital stay.
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Affiliation(s)
- Eugene Crystal
- Faculty of Medicine, University of Toronto, Electrophysiology Program, Schulich Heart Centre, Sunnybrook and Womens' College Health Scoence Center, Toronto, Ontario, Canada.
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Chandy J, Nakai T, Lee RJ, Bellows WH, Dzankic S, Leung JM. Increases in P-Wave Dispersion Predict Postoperative Atrial Fibrillation After Coronary Artery Bypass Graft Surgery. Anesth Analg 2004; 98:303-310. [PMID: 14742359 DOI: 10.1213/01.ane.0000096195.47734.2f] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Atrial fibrillation (AF) is a common complication after coronary artery bypass graft (CABG) surgery. In this study we examined the effect of surgery on atrial electrophysiology as measured by P-wave characteristics and to determine the potential predictive value of P-wave characteristics on the incidences of postoperative AF in patients undergoing CABG surgery. Patients undergoing elective CABG surgery were monitored by continuous electrocardiogram (ECG) telemetry during the in-hospital period until discharge for the occurrence of postoperative AF. Differences in P-wave characteristics (P-wave duration, amplitude, axis, dispersion, PR interval, segment depression, and dispersion) were compared between the pre- and postoperative 12-lead ECG measurements, and also between patients with and without postoperative AF. The association of postoperative AF and potential clinical predictors and P-wave characteristics were determined by multivariate logistic regression. Postoperative AF occurred in 81 (27%) of 300 patients. Univariate analysis showed that patients who subsequently developed postoperative AF compared with those without AF were significantly older (mean age 68 +/- 8 versus 63 +/- 10 yr, P < 0.0001), had a larger body surface area (BSA) (2.03 +/- 0.24 versus 1.92 +/- 0.22 m(2), P = 0.0002), were more likely to have a history of AF (8 of 81 versus 1 of 219, P = 0.003), used preoperative antiarrhythmic medications more frequently (7 of 81 versus 4 of 219, P = 0.01), and had a more frequent rate of return to the operating room for postoperative complications (9 of 81 versus 9 of 219, P = 0.029). Furthermore, the postoperative P-wave duration decreased to a larger extent (mean change -11.3 +/- 0.1 ms versus -8.4 +/- 0.1 ms, P < 0.0001), and the P-wave dispersion increased postoperatively to a larger extent (3.1 +/- 15.5 ms versus -1.6 +/- 14.6 ms, P = 0.028) in those who subsequently developed AF compared with those without AF. Multivariate logistic regression showed age (odds ratio [OR] = 1.1, 95% confidence interval [CI]: 1.06-1.15, P < 0.0001), BSA (OR = 38.1, 95% CI: 8.2-176, P < 0.0001), and an increase in postoperative P-wave dispersion (OR = 1.03, 95% CI: 1.01-1.05, P = 0.01) to be independent predictors of postoperative AF. No surgical factor was identified to be responsible for this postoperative change in atrial electrophysiology. IMPLICATIONS In addition to clinical factors, such as advanced age and body surface area, we demonstrated that electrophysiologic changes involving an increase in P-wave dispersion postoperatively independently predict atrial fibrillation after coronary artery bypass graft surgery.
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Affiliation(s)
- Joby Chandy
- *Department of Anesthesia and Perioperative Care; the †Department of Medicine, Section of Cardiac Electrophysiology, University of California, San Francisco, CA, and the ‡Department of Cardiovascular Anesthesia, Kaiser Permanente Medical Center, San Francisco, California
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Wu ZK, Iivainen T, Pehkonen E, Laurikka J, Zhang S, Tarkka MR. Fibrillation in patients subjected to coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003; 126:1477-82. [PMID: 14666022 DOI: 10.1016/s0022-5223(03)00749-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Atrial fibrillation is the most frequently encountered postoperative arrhythmic complication after coronary artery bypass grafting. Ischemic preconditioning has proved a potent endogenous factor in suppressing ischemia-reperfusion-induced arrhythmias. The protective effect of ischemic preconditioning on atrial fibrillation after coronary artery bypass grafting has not been studied. The purpose of the present study was to investigate whether ischemic preconditioning had an effect on postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting. METHODS Eighty-five patients undergoing coronary artery bypass grafting were randomized into ischemic preconditioning and control groups. Holter data from 24-hour electrocardiography were collected 1 day before the operation to the second postoperative day. Atrial fibrillation was registered as positive if any atrial fibrillation event occurred. RESULTS The overall incidence of postoperative atrial fibrillation and sustained atrial fibrillation was 34.1% and 27.1%, respectively. The occurrence of atrial fibrillation was significantly lower in the ischemic preconditioning group (21.4% in patients undergoing ischemic preconditioning and 46.5% in control subjects, P =.015). Preoperative recent unstable angina did not influence the incidence of atrial fibrillation. Patients with atrial fibrillation had longer intensive care unit stays and compromised postoperative hemodynamic outcomes. Binary logistic regression analysis showed that ischemic preconditioning, preoperative mean heart rate, and postoperative pulmonary capillary wedge pressure were the independent predictors of atrial fibrillation. CONCLUSIONS Postcoronary artery bypass grafting atrial fibrillation is associated with more complicated postoperative outcome. Higher preoperative heart rate and postoperative pulmonary capillary wedge pressure were the independent predictors of atrial fibrillation. Recent unstable angina is not related to the occurrence of postcoronary artery bypass grafting atrial fibrillation. Ischemic preconditioning significantly suppresses postcoronary artery bypass grafting atrial fibrillation, suggesting that ischemic preconditioning can be used as an effective prophylactic method for postoperative atrial fibrillation.
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Affiliation(s)
- Zhong-Kai Wu
- Division of Cardiothoracic Surgery, Department of Surgery, Tampere University Hospital, Finland
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Funk M, Richards SB, Desjardins J, Bebon C, Wilcox H. Incidence, Timing, Symptoms, and Risk Factors for Atrial Fibrillation After Cardiac Surgery. Am J Crit Care 2003. [DOI: 10.4037/ajcc2003.12.5.424] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
• Background Atrial fibrillation is the most common complication after cardiac surgery and a major cause of morbidity and increased cost of care.• Objectives To examine the incidence, timing, symptoms, and risk factors for atrial fibrillation after cardiac surgery.• Methods A total of 302 patients were continuously monitored for atrial fibrillation with standard hardwire and telemetry devices during hospitalization after coronary artery bypass graft and/or valve surgery and with wearable cardiac event recorders for 2 weeks after discharge from the hospital. After discharge, patients recorded and transmitted their rhythm by telephone daily and whenever they had symptoms suggestive of atrial fibrillation.• Results Of the 302 patients, 127 (42%) had atrial fibrillation; 41 had it after discharge, and for 10 it was their first episode. The first episode occurred at a mean of 2.9 days after surgery (SD, 3.1; range, day of surgery to 21 days after surgery). Although palpitations was the most common symptom (17%), most episodes of atrial fibrillation (69%) were not associated with symptoms. Independent predictors of atrial fibrillation were age 65 years or greater, history of intermittent atrial fibrillation, atrial pacing, male sex, white race, and not having hyperlipidemia. Independent predictors of atrial fibrillation after discharge from the hospital were having atrial fibrillation while hospitalized, valve surgery, and pulmonary hypertension.• Conclusions Atrial fibrillation is common after cardiac surgery and often occurs after discharge from the hospital and without accompanying symptoms. Outpatient monitoring may be warranted in patients with characteristics that place them at increased risk for atrial fibrillation.
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Affiliation(s)
- Marjorie Funk
- Yale University School of Nursing, New Haven, Conn (MF, SBR), John Dempsey Hospital, University of Connecticut Health Center, Farmington, Conn (JS, HW), and Yale-New Haven Hospital, New Haven, Conn (CB)
| | - Sally B. Richards
- Yale University School of Nursing, New Haven, Conn (MF, SBR), John Dempsey Hospital, University of Connecticut Health Center, Farmington, Conn (JS, HW), and Yale-New Haven Hospital, New Haven, Conn (CB)
| | - Jill Desjardins
- Yale University School of Nursing, New Haven, Conn (MF, SBR), John Dempsey Hospital, University of Connecticut Health Center, Farmington, Conn (JS, HW), and Yale-New Haven Hospital, New Haven, Conn (CB)
| | - Christy Bebon
- Yale University School of Nursing, New Haven, Conn (MF, SBR), John Dempsey Hospital, University of Connecticut Health Center, Farmington, Conn (JS, HW), and Yale-New Haven Hospital, New Haven, Conn (CB)
| | - Heather Wilcox
- Yale University School of Nursing, New Haven, Conn (MF, SBR), John Dempsey Hospital, University of Connecticut Health Center, Farmington, Conn (JS, HW), and Yale-New Haven Hospital, New Haven, Conn (CB)
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Yagdi T, Nalbantgil S, Ayik F, Apaydin A, Islamoglu F, Posacioglu H, Calkavur T, Atay Y, Buket S. Amiodarone reduces the incidence of atrial fibrillation after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003; 125:1420-5. [PMID: 12830063 DOI: 10.1016/s0022-5223(02)73292-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the safety and efficacy of postoperative administration of prophylactic amiodarone in the prevention of new-onset postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting. METHODS In this prospective study 157 patients were randomly divided into two groups: 77 patients (amiodarone group) received intravenous amiodarone in a dose of 10 mg/kg/d for postoperative 48 hours. On postoperative day 2 oral amiodarone was started with a dose of 600 mg/d for 5 days, 400 mg/d for the following 5 days, and 200 mg/d for 20 days, and 80 patients received placebo (control group). RESULTS Preoperative patient characteristics and operative variables were similar in the two groups. Postoperative atrial fibrillation occurred in 8 patients (10.4%) receiving amiodarone and in 20 (25.0%) patients receiving placebo (P =.017). Duration of atrial fibrillation was 12.8 +/- 4.8 hours for the amiodarone group compared with 34.7 +/- 28.7 hours for the control group (P =.003). The maximum ventricular rate during atrial fibrillation was slower in the amiodarone group than in the control group (105.9 +/- 19.1 beats per minute and 126.0 +/- 18.5 beats per minute, respectively, P =.016). The two groups had a similar incidence of complication other than rhythm disturbances (20.8% vs 20.0%, P =.904). Amiodarone group patients had shorter hospital stays than that of control group patients (6.8 +/- 1.7 days vs 7.8 +/- 2.9 days, P =.014). The in-hospital mortality was not different between two groups (1.3% vs 3.8, P =.620). CONCLUSIONS Postoperative intravenous amiodarone, followed by oral amiodarone, appears to be effective in the prevention of new-onset postoperative atrial fibrillation. It also reduces ventricular rate and duration of atrial fibrillation after coronary artery bypass grafting. It is well tolerated and decreases the length of hospital stay.
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Affiliation(s)
- Tahir Yagdi
- Ege University Medical Faculty, Department of Cardiovascular Surgery, Izmir, Turkey.
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Wu ZK, Iivainen T, Pehkonen E, Laurikka J, Tarkka MR. Perioperative and postoperative arrhythmia in three-vessel coronary artery disease patients and antiarrhythmic effects of ischemic preconditioning. Eur J Cardiothorac Surg 2003; 23:578-84. [PMID: 12694779 DOI: 10.1016/s1010-7940(03)00007-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE Sudden cardiac death caused by arrhythmia remains a major unsolved problem after coronary artery bypass grafting (CABG). Ischemic preconditioning (IP) has proved effective in suppressing ischemia reperfusion arrhythmias in animals and humans. The purpose of the present study was to establish whether IP reduces postoperative arrhythmias in three-vessel coronary artery disease patients undergoing CABG. METHODS Forty-five patients with stable angina and three main coronary artery stenosis admitted for primary CABG surgery were randomized into an IP and a control group. The IP protocol entailed twice occluding the ascending aorta by cross-clamping for 2 min, followed by 3 min of reperfusion. Electrocardiography was continuously recorded from the day before surgery to the second postoperative day. RESULTS During the recording, all patients developed SVES and VES after the operation. The incidences of SVT and ventricular tachycardia (VT) after surgery were 73.3 and 77.8%, respectively. IP significantly reduced VES events per hour during 2h after reperfusion. The SVT and VT incidence and events per hour were significantly lower in the IP group during 2h after reperfusion and 24h later. CONCLUSIONS IP significantly reduced VES, SVT, and VT after surgery. The antiarrhythmic effect 24h after surgery indicates a delayed antiarrhythmic IP phenomenon in these patients. These findings would indicate that IP constitutes a potential additional myocardial protective strategy in multi-vessel diseased patients undergoing CABG.
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Affiliation(s)
- Zhong-Kai Wu
- Division of Cardiac Surgery, Department of Surgery, Tampere University Hospital, 33521 Tampere, Finland
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Vassilikos V, Dakos G, Chouvarda I, Karagounis L, Karvounis H, Maglaveras N, Mochlas S, Spanos P, Louridas G. Can P wave wavelet analysis predict atrial fibrillation after coronary artery bypass grafting? Pacing Clin Electrophysiol 2003; 26:305-9. [PMID: 12687834 DOI: 10.1046/j.1460-9592.2003.00038.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The purpose of this study was the evaluation of Morlet wavelet analysis of the P wave as a means of predicting the development of atrial fibrillation (AF) in patients who undergo coronary artery bypass grafting (CABG). The P wave was analyzed using the Morlet wavelet in 50 patients who underwent successful CABG. Group A consisted of 17 patients, 12 men and 5 women, of mean age 66.9 +/- 5.9 years, who developed AF postoperatively. Group B consisted of 33 patients, 29 men and 4 women, mean age 62.4 +/- 7.8 years, who remained arrhythmid-free. Using custom-designed software, P wave duration and wavelet parameters expressing the mean and maximum energy of the P wave were calculated from 3-channel digital recordings derived from orthogonal ECG leads (X, Y, and Z), and the vector magnitude (VM) was determined in each of 3 frequency bands (200-160 Hz, 150-100 Hz and 90-50 Hz). Univariate logistic-regression analysis identified a history of hypertension, the mean and maximum energies in all frequency bands along the Z axis, the mean and maximum energies (expressed by the VM) in the 200-160 Hz frequency band, and the mean energy in the 150-100 Hz frequency band along the Y axis as predictors for post-CABG AF. Multivariate analysis identified hypertension, ejection fraction, and the maximum energies in the 90-50 Hz frequency band along the Z and composite-vector axes as independent predictors. This multivariate model had a sensitivity of 91% and a specificity of 65%. We conclude that the Morlet wavelet analysis of the P wave is a very sensitive method of identifying patients who are likely to develop AF after CABG. The occurrence of post-CABG AF can be explained by a different activation pattern along the Z axis.
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Hakala T, Berg E, Hartikainen JEK, Hippelainen MJ. Intraoperative high-rate atrial pacing test as a predictor of atrial fibrillation after coronary artery bypass surgery. Ann Thorac Surg 2002; 74:2072-5. [PMID: 12643397 DOI: 10.1016/s0003-4975(02)04076-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common complication after coronary artery bypass grafting (CABG) operations. The aim of this prospective trial was to test the hypothesis that intraoperative high-rate atrial pacing may induce AF by mimicking rapid atrial tachycardia and can identify the patients at risk for postoperative AF. METHODS; Eighty patients having on-pump CABG without additional procedures were included in the study. After cannulation but before initiation of cardiopulmonary bypass two pacing wires were placed on the lateral surface of the right atrium. The right atrium was paced with the rate of 200 beats per minute for 10 seconds. If the patient was in sinus rhythm after the high-rate pacing, the pacing test was repeated with the rate of 250 and finally 300 beats per minute. RESULTS Postoperatively AF developed in 28 patients (35%). The high-rate atrial pacing test induced AF in 27 patients (33.7%). Of the 28 patients who experienced AF during the postoperative period, 17 patients were inducible in the atrial-pacing test (sensitivity 0.61). Of the 52 patients who did not develop AF postoperatively, 42 patients were not inducible in the atrial-pacing test (specificity of the test was 0.81). Positive and negative predictive values of the test were 0.63 and 0.79, respectively. CONCLUSIONS The intraoperative high-rate atrial pacing test turned out to be a simple, safe, and fast way to identify the patients at risk for AF after CABG. The diagnostic accuracy of this test is sufficient to identify a group of patients to whom prophylactic treatment could be directed.
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Affiliation(s)
- Tapio Hakala
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland. tapio.hakala@kuh
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Skubas NJ, Barzilai B, Hogue CW. Atrial fibrillation after coronary artery bypass graft surgery is unrelated to cardiac abnormalities detected by transesophageal echocardiography. Anesth Analg 2001; 93:14-9. [PMID: 11429330 DOI: 10.1097/00000539-200107000-00004] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED Atrial fibrillation is a common complication of coronary artery bypass graft (CABG) surgery that is associated with adverse patient outcomes. We evaluated whether preexisting abnormalities of cardiac structure or function detected with transesophageal echocardiography (TEE) are prevalent in patients later developing atrial fibrillation after CABG surgery. TEE imaging was performed after induction of general anesthesia, but before primary CABG surgery, in 62 consecutive patients without cardiac valvular disease or preexisting atrial fibrillation. Measurements included left atrial diameter, left ventricular wall thickness, left ventricular end-systolic and end-diastolic dimensions and fractional area change. Pulsed-wave Doppler measurements of pulmonary venous and trans-mitral blood flow velocity were obtained. Continuous monitoring with telemetry electrocardiography for the development of atrial fibrillation was performed. Eighteen patients (29%) developed postoperative atrial fibrillation. There were no significant differences in left atrial or left ventricular TEE variables or pulsed-wave Doppler pulmonary venous flow measurements between patients with and without postoperative atrial fibrillation. After adjusting for age and duration of aortic cross-clamping, there were no differences in the transmitral Doppler diastolic filling variables between these same groups. These data suggest that atrial fibrillation commonly occurs after CABG surgery in the absence of atrial enlargement or Doppler-derived cardiac functional abnormalities. The data imply that the use of TEE immediately before surgery would be an insensitive means for routine identification of patients susceptible to this arrhythmia. IMPLICATIONS Transesophageal echocardiography performed immediately before coronary artery bypass graft (CABG) surgery is not useful for prediction of susceptibility to develop atrial fibrillation postoperatively. Postoperative atrial fibrillation commonly occurs after CABG surgery in the absence of preoperative atrial enlargement or Doppler derived functional abnormalities.
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Affiliation(s)
- N J Skubas
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, and the Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Mueller XM, Tevaearai HT, Ruchat P, Stumpe F, von Segesser LK. Did the introduction of a minimally invasive technique change the incidence of atrial fibrillation after single internal thoracic artery-left anterior descending artery grafting? J Thorac Cardiovasc Surg 2001; 121:683-8. [PMID: 11279408 DOI: 10.1067/mtc.2001.112529] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Atrial fibrillation after coronary artery bypass operations remains frequent and increases morbidity, as well as resource use. Its cause remains unclear. The introduction of a minimally invasive technique provides an opportunity to evaluate the effect of intraoperative factors, such as cardiopulmonary bypass, global myocardial ischemia, and myocardial protection technique, on the occurrence of this arrhythmia. METHODS All the patients undergoing isolated left internal thoracic artery-left anterior descending artery grafting between January 1994 and December 1999 were reviewed. Twenty possible risk factors for postoperative atrial fibrillation, including the choice of operative technique--minimally invasive technique was introduced in January 1997--were entered into univariate and multivariable logistic regression analysis. RESULTS Postoperative atrial fibrillation occurred in 36 (20%) of 183 patients. On univariate analysis, age (P <.001) and a history of supraventricular arrhythmia (P <.001) were found to be risk factors. In particular, 15 (22%) of 69 patients operated on with the minimally invasive technique had postoperative atrial fibrillation versus 21 (18%) of 114 in the standard group (P =.58). On multivariable analysis, including the operative technique, the same variables (P =.001 and.01, respectively) were identified as independent risk factors. CONCLUSIONS The introduction of a minimally invasive technique for coronary artery bypass operations did not reduce the occurrence of postoperative atrial fibrillation in this study population. This suggests that prophylactic measures to reduce this arrhythmia should be focused on factors unrelated to cardiopulmonary bypass or myocardial preservation technique.
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Affiliation(s)
- X M Mueller
- Clinic for Cardiovascular Surgery, CHUV (Centre Hospitalier Universitaire Vaudois), CH-1011 Lausanne, Switzerland.
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