1
|
Gibbison B, Murphy G, O'Brien B, Pufulete M. An Update on Guidelines to Prevent and Manage Atrial Fibrillation After Cardiac Surgery and a Survey of Practice in the UK. J Cardiothorac Vasc Anesth 2024; 38:2307-2313. [PMID: 39122642 DOI: 10.1053/j.jvca.2024.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 07/22/2024] [Accepted: 07/24/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVES Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery and affects around 30% of patients. Variable guidelines from multiple organizations exist for the prevention of POAF after cardiac surgery. A survey of UK practice was conducted to define "usual care" for a platform trial of interventions to prevent POAF after cardiac surgery. To provide context for the survey, all current guidelines for the prevention and management of atrial fibrillation (AF) after cardiac surgery were reviewed. DESIGN Online survey and literature review. SETTING All 35 UK National Health Service Cardiac Surgery Centres participated in the survey. Guidelines from specialist societies and other guideline-making organizations from the UK, Europe, and North America were reviewed. PARTICIPANTS Established a link network of researchers. MEASUREMENTS AND MAIN RESULTS Five relevant guidelines were identified from the literature review. All guidelines recommend β-blockade for prevention of AF after cardiac surgery. Treatment of AF is recommended using either rate or rhythm control. Cardioversion is recommended only for the hemodynamically unstable patient. Patients who remain in AF for over 48 hours should be considered for anticoagulation. Patients should be followed up within 60 days to review the need for antiarrhythmic and anticoagulant therapy. Of 35 centers, 31 (89%) responded. A total of 11 of 31 (35.5%) centers followed local guidance for prevention of POAF, 4 (13%) centers followed Society of Cardiovascular Anesthesiologists/European Association of Cardiothoracic Anaesthesia guidelines, 4 (13%) followed UK National Institute of Health and Care Excellence guidance and 4 followed "other" guidance. Of 31 centers, 8 (26%) followed no guidelines to prevent POAF; 28 of 31 (90%) centers did not risk-stratify their patients for POAF. Most centers (23/31, 74%) did not have a care package in place to prevent POAF, but 14 of 31 (45%) try in some way to prevent AF in patients presenting with sinus rhythm. The most common interventions to prevent POAF are β-blocker use postoperatively (23/31, 74%), magnesium (20/31, 64.5%), and maintaining a serum K+ ≥4.5 mmol/L (26/31, 84%). CONCLUSIONS Guidance to prevent AF after cardiac surgery centers around the use of β-blockade. Although patients in the UK do not appear to be risk-assessed for POAF, the main interventions used to prevent it are similar: β-blockade and maintenance of serum K+ and Mg2+ levels.
Collapse
Affiliation(s)
- Ben Gibbison
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Gavin Murphy
- Department of Cardiovascular Sciences. University of Leicester, Leicester, UK
| | - Benjamin O'Brien
- Deutsches Herzzentrum der Charité, Charité Universitätsmedizin, Berlin, Germany; St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Maria Pufulete
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol, UK
| |
Collapse
|
2
|
O’Brien B, Campbell NG, Allen E, Jamal Z, Sturgess J, Sanders J, Opondo C, Roberts N, Aron J, Maccaroni MR, Gould R, Kirmani BH, Gibbison B, Kunst G, Zarbock A, Kleine-Brüggeney M, Stoppe C, Pearce K, Hughes M, Van Dyck L, Evans R, Montgomery HE, Elbourne D. Potassium Supplementation and Prevention of Atrial Fibrillation After Cardiac Surgery: The TIGHT K Randomized Clinical Trial. JAMA 2024:2823246. [PMID: 39215972 PMCID: PMC11366075 DOI: 10.1001/jama.2024.17888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 08/16/2024] [Indexed: 09/04/2024]
Abstract
IMPORTANCE Supplementing potassium in an effort to maintain high-normal serum concentrations is a widespread strategy used to prevent atrial fibrillation after cardiac surgery (AFACS), but is not evidence-based, carries risks, and is costly. OBJECTIVE To determine whether a lower serum potassium concentration trigger for supplementation is noninferior to a high-normal trigger. DESIGN, SETTING, AND PARTICIPANTS This open-label, noninferiority, randomized clinical trial was conducted at 23 cardiac surgical centers in the United Kingdom and Germany. Between October 20, 2020, and November 16, 2023, patients with no history of atrial dysrhythmias scheduled for isolated coronary artery bypass grafting (CABG) surgery were enrolled. The last study patient was discharged from the hospital on December 11, 2023. INTERVENTIONS Patients were randomly assigned to a strategy of tight or relaxed potassium control (only supplementing if serum potassium concentration fell below 4.5 mEq/L or 3.6 mEq/L, respectively). Patients wore an ambulatory heart rhythm monitor, which was analyzed by a core laboratory masked to treatment assignment. MAIN OUTCOMES AND MEASURES The prespecified primary end point was clinically detected and electrocardiographically confirmed new-onset AFACS in the first 120 hours after CABG surgery or until hospital discharge, whichever occurred first. All primary outcome events were validated by an event validation committee, which was masked to treatment assignment. Noninferiority of relaxed potassium control was defined as a risk difference for new-onset AFACS with associated upper bound of a 1-sided 97.5% CI of less than 10%. Secondary outcomes included other heart rhythm-related events, clinical outcomes, and cost related to the intervention. RESULTS A total of 1690 patients (mean age, 65 years; 256 [15%] females) were randomized. The primary end point occurred in 26.2% of patients (n = 219) in the tight group and 27.8% of patients (n = 231) in the relaxed group, which is a risk difference of 1.7% (95% CI, -2.6% to 5.9%). There was no difference between the groups in the incidence of at least 1 AFACS episode detected by any means or by ambulatory heart rhythm monitor alone, non-AFACS dysrhythmias, in-patient mortality, or length of stay. Per-patient cost for purchasing and administering potassium was significantly lower in the relaxed group (mean difference, $111.89 [95% CI, $103.60-$120.19]; P <.001). CONCLUSIONS AND RELEVANCE For AFACS prophylaxis, supplementation only when serum potassium concentration fell below 3.6 mEq/L was noninferior to the current widespread practice of supplementing potassium to maintain a serum potassium concentration greater than or equal to 4.5 mEq/L. The lower threshold of supplementation was not associated with any increase in dysrhythmias or adverse clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04053816.
Collapse
Affiliation(s)
- Benjamin O’Brien
- Deutsches Herzzentrum der Charité, Charité - Universitätsmedizin Berlin, Germany
- St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
- Outcomes Research Consortium, Cleveland, Ohio
| | - Niall G. Campbell
- University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Elizabeth Allen
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Zahra Jamal
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Joanna Sturgess
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Julie Sanders
- St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
- King’s College London, London, United Kingdom
| | - Charles Opondo
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Neil Roberts
- St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Jonathan Aron
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom
| | | | | | | | - Ben Gibbison
- University of Bristol, Bristol, United Kingdom
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Gudrun Kunst
- King’s College London, London, United Kingdom
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | | | | | - Christian Stoppe
- Deutsches Herzzentrum der Charité, Charité - Universitätsmedizin Berlin, Germany
- University Hospital, Würzburg, Würzburg, Germany
| | - Keith Pearce
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Mark Hughes
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- King’s College London, London, United Kingdom
| | - Laura Van Dyck
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Richard Evans
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Diana Elbourne
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| |
Collapse
|
3
|
Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024:ehae176. [PMID: 39210723 DOI: 10.1093/eurheartj/ehae176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
|
4
|
Quan I, Belley-Côté EP, Spence J, Wang A, Sidhom K, Wang MK, Conen D, Sun B, Shankar AU, Whitlock RP, Devereaux PJ, Healey JS, McIntyre WF. A Systematic Review of Ongoing Registered Research Studies on Post-Operative Atrial Fibrillation after Cardiac Surgery. J Clin Med 2024; 13:4948. [PMID: 39201089 PMCID: PMC11355732 DOI: 10.3390/jcm13164948] [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: 07/15/2024] [Revised: 08/13/2024] [Accepted: 08/20/2024] [Indexed: 09/02/2024] Open
Abstract
Background/Objectives: New-onset atrial fibrillation (AF) after cardiac surgery is associated with patient-important outcomes. Uncertainty persists regarding its prevention, detection, and management. This review seeks to identify, compile, and describe ongoing registered research studies involving patients with or at risk for post-operative AF (POAF) after cardiac surgery. Methods: We searched clinical trial registries in January 2023 for studies focusing on POAF prediction, prevention, detection, or management. We extracted data from each record and performed descriptive analyses. Results: In total, 121 studies met the eligibility criteria, including 82 randomized trials. Prevention studies are the most common (n = 77, 63.6%), followed by prediction (n = 21, 17.4%), management (n = 16, 13.2%), and detection studies (n = 7, 5.8%). POAF after cardiac surgery is an area of active research. Conclusions: There are many ongoing randomized prevention studies. However, two major clinical gaps persist; future randomized trials should compare rate and rhythm control in patients who develop POAF, and long-term follow-up studies should investigate strategies to monitor for AF recurrence in patients with POAF.
Collapse
Affiliation(s)
- Ivy Quan
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8L 2X2, Canada; (I.Q.); (A.W.); (K.S.); (B.S.); (A.U.S.)
| | - Emilie P. Belley-Côté
- Population Health Research Institute, Hamilton, ON L8L 2X2, Canada; (E.P.B.-C.); (J.S.); (D.C.); (R.P.W.); (P.J.D.); (J.S.H.)
| | - Jessica Spence
- Population Health Research Institute, Hamilton, ON L8L 2X2, Canada; (E.P.B.-C.); (J.S.); (D.C.); (R.P.W.); (P.J.D.); (J.S.H.)
| | - Austine Wang
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8L 2X2, Canada; (I.Q.); (A.W.); (K.S.); (B.S.); (A.U.S.)
| | - Karen Sidhom
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8L 2X2, Canada; (I.Q.); (A.W.); (K.S.); (B.S.); (A.U.S.)
| | - Michael Ke Wang
- Population Health Research Institute, Hamilton, ON L8L 2X2, Canada; (E.P.B.-C.); (J.S.); (D.C.); (R.P.W.); (P.J.D.); (J.S.H.)
| | - David Conen
- Population Health Research Institute, Hamilton, ON L8L 2X2, Canada; (E.P.B.-C.); (J.S.); (D.C.); (R.P.W.); (P.J.D.); (J.S.H.)
| | - Bryan Sun
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8L 2X2, Canada; (I.Q.); (A.W.); (K.S.); (B.S.); (A.U.S.)
| | - Aadithya Udaya Shankar
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8L 2X2, Canada; (I.Q.); (A.W.); (K.S.); (B.S.); (A.U.S.)
| | - Richard P. Whitlock
- Population Health Research Institute, Hamilton, ON L8L 2X2, Canada; (E.P.B.-C.); (J.S.); (D.C.); (R.P.W.); (P.J.D.); (J.S.H.)
| | - P. J. Devereaux
- Population Health Research Institute, Hamilton, ON L8L 2X2, Canada; (E.P.B.-C.); (J.S.); (D.C.); (R.P.W.); (P.J.D.); (J.S.H.)
| | - Jeff S. Healey
- Population Health Research Institute, Hamilton, ON L8L 2X2, Canada; (E.P.B.-C.); (J.S.); (D.C.); (R.P.W.); (P.J.D.); (J.S.H.)
| | - William F. McIntyre
- Population Health Research Institute, Hamilton, ON L8L 2X2, Canada; (E.P.B.-C.); (J.S.); (D.C.); (R.P.W.); (P.J.D.); (J.S.H.)
| |
Collapse
|
5
|
Shahian DM, Paone G, Habib RH, Krohn C, Bollen BA, Jacobs JP, Bowdish ME, Kertai MD. The Society of Thoracic Surgeons Preoperative Beta Blocker Working Group Interim Report. Ann Thorac Surg 2024:S0003-4975(24)00670-2. [PMID: 39159910 DOI: 10.1016/j.athoracsur.2024.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/26/2024] [Accepted: 06/26/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) occurs commonly after cardiac surgery and is associated with multiple adverse outcomes. Older randomized trials suggested that perioperative β- blockade reduced postoperative AF, and The Society of Thoracic Surgeons (STS) coronary artery bypass grafting (CABG) composite measure includes β-blocker administration preoperatively within 24 hours of surgery and at discharge. However, some more recent studies suggest preoperative β-blockade has limited value and question its continuation as an STS quality measure. METHODS In 2022, an STS Preoperative Beta Blocker Working Group was formed with representatives from the STS and the Society of Cardiovascular Anesthesiologists. Published randomized trials, observational studies, societal guidelines, and the current state of available data from the STS Adult Cardiac Surgery Database (ACSD) were reviewed. RESULTS Review of existing studies reveals substantial heterogeneity or insufficient detail regarding specific β-blockers used, timing of initiation, management of patients on chronic β-blockade, and whether other proarrhythmic or antiarrhythmic drugs were used concurrently. Further, β-blocker data currently collected in the STS ACSD lack sufficient granularity. CONCLUSIONS Because a new randomized trial seems unlikely, the Working Group believes that more granular data on real-world practice would facilitate assessment of the value of preoperative β-blockade in the current era, development of best practice recommendations, and evaluation of their continued appropriateness as an STS quality metric. STS ACSD participants have been invited to participate in a voluntary survey whose additional data, when linked to STS ACSD records, will better delineate contemporary β-blocker practice and outcomes.
Collapse
Affiliation(s)
- David M Shahian
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts.
| | - Gaetano Paone
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - Carole Krohn
- The Society of Thoracic Surgeons, Chicago, Illinois
| | - Bruce A Bollen
- Missoula Anesthesiology PC, St. Patrick Hospital, Providence Heart Center, Missoula, Montana
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Michael E Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
6
|
Fialka NM, Watkins AR, Alam A, EL-Andari R, Kang JJH, Hong Y, Bozso SJ, Moon MC, Nagendran J. Tissue versus mechanical mitral valve replacement in patients aged 50-70: a propensity-matched analysis. Eur J Cardiothorac Surg 2024; 66:ezae283. [PMID: 39167084 PMCID: PMC11344592 DOI: 10.1093/ejcts/ezae283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 07/08/2024] [Accepted: 08/19/2024] [Indexed: 08/23/2024] Open
Abstract
OBJECTIVES There remains debate over the optimal mitral valve replacement (MVR) option for patients aged 50-70 years. The objective of this study was to retrospectively compare the long-term outcomes of mechanical and bioprosthetic MVR in this patient population. METHODS Data from patients undergoing MVR between 2004 and 2018 were retrospectively reviewed. The primary outcome was all-cause mortality. Secondary outcomes included perioperative and late morbidity. RESULTS Two hundred and eight-six propensity-matched patients (n = 143 mechanical; n = 143 bioprosthetic) aged 50-70 years were included in the final analysis. Maximum follow-up was 15.8 years. There was no significant difference in all-cause mortality between the groups at 30 days, 1 year, 5 years, 10 years, and at the longest follow-up. Patients who underwent mechanical MVR experienced significantly lower rates of postoperative atrial fibrillation (P = 0.001). There were no significant differences in rates of sepsis, acute kidney injury, superficial and deep sternal wound infection, mediastinal bleeding, and permanent pacemaker implantation. At the longest follow-up, there were no differences in myocardial infarction, stroke, heart failure or overall rehospitalization. At the same time point, there was an increased rate of MVR in patients receiving a bioprosthetic valve (P = 0.015). CONCLUSIONS Survival following mechanical and bioprosthetic MVR in patients 50-70 years of age is similar to up to 15 years of follow-up. Bioprosthetic MVR is associated with an increased risk of repeat MVR. Mechanical MVR is not associated with an increased risk of stroke. Valve selection in this patient population requires diligent consideration of structural valve deterioration and subsequent reoperation risk as well as bleeding and thromboembolic risk.
Collapse
Affiliation(s)
- Nicholas M Fialka
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Abeline R Watkins
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Abrar Alam
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ryaan EL-Andari
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Jimmy J H Kang
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Yongzhe Hong
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Sabin J Bozso
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Michael C Moon
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Jeevan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
7
|
Levy B, Slama M, Lakbar I, Maizel J, Kato H, Leone M, Okada M. Landiolol for Treatment of New-Onset Atrial Fibrillation in Critical Care: A Systematic Review. J Clin Med 2024; 13:2951. [PMID: 38792492 PMCID: PMC11122541 DOI: 10.3390/jcm13102951] [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: 01/06/2024] [Revised: 05/08/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024] Open
Abstract
Background: new-onset atrial fibrillation remains a common complication in critical care settings, often necessitating treatment when the correction of triggers is insufficient to restore hemodynamics. The treatment strategy includes electric cardioversion in cases of hemodynamic instability and either rhythm control or rate control in the absence of instability. Landiolol, an ultrashort beta-blocker, effectively controls heart rate with the potential to regulate rhythm. Objectives This review aims to compare the efficacy of landiolol in controlling heart rate and converting to sinus rhythm in the critical care setting. Methods: We conducted a comprehensive review of the published literature from 2000 to 2022 describing the use of landiolol to treat atrial fibrillation in critical care settings, excluding both cardiac surgery and medical cardiac care settings. The primary outcome assessed was sinus conversion following landiolol treatment. Results: Our analysis identified 17 publications detailing the use of landiolol for the treatment of 324 critical care patients. While the quality of the data was generally low, primarily comprising non-comparative studies, landiolol consistently demonstrated similar efficacy in controlling heart rate and facilitating conversion to sinus rhythm in both non-surgical (75.7%) and surgical (70.1%) settings. The incidence of hypotension associated with landiolol use was 13%. Conclusions: The use of landiolol in critical care patients with new-onset atrial fibrillation exhibited comparable efficacy and tolerance in both non-surgical and surgical settings. Despite these promising results, further validation through randomized controlled trials is necessary.
Collapse
Affiliation(s)
- Bruno Levy
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Université de Lorraine, 54511 Vandœuvre-lès-Nancy, France
| | - Michel Slama
- Intensive Care Unit, Amiens Picardie University Hospital, 80054 Amiens, France; (M.S.); (J.M.)
| | - Ines Lakbar
- Department of Anesthesiology and Intensive Care Unit, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille University, 13385 Marseille, France; (I.L.); (M.L.)
| | - Julien Maizel
- Intensive Care Unit, Amiens Picardie University Hospital, 80054 Amiens, France; (M.S.); (J.M.)
| | - Hiromi Kato
- Department of Anesthesiology and Intensive Care, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France;
| | - Marc Leone
- Department of Anesthesiology and Intensive Care Unit, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille University, 13385 Marseille, France; (I.L.); (M.L.)
| | - Motoi Okada
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa 078-8510, Japan;
| |
Collapse
|
8
|
Piccini JP, Ahlsson A, Dorian P, Gillinov AM, Kowey PR, Mack MJ, Milano CA, Noiseux N, Perrault LP, Ryan W, Steinberg JS, Voisine P, Waldron NH, Gleason KJ, Titanji W, Leaback RD, O'Sullivan A, Ferguson WG, Benussi S. Efficacy and Safety of Botulinum Toxin Type A for the Prevention of Postoperative Atrial Fibrillation. JACC Clin Electrophysiol 2024; 10:930-940. [PMID: 38661602 DOI: 10.1016/j.jacep.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 01/30/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is associated with increased morbidity and mortality. Epicardial injection of botulinum toxin may suppress POAF. OBJECTIVES This study sought to assess the safety and efficacy of AGN-151607 for the prevention of POAF after cardiac surgery. METHODS This phase 2, randomized, placebo-controlled trial assessed the safety and efficacy of AGN-151607, 125 U and 250 U vs placebo (1:1:1), for the prevention of POAF after cardiac surgery. Randomization was stratified by age (<65, ≥65 years) and type of surgery (nonvalvular/valve surgery). The primary endpoint was the occurrence of continuous AF ≥30 seconds. RESULTS Among 312 modified intention-to-treat participants (placebo, n = 102; 125 U, n = 104; and 250 U, n = 106), the mean age was 66.9 ± 6.8 years; 17% were female; and 64% had coronary artery bypass graft (CABG) only, 12% had CABG + valve, and 24% had valve surgery. The primary endpoint occurred in 46.1% of the placebo group, 36.5% of the 125-U group (relative risk [RR] vs placebo: 0.80; 95% CI: 0.58-1.10; P = 0.16), and 47.2% of the 250-U group (RR vs placebo: 1.04; 95% CI: 0.79-1.37; P = 0.78). The primary endpoint was reduced in the 125-U group in those ≥65 years of age (RR: 0.64; 95% CI: 0.43-0.94; P = 0.02) with a greater reduction in CABG-only participants ≥65 years of age (RR: 0.49; 95% CI: 0.27-0.87; P = 0.01). Rehospitalization and rates of adverse events were similar across the 3 groups. CONCLUSIONS There were no significant differences in the rate of POAF with either dose compared with placebo; however, there was a lower rate of POAF in participants ≥65 years undergoing CABG only and receiving 125 U of AGN-151607. These hypothesis-generating findings require investigation in a larger, adequately powered randomized clinical trial. (Botulinum Toxin Type A [AGN-151607] for the Prevention of Post-operative Atrial Fibrillation in Adult Participants Undergoing Open-chest Cardiac Surgery [NOVA]; NCT03779841); A Phase 2, Multi-Center, Randomized, Double-Blind, Placebo-Controlled, Dose Ranging Study to Evaluate the Efficacy and Safety of Botulinum Toxin Type A [AGN 151607] Injections into the Epicardial Fat Pads to Prevent Post-Operative Atrial Fibrillation in Patients Undergoing Open-Chest Cardiac Surgery; 2017-004399-68).
Collapse
Affiliation(s)
- Jonathan P Piccini
- Department of Electrophysiology, Duke Clinical Research Institute/Duke University Medical Center, Durham, North Carolina, USA.
| | - Anders Ahlsson
- Cardiovascular Division, Karolinska Institute, Stockholm, Sweden
| | - Paul Dorian
- Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Peter R Kowey
- Division of Cardiovascular Research, Lankenau Heart Institute, Wynnewood, Pennsylvania, USA
| | - Michael J Mack
- Department of Thoracic Surgery, Baylor Scott and White Health, Dallas, Texas, USA
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Duke Clinical Research Institute/Duke University Medical Center, Durham, North Carolina, USA
| | - Nicolas Noiseux
- Division of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - Louis P Perrault
- Department of Surgery, Montréal Heart Institute, Université de Montréal, Montréal, Quebec City, Quebec, Canada
| | - William Ryan
- Department of Thoracic Surgery, Baylor Scott and White Health, Dallas, Texas, USA
| | - Jonathan S Steinberg
- Clinical Cardiovascular Research Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Pierre Voisine
- Division of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada
| | - Nathan H Waldron
- Department of Anesthesiology and Critical Care, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | | | | | | | - Stefano Benussi
- Department of Cardiothoracic Surgery, University of Brescia, Brescia, Italy
| |
Collapse
|
9
|
Campbell NG, Allen E, Evans R, Jamal Z, Opondo C, Sanders J, Sturgess J, Montgomery HE, Elbourne D, O’Brien B. Impact of maintaining serum potassium concentration ≥ 3.6mEq/L versus ≥ 4.5mEq/L for 120 hours after isolated coronary artery bypass graft surgery on incidence of new onset atrial fibrillation: Protocol for a randomized non-inferiority trial. PLoS One 2024; 19:e0296525. [PMID: 38478488 PMCID: PMC10936833 DOI: 10.1371/journal.pone.0296525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/20/2023] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND Atrial Fibrillation After Cardiac Surgery (AFACS) occurs in about one in three patients following Coronary Artery Bypass Grafting (CABG). It is associated with increased short- and long-term morbidity, mortality and costs. To reduce AFACS incidence, efforts are often made to maintain serum potassium in the high-normal range (≥ 4.5mEq/L). However, there is no evidence that this strategy is efficacious. Furthermore, the approach is costly, often unpleasant for patients, and risks causing harm. We describe the protocol of a planned randomized non-inferiority trial to investigate the impact of intervening to maintain serum potassium ≥ 3.6 mEq/L vs ≥ 4.5 mEq/L on incidence of new-onset AFACS after isolated elective CABG. METHODS Patients undergoing isolated CABG at sites in the UK and Germany will be recruited, randomized 1:1 and stratified by site to protocols maintaining serum potassium at either ≥ 3.6 mEq/L or ≥ 4.5 mEq/L. Participants will not be blind to treatment allocation. The primary endpoint is AFACS, defined as an episode of atrial fibrillation, flutter or tachycardia lasting ≥ 30 seconds until hour 120 after surgery, which is both clinically detected and electrocardiographically confirmed. Assuming a 35% incidence of AFACS in the 'tight control group', and allowing for a 10% loss to follow-up, 1684 participants are required to provide 90% certainty that the upper limit of a one-sided 97.5% confidence interval (CI) will exclude a > 10% difference in favour of tight potassium control. Secondary endpoints include mortality, use of hospital resources and incidence of dysrhythmias not meeting the primary endpoint (detected using continuous heart rhythm monitoring). DISCUSSION The Tight K Trial will assess whether a protocol to maintain serum potassium ≥ 3.6 mEq/L is non inferior to maintaining serum potassium ≥ 4.5 mEq/L in preventing new-onset AFACS after isolated CABG. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04053816. Registered on 13 August 2019. Last update 7 January 2021.
Collapse
Affiliation(s)
- Niall G. Campbell
- Faculty of Biology, Division of Cardiovascular Sciences, School of Medical Sciences, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Manchester Heart Institute, Manchester University Foundation NHS Trust, Manchester, United Kingdom
| | - Elizabeth Allen
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard Evans
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Zahra Jamal
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Charles Opondo
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Julie Sanders
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Joanna Sturgess
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Hugh E. Montgomery
- Division of Medicine and Institute for Sport, Exercise and Health, University College London, London, United Kingdom
| | - Diana Elbourne
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Benjamin O’Brien
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Berlin, Germany
- Department of Perioperative Medicine, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
- Outcomes Research Consortium, Cleveland, Ohio, United States of America
| |
Collapse
|
10
|
Adamowicz S, Kilger E, Klarwein R. [Perioperative atrial fibrillation : Diagnosis with underestimated relevance]. DIE ANAESTHESIOLOGIE 2024; 73:133-144. [PMID: 38285210 DOI: 10.1007/s00101-023-01375-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/30/2024]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults, both in general and perioperatively and is associated with significant morbidity and mortality. The age of the patients is a major risk factor. The prevalence of AF in noncardiac surgery (NCS) varies widely from 0.4% to 30% and for cardiac surgery, especially major combined procedures, up to approximately 50%. Ectopic excitation centers and reentry mechanisms at the atrial level are favored as the main process of uncoordinated electrical atrial activity. The loss of atrial contraction can lead to a reduction in cardiac output of up to 20-25%. The increased risk of thromboembolism due to AF extends beyond the perioperative period. Medication-based prevention strategies have not yet gained widespread acceptance. Treatment strategies include frequency and rhythm control as well as the avoidance of thromboembolisms through anticoagulation.
Collapse
Affiliation(s)
- Sebastian Adamowicz
- Klinik für Anästhesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland.
| | - Erich Kilger
- Klinik für Anästhesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - Raphael Klarwein
- Klinik für Anästhesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| |
Collapse
|
11
|
Meenashi Sundaram D, Vasavada AM, Ravindra C, Rengan V, Meenashi Sundaram P. The Management of Postoperative Atrial Fibrillation (POAF): A Systematic Review. Cureus 2023; 15:e42880. [PMID: 37664333 PMCID: PMC10474445 DOI: 10.7759/cureus.42880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Postoperative atrial fibrillation (POAF) refers to new-onset atrial fibrillation (AF) that develops after surgery and is associated with an increased risk of mortality and thromboembolic events. The optimal management and treatment methods for POAF complications are not yet fully established. This systematic review aimed to evaluate the various treatment and management approaches currently available in terms of their suitability, efficacy, and side effects in handling POAF incidence post-surgery. Google Scholar and PubMed electronic databases were searched extensively for relevant articles examining the various management techniques currently used to manage POAF and published between 2018 and 2023. Data were collected on the type of surgery the patients underwent, POAF definition period, intervention, and outcome of interest. Following a systematic assessment guided by the inclusion criteria, 10 of the 579 studies retrieved were included in this study, and 293,417 POAF cases were recorded. Three of these studies used different rhythm control and rate control treatments to manage POAF cases, while seven studies used various anticoagulation therapies to manage POAF incidence. For asymptomatic patients within one to three days of surgery, rate control is sufficient to manage POAF, and routine rhythm control is not needed; rhythm control should be reserved for patients who develop complications such as hemodynamic instability. Anticoagulation was performed in patients whose POAF exceeded four days after surgery. Anticoagulation was associated with an increased risk of mortality, stroke, thromboembolic events, and major bleeding in patients who underwent coronary artery bypass graft (CABG) surgery. In contrast, in a few other studies, anticoagulation treatment led to improved outcomes in patients who developed POAF. A wide range of management methods are available for POAF after different types of surgery. However, there is only limited evidence to guide the clinical practice. The data available are mainly retrospective and insufficient to accurately evaluate the efficacy of the various management methods available for POAF. Future research should make efforts to standardize the treatment for this condition.
Collapse
|
12
|
Fields KG, Ma J, Petrinic T, Alhassan H, Eze A, Reddy A, Hedayat M, Providencia R, Lip GYH, Bedford JP, Clifton DA, Redfern OC, O'Brien B, Watkinson PJ, Collins GS, Muehlschlegel JD. Multivariable prediction models for atrial fibrillation after cardiac surgery: a systematic review protocol. BMJ Open 2023; 13:e067260. [PMID: 36914189 PMCID: PMC10016290 DOI: 10.1136/bmjopen-2022-067260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
INTRODUCTION Dozens of multivariable prediction models for atrial fibrillation after cardiac surgery (AFACS) have been published, but none have been incorporated into regular clinical practice. One of the reasons for this lack of adoption is poor model performance due to methodological weaknesses in model development. In addition, there has been little external validation of these existing models to evaluate their reproducibility and transportability. The aim of this systematic review is to critically appraise the methodology and risk of bias of papers presenting the development and/or validation of models for AFACS. METHODS We will identify studies that present the development and/or validation of a multivariable prediction model for AFACS through searches of PubMed, Embase and Web of Science from inception to 31 December 2021. Pairs of reviewers will independently extract model performance measures, assess methodological quality and assess risk of bias of included studies using extraction forms adapted from a combination of the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies checklist and the Prediction Model Risk of Bias Assessment Tool. Extracted information will be reported by narrative synthesis and descriptive statistics. ETHICS AND DISSEMINATION This systemic review will only include published aggregate data, so no protected health information will be used. Study findings will be disseminated through peer-reviewed publications and scientific conference presentations. Further, this review will identify weaknesses in past AFACS prediction model development and validation methodology so that subsequent studies can improve upon prior practices and produce a clinically useful risk estimation tool. PROSPERO REGISTRATION NUMBER CRD42019127329.
Collapse
Affiliation(s)
- Kara G Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jie Ma
- Centre for Statistics in Medicine, Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Tatjana Petrinic
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Hassan Alhassan
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Anthony Eze
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Ankith Reddy
- University of Texas Medical Branch, School of Medicine, Galveston, Texas, USA
| | - Mona Hedayat
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rui Providencia
- Institute of Health Informatics Research, University College London, London, UK
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jonathan P Bedford
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - David A Clifton
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - Oliver C Redfern
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Benjamin O'Brien
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Deutsches Herzzentrum Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Perioperative Medicine, St. Bartholomew's Hospital and Barts Heart Centre, Barts Health NHS Trust, London, UK
- Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Peter J Watkinson
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Trust, Oxford, UK
- NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jochen D Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
13
|
Liu Y, Yu M, Wu Y, Wu F, Feng X, Zhao H. Myeloperoxidase in the pericardial fluid improves the performance of prediction rules for postoperative atrial fibrillation. J Thorac Cardiovasc Surg 2023; 165:1064-1077.e8. [PMID: 34275621 DOI: 10.1016/j.jtcvs.2021.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 05/15/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES After surgery, inflammation is a prominent factor influencing postoperative atrial fibrillation. Myeloperoxidase is a major contributor to inflammatory responses after surgical tissue damage. We evaluated whether myeloperoxidase is associated with postoperative atrial fibrillation clinically and in an animal model. METHODS This prospective cohort study included patients undergoing isolated coronary artery bypass grafting. Myeloperoxidase concentrations in blood and pericardial fluid were determined at baseline and 6, 12, and 18 hours after coronary artery bypass grafting. Myeloperoxidase activity in blood, pericardial fluid, and atrium were also evaluated in a canine coronary artery bypass grafting model. Electrophysiologic, histologic, and immunohistochemistry analyses were performed to explore underlying mechanisms. RESULTS Postoperative atrial fibrillation occurred in 45 of 137 patients (32.8%). Patients with postoperative atrial fibrillation had significantly higher serum and pericardial myeloperoxidase levels. Individual clinical and surgical factors had moderate predictive value (area under the curve, 0.760) for postoperative atrial fibrillation. Discrimination improved remarkably when myeloperoxidase was combined with other parameters (area under the curve, 0.901). Pericardial myeloperoxidase at 6 hours postoperatively was the strongest independent predictor of postoperative atrial fibrillation (odds ratio, 19.215). The rate of postoperative atrial fibrillation increased exponentially across pericardial myeloperoxidase grades. Compared with controls, coronary artery bypass grafting-treated dogs showed higher atrial fibrillation vulnerability and maintenance, shorter atrial effective refractory period, attenuated connexin 43 expression, and increased myocardial and pericardial myeloperoxidase activity. Connexin 43 expression and atrial effective refractory period were strongly negatively correlated with myocardial and pericardial myeloperoxidase activity. CONCLUSIONS Myeloperoxidase is linked to postoperative atrial fibrillation, and the ability to predict postoperative atrial fibrillation was remarkably improved by adding pericardial myeloperoxidase. Myeloperoxidase-related atrial structural and electrical remodeling is a physiologic substrate for this arrhythmia.
Collapse
Affiliation(s)
- Yisi Liu
- Capital Medical University, Beijing, P. R. China
| | - Meng Yu
- Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, P.R. China
| | - Ying Wu
- Capital Medical University, Beijing, P. R. China.
| | - Fangqin Wu
- Capital Medical University, Beijing, P. R. China
| | - Xinwei Feng
- Capital Medical University, Beijing, P. R. China
| | - Haibo Zhao
- Beijing Chao-yang Hospital affiliated to Capital Medical University, Beijing, P.R. China
| |
Collapse
|
14
|
McIntyre WF. Post-operative atrial fibrillation after cardiac surgery: Challenges throughout the patient journey. Front Cardiovasc Med 2023; 10:1156626. [PMID: 36960472 PMCID: PMC10027741 DOI: 10.3389/fcvm.2023.1156626] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 03/09/2023] Open
Abstract
Atrial fibrillation (AF) is the most common complication of cardiac surgery, occurring in up to half of patients. Post-operative AF (POAF) refers to new-onset AF in a patient without a history of AF that occurs within the first 4 weeks after cardiac surgery. POAF is associated with short-term mortality and morbidity, but its long-term significance is unclear. This article reviews existing evidence and research challenges for the management of POAF in patients who have had cardiac surgery. Specific challenges are discussed in four phases of care. Pre-operatively, clinicians need to be able to identify high-risk patients, and initiate prophylaxis to prevent POAF. In hospital, when POAF is detected, clinicians need to manage symptoms, stabilize hemodynamics and prevent increases in length of stay. In the month after discharge, the focus is on minimizing symptoms and preventing readmission. Some patients require short term oral anticoagulation for stroke prevention. Over the long term (2-3 months after surgery and beyond), clinicians need to identify which patients with POAF have paroxysmal or persistent AF and can benefit from evidence-based therapies for AF, including long-term oral anticoagulation.
Collapse
|
15
|
Feilberg Rasmussen L, Andreasen JJ, Riahi S, Lundbye‐Christensen S, Johnsen SP, Andersen G, Mortensen JK. Risk and Subtypes of Stroke Following New-Onset Postoperative Atrial Fibrillation in Coronary Bypass Surgery: A Population-Based Cohort Study. J Am Heart Assoc 2022; 11:e8032. [PMID: 36533595 PMCID: PMC9798791 DOI: 10.1161/jaha.122.027010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background New-onset postoperative atrial fibrillation (POAF) develops in approximately one-third of patients undergoing cardiac surgery and is associated with a higher incidence of ischemic stroke and increased mortality. However, it remains unknown to what extent ischemic stroke events in patients with POAF are cardioembolic and whether anticoagulant therapy is indicated. We investigated the long-term risk and pathogenesis of postoperative stroke in patients undergoing coronary artery bypass grafting experiencing POAF. Methods and Results This was a register-based cohort study. Data from the WDHR (Western Denmark Heart Registry) were linked with the DNPR (Danish National Patient Register), the Danish National Prescription Register, and the Cause of Death Register. All stroke diagnoses were verified, and ischemic stroke cases were subclassified according to pathogenesis. Furthermore, investigations of all-cause mortality and the use of anticoagulation medicine for the individual patient were performed. A total of 7813 patients without a preoperative history of atrial fibrillation underwent isolated coronary artery bypass grafting between January 1, 2010, and December 31, 2018, in Western Denmark. POAF was registered in 2049 (26.2%) patients, and a postoperative ischemic stroke was registered in 195 (2.5%) of the patients. After adjustment, there was no difference in the risk of ischemic stroke (hazard ratio [HR], 1.08 [95% CI, 0.74-1.56]) or all-cause mortality (HR, 1.09 [95% CI, 0.98-1.23]) between patients who developed POAF and non-POAF patients. Although not statistically significant, patients with POAF had a higher incidence rate (IR; per 1000 patient-years) of cardioembolic stroke (IR, 1 [95% CI, 0.6-1.6] versus IR, 0.5 [95% CI, 0.3-0.8]), whereas non-POAF patients had a higher incidence rate of large-artery occlusion stroke (IR, 1.1 [95% CI, 0.8-1.5] versus IR, 0.7 [95% CI, 0.4-1.4]). Early initiation of anticoagulation medicine was not associated with a lower risk of ischemic stroke. However, patients with POAF were more likely to die of cardiovascular causes than non-POAF patients (P<0.001). Conclusions We found no difference in the adjusted risk of postoperative stroke or all-cause mortality in POAF versus non-POAF patients. Patients with POAF after coronary artery bypass grafting presented with a higher, although not significant, proportion of ischemic strokes of the cardioembolic type.
Collapse
Affiliation(s)
- Louise Feilberg Rasmussen
- Department of Cardiothoracic SurgeryAalborg University HospitalAalborgDenmark,Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Jan J. Andreasen
- Department of Cardiothoracic SurgeryAalborg University HospitalAalborgDenmark,Department of Clinical MedicineAalborg UniversityAalborgDenmark,Atrial Fibrillation Study GroupAalborg University HospitalAalborgDenmark
| | - Sam Riahi
- Department of Clinical MedicineAalborg UniversityAalborgDenmark,Atrial Fibrillation Study GroupAalborg University HospitalAalborgDenmark,Department of CardiologyAalborg University HospitalAalborgDenmark
| | - Søren Lundbye‐Christensen
- Atrial Fibrillation Study GroupAalborg University HospitalAalborgDenmark,Unit of Clinical BiostatisticsAalborg University HospitalAalborgDenmark
| | - Søren P. Johnsen
- Department of Clinical MedicineAalborg UniversityAalborgDenmark,Danish Center for Clinical Health Services ResearchAalborg UniversityAalborgDenmark
| | - Grethe Andersen
- Department of Neurology, Danish Stroke CentreAarhus University HospitalAarhusDenmark,Department of Clinical Medicine, Faculty of HealthAarhus UniversityAarhusDenmark
| | - Janne K. Mortensen
- Department of Neurology, Danish Stroke CentreAarhus University HospitalAarhusDenmark,Department of Clinical Medicine, Faculty of HealthAarhus UniversityAarhusDenmark
| |
Collapse
|
16
|
Predictors and clinical outcomes of post-coronary artery bypass grafting cerebrovascular strokes. Egypt Heart J 2022; 74:76. [PMID: 36255549 DOI: 10.1186/s43044-022-00315-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
Despite the improved medical and surgical managements, still there is a significant risk of developing acute cerebrovascular strokes after coronary artery bypass grafting (CABG). Our objectives were to study the immediate and long-term outcomes after CABG and to identify the possible predictors of post-CABG strokes.
Results
Between January 2016 and August 2020, 410 adult patients, mostly males (82.2%), were retrospectively enrolled after CABG. Acute postoperative strokes occurred in 31 (7.5%) patients; of them, 30 (96.8%) patients had ischemic stroke, while 1 (3.2%) had hemorrhagic stroke. Mechanical thrombectomy was done in two cases. The patients who developed acute cerebral stroke had significantly higher admission (p = 0.02) and follow-up (p < 0.001) SOFA scores, higher arterial blood lactate level (p < 0.001), longer hospitalization (p < 0.001) and more hospital mortality (p < 0.001) compared with the patients who did not develop stroke. Kaplan–Meier curves for 5-year mortality showed increased risk in those patients with postoperative stroke (HR: 23.03; 95% CI: 6.10–86.92, p < 0.001). After multivariate regression, the predictors of early postoperative stroke were carotid artery stenosis (CAS), postoperative atrial fibrillation, cardiopulmonary bypass time, prior cerebral stroke, admission SOFA score and chronic kidney disease (CKD). The predictors of late cerebrovascular stroke were CAS, combined CABG and valve surgery, CKD, atrial fibrillation, prior stroke and HbA1c.
Conclusions
The development of post-CABG acute cerebrovascular stroke is associated with longer hospitalization, multiple morbidities and increased mortality. Careful assessment and management of risk factors especially atrial fibrillation and carotid artery stenosis should be implemented to decrease this substantial complication after CABG.
Collapse
|
17
|
Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 287] [Impact Index Per Article: 143.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
18
|
Fatehi Hassanabad A, Schoettler FI, Kent WD, Adams CA, Holloway DD, Ali IS, Novick RJ, Ahsan MR, McClure RS, Shanmugam G, Kidd WT, Kieser TM, Fedak PW, Deniset JF. Comprehensive characterization of the postoperative pericardial inflammatory response: Potential implications for clinical outcomes. JTCVS OPEN 2022; 12:118-136. [PMID: 36590740 PMCID: PMC9801292 DOI: 10.1016/j.xjon.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/23/2022] [Accepted: 09/06/2022] [Indexed: 01/04/2023]
Abstract
Objective There is a paucity of data on the inflammatory response that takes place in the pericardial space after cardiac surgery. This study provides a comprehensive assessment of the local postoperative inflammatory response. Methods Forty-three patients underwent cardiotomy, where native pericardial fluid was aspirated and compared with postoperative pericardial effluent collected at 4, 24, and 48 hours' postcardiopulmonary bypass. Flow cytometry was used to define the levels and proportions of specific immune cells. Samples were also probed for concentrations of inflammatory cytokines, matrix metalloproteinases (MMPs), and tissue inhibitors of metalloproteinases (TIMPs). Results Preoperatively, the pericardial space mainly contains macrophages and T cells. However, the postsurgical pericardial space was populated predominately by neutrophils, which constituted almost 80% of immune cells present, and peaked at 24 hours. When surgical approaches were compared, minimally invasive surgery was associated with fewer neutrophils in the pericardial space at 4 hours' postsurgery. Analysis of the intrapericardial concentrations of inflammatory mediators showed interleukin-6, MMP-9, and TIMP-1 to be highest postsurgery. Over time, MMP-9 concentrations decreased significantly, whereas TIMP-1 levels increased, resulting in a significant reduction of the ratio of MMP:TIMP after surgery, suggesting that active inflammatory processes may influence extracellular matrix remodeling. Conclusions These results show that cardiac surgery elicits profound alterations in the immune cell profile in the pericardial space. Defining the cellular and molecular mediators that drive pericardial-specific postoperative inflammatory processes may allow for targeted therapies to reduce immune-mediated complications.
Collapse
Key Words
- AVR, aortic valve replacement
- CABG, coronary artery bypass graft
- CD, cluster of differentiation
- CPB, cardiopulmonary bypass
- DC, dendritic cell
- ECM, extracellular matrix
- FS, full median sternotomy
- IL, interleukin
- IL-1Ra, interleukin-1 receptor antagonist
- Inf DC, inflammatory dendritic cell
- MICS, minimally invasive cardiac surgery
- MMP, matrix metalloproteinase
- MMPtot, total matrix metalloproteinases
- Mφ, macrophage
- NK, natural killer cell
- PAOF, postoperative atrial fibrillation
- PPS, postpericardiotomy syndrome
- RAMT-AVR, right anterior minithoracotomy aortic valve replacement
- SSC, side scatter
- TGFβ, transforming growth factor-beta
- TIMP, tissue inhibitor of metalloproteinases
- TIMPtot, total tissue inhibitors of metalloproteinases
- cDC, classical dendritic cell
- conventional cardiac surgery
- inflammation
- minimally invasive cardiac surgery
- pericardial space
- postoperative pericardial fluid
- sAVR, conventional full median sternotomy surgical aortic valve replacement
Collapse
Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Friederike I. Schoettler
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Surgery, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - William D.T. Kent
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Corey A. Adams
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel D. Holloway
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Imtiaz S. Ali
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Richard J. Novick
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Muhammad R. Ahsan
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert Scott McClure
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ganesh Shanmugam
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - William T. Kidd
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Teresa M. Kieser
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul W.M. Fedak
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Justin F. Deniset
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Calgary, Alberta, Canada
- Address for reprints: Justin F. Deniset, PhD, Department of Physiology & Pharmacology, Department of Cardiac Sciences, Libin Cardiovascular Institute Cumming School of Medicine, Health Research Innovation Centre, University of Calgary, 3330 Hospital Dr NW, Room GAC56, Calgary, Alberta, Canada, T2N 4N1.
| |
Collapse
|
19
|
Piccini JP, Ahlsson A, Dorian P, Gillinov MA, Kowey PR, Mack MJ, Milano CA, Perrault LP, Steinberg JS, Waldron NH, Adams LM, Bharucha DB, Brin MF, Ferguson WG, Benussi S. Design and Rationale of a Phase 2 Study of NeurOtoxin (Botulinum Toxin Type A) for the PreVention of Post-Operative Atrial Fibrillation - The NOVA Study. Am Heart J 2022; 245:51-59. [PMID: 34687654 DOI: 10.1016/j.ahj.2021.10.114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 10/06/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Post-operative AF (POAF) is the most common complication following cardiac surgery, occurring in 30% to 60% of patients undergoing bypass and/or valve surgery. POAF is associated with longer intensive care unit/hospital stays, increased healthcare utilization, and increased morbidity and mortality. Injection of botulinum toxin type A into the epicardial fat pads resulted in reduction of AF in animal models, and in two clinical studies of cardiac surgery patients, without new safety observations. METHODS The objective of NOVA is to assess the use of AGN-151607 (botulinum toxin type A) for prevention of POAF in cardiac surgery patients. This randomized, multi-site, placebo-controlled trial will study one-time injections of AGN-151607 125 U (25 U / fat pad) and 250 U (50 U / fat pad) or placebo during cardiac surgery in ∼330 participants. Primary endpoint: % of patients with continuous AF ≥ 30 s. Secondary endpoints include several measures of AF frequency, duration, and burden. Additional endpoints include clinically important tachycardia during AF, time to AF termination, and healthcare utilization. Primary and secondary efficacy endpoints will be assessed using continuous ECG monitoring for 30 days following surgery. All patients will be followed for up to 1 year for safety. CONCLUSIONS The NOVA Study will test the hypothesis that injections of AGN-151607 will reduce the incidence of POAF and associated resource utilization. If demonstrated to be safe and effective, the availability of a one-time therapy for the prevention of POAF would represent an important treatment option for patients undergoing cardiac surgery.
Collapse
Affiliation(s)
- Jonathan P Piccini
- Duke Clinical Research Institute / Duke University Medical Center, Durham, NC.
| | | | | | | | | | | | | | | | | | - Nathan H Waldron
- Duke Clinical Research Institute / Duke University Medical Center, Durham, NC
| | | | | | | | | | | |
Collapse
|
20
|
Campbell NG, Wollborn J, Fields KG, Lip GY, Ruetzler K, Muehlschlegel JD, O’Brien B. Inconsistent Methodology as a Barrier to Meaningful Research Outputs From Studies of Atrial Fibrillation After Cardiac Surgery. J Cardiothorac Vasc Anesth 2022; 36:739-745. [PMID: 34763979 PMCID: PMC9901359 DOI: 10.1053/j.jvca.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/19/2021] [Accepted: 10/08/2021] [Indexed: 02/08/2023]
Abstract
Atrial fibrillation after cardiac surgery (AFACS) is a serious postoperative complication. There is significant research interest in this field but also relevant heterogeneity in reported AFACS definitions and approaches used for its identification. Few data exist on the extent of this variation in clinical studies. The authors reviewed the literature since 2001 and included manuscripts reporting outcomes of AFACS in adults. They excluded smaller studies and studies in which patients did not undergo a sternotomy. The documented protocol in each manuscript was analyzed according to six different categories to determine how AFACS was defined, which techniques were used to identify it, and the inclusion and/or exclusion criteria. They also noted when a category was not described in the documented protocol. The authors identified 302 studies, of which 92 were included. Sixty-two percent of studies were randomized controlled trials. There was significant heterogeneity in the manuscripts, including the exclusion of patients with preoperative AF, the definition and duration of AF needed to meet the primary endpoint, the type of screening approach (continuous, episodic, or opportunistic), the duration of monitoring during the study period in days, the diagnosis with predefined electrocardiogram criteria, and the requirement for independent confirmation by study investigators. Furthermore, the definitions of these criteria frequently were not described. Consistent reporting standards for AFACS research are needed to advance scientific progress in the field. The authors here propose pragmatic standards for trial design and reporting standards. These include adequate sample size estimation, a clear definition of the AFACS endpoints, and a protocol for AFACS detection.
Collapse
Affiliation(s)
- Niall G. Campbell
- Division of Cardiovascular Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Jakob Wollborn
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - Kara G. Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kurt Ruetzler
- Anesthesiology Institute, Departments of Outcomes Research and General Anesthesiology, Cleveland Clinic, Cleveland, USA,Outcomes Research Consortium, Cleveland, USA
| | - Jochen D. Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - Benjamin O’Brien
- Outcomes Research Consortium, Cleveland, USA,Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany,Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Germany,Department of Perioperative Medicine, St Bartholomew’s Hospital, London, U.K
| |
Collapse
|
21
|
Karamnov S, O'Brien B, Muehlschlegel JD. A Wolf in Sheep's Skin? Postoperative Atrial Fibrillation After Cardiac Surgery and the Risk of Stroke and Mortality. J Cardiothorac Vasc Anesth 2021; 35:3565-3567. [PMID: 34518104 DOI: 10.1053/j.jvca.2021.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Sergey Karamnov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Benjamin O'Brien
- Departments of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Centre Berlin and Charité Universitätsmedizin Berlin
| | - Jochen D Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
22
|
Heo SK, Kim KS, Lee JH, Song JG. Tachycardia-polyuria syndrome after swan-ganz catheterization in liver transplant patient - A case report. Anesth Pain Med (Seoul) 2021; 16:284-289. [PMID: 34233409 PMCID: PMC8342823 DOI: 10.17085/apm.21008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/26/2021] [Indexed: 11/17/2022] Open
Abstract
Background Tachycardia-polyuria syndrome is characterized by polyuria occurring because of tachycardia with a heart rate of ≥ 120 beats/min lasting ≥ 30 min. We report such a case occurring after swan-ganz catheterization. Case A 41-year-old male was scheduled for living-donor liver transplantation. After general anesthesia, atrial fibrillation occurred during swan-ganz catheterization, and polyuria developed 1 h later. During the anhepatic phase, the patient’s heart rate increased further, and cardioversion was performed. After a normal sinus rhythm was achieved, the patient’s urine output returned to normal. Conclusions The patient’s polyuria seemed related to the iatrogenic atrial fibrillation occurring during swan-ganz catheterization. Although we did not measure atrial natriuretic peptide, an increase in its concentration may have been the main mechanism of polyuria, as natriuresis was observed.
Collapse
Affiliation(s)
- Sang-Kwon Heo
- Department of Anesthesiology and Pain Medicine, Seoul Medical Center, Seoul, Korea
| | - Kyoung-Sun Kim
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul Medical Center, Seoul, Korea
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
23
|
Wang KKP, Liu W, Chew STH, Ti LK, Shen L. New-Onset Atrial Fibrillation After Cardiac Surgery is a Significant Risk Factor for Long-Term Stroke: An Eight-Year Prospective Cohort Study. J Cardiothorac Vasc Anesth 2021; 35:3559-3564. [PMID: 34330576 DOI: 10.1053/j.jvca.2021.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/19/2021] [Accepted: 07/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study sought to determine the incidence and significance of new-onset atrial fibrillation as a risk factor for long-term stroke and mortality after cardiac surgery. DESIGN A prospective cohort study. SETTING Two large tertiary public hospitals. PARTICIPANTS The study comprised 3008 patients who underwent coronary artery bypass grafting and/or valve surgery from 2008 to 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS New-onset atrial fibrillation was analyzed as a risk factor for postoperative stroke using a multivariate logistic regression model after adjustment for potential confounders. A Cox regression model with time-dependent variables was used to analyze relationships between new-onset atrial fibrillation and postoperative survival. New-onset atrial fibrillation was detected in 573 (19.0%) patients. Stroke occurred in 234 (7.8%) patients during the mean postoperative follow-up period of six ± two years. The incidence of postoperative stroke in patients with new-onset atrial fibrillation (9.9%) and patients with both preoperative and postoperative atrial fibrillation (13.8%) was higher than in patients with no atrial fibrillation (6.8%) (p = 0.002). New-onset atrial fibrillation (odds ratio, 1.53; 95% confidence interval [CI], 1.08-2.18; p = 0.017) was identified as an independent risk factor for postoperative stroke. A total of 518 (17.2%) mortalities occurred within the mean postoperative follow-up period of eight ± two years. New-onset atrial fibrillation was associated with shorter survival (hazard ratio, 1.49; 95% CI, 1.22-1.81; p < 0.001) compared with patients with no atrial fibrillation. CONCLUSIONS New-onset atrial fibrillation is a significant risk factor for long-term stroke and mortality after cardiac surgery. Close monitoring and treatment of this condition may be necessary to reduce the risk of postoperative stroke and mortality.
Collapse
Affiliation(s)
- Kevin K P Wang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Weiling Liu
- Department of Anesthesia, National University Health System, Singapore
| | - Sophia T H Chew
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore
| | - Lian Kah Ti
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Anesthesia, National University Health System, Singapore.
| | - Liang Shen
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| |
Collapse
|
24
|
Campbell NG, Allen E, Montgomery H, Aron J, Canter RR, Dodd M, Sanders J, Sturgess J, Elbourne D, O'Brien B. Maintenance of Serum Potassium Levels ≥3.6 mEq/L Versus ≥4.5 mEq/L After Isolated Elective Coronary Artery Bypass Grafting and the Incidence of New-Onset Atrial Fibrillation: Pilot and Feasibility Study Results. J Cardiothorac Vasc Anesth 2021; 36:847-854. [PMID: 34404592 DOI: 10.1053/j.jvca.2021.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/26/2021] [Accepted: 06/16/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Serum potassium levels frequently are maintained at high levels (≥4.5 mEq/L) to prevent atrial fibrillation after cardiac surgery (AFACS), with limited evidence. Before undertaking a noninferiority randomized controlled trial to investigate the noninferiority of maintaining levels ≥3.6 mEq/L compared with this strategy, the authors wanted to assess the feasibility, acceptability, and safety of recruiting for such a trial. DESIGN Pilot and feasibility study of full trial protocol. SETTING Two university tertiary-care hospitals. PARTICIPANTS A total of 160 individuals undergoing first-time elective isolated coronary artery bypass grafting. INTERVENTIONS Randomization (1:1) to protocols aiming to maintain serum potassium at either ≥3.6 mEq/L or ≥4.5 mEq/L after arrival in the postoperative care facility and for 120 hours or until discharge from the hospital or AFACS occurred, whichever happened first. MEASUREMENTS AND MAIN RESULTS Primary outcomes: (1) whether it was possible to recruit and randomize 160 patients for six months (estimated 20% of those eligible); (2) maintaining supplementation protocol violation rate ≤10% (defined as potassium supplementation being inappropriately administered or withheld according to treatment allocation after a serum potassium measurement); and (3) retaining 28-day follow-up rates ≥90% after surgery. Between August 2017 and April 2018, 723 patients were screened and 160 (22%) were recruited. Potassium protocol violation rate = 9.8%. Follow-up rate at 28 days = 94.3%. Data on planned outcomes for the full trial also were collected. CONCLUSIONS It is feasible to recruit and randomize patients to a study assessing the impact of maintaining serum potassium concentrations at either ≥3.6 mEq/L or ≥4.5 mEq/L on the incidence of AFACS.
Collapse
Affiliation(s)
- Niall G Campbell
- Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom; Wythenshawe Hospital, Manchester University Foundation NHS Trust, Manchester, United Kingdom.
| | - Elizabeth Allen
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Hugh Montgomery
- UCL Division of Medicine and Institute for Sport, Exercise, and Health, London, United Kingdom
| | - Jon Aron
- St. George's Hospital, London, United Kingdom
| | - Ruth R Canter
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Matthew Dodd
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Julie Sanders
- St. Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, United Kingdom
| | - Joanna Sturgess
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Diana Elbourne
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ben O'Brien
- St. Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, United Kingdom; German Heart Center, Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany; Outcomes Research Consortium, Cleveland, OH
| |
Collapse
|
25
|
Fegley MW, Cardi A, Augoustides JG, Horak J, Gutsche JT, Nanda S, Kornfield ZN, Saluja A, Sanders J, Marchant BE, Fernando RJ. Acute Lung Injury Associated With Perioperative Amiodarone Therapy-Navigating the Challenges in Diagnosis and Management. J Cardiothorac Vasc Anesth 2021; 36:608-615. [PMID: 34172364 DOI: 10.1053/j.jvca.2021.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Mark W Fegley
- Critical Care Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alessandra Cardi
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Jiri Horak
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sudip Nanda
- Clinical Electrophysiology, Cardiology Associates, St. Luke's University Health Network, Bethlehem, PA
| | - Zev N Kornfield
- Critical Care Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Abhishek Saluja
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, School of Medicine, Wayne State University, Henry Ford Health System, Detroit, MI
| | - Joseph Sanders
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, School of Medicine, Wayne State University, Henry Ford Health System, Detroit, MI
| | - Bryan E Marchant
- Division of Cardiothoracic Anesthesia and Critical Care, Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| | - Rohesh J Fernando
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| |
Collapse
|
26
|
Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
27
|
Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
Collapse
Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| |
Collapse
|
28
|
Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
|
29
|
Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5370] [Impact Index Per Article: 1790.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
30
|
Boons J, Van Biesen S, Fivez T, de Velde MV, Al Tmimi L. Mechanisms, Prevention, and Treatment of Atrial Fibrillation After Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 35:3394-3403. [PMID: 33308918 DOI: 10.1053/j.jvca.2020.11.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/20/2020] [Accepted: 11/15/2020] [Indexed: 11/11/2022]
Abstract
New onset of postoperative atrial fibrillation (AF) generally is recognized as a frequent and debilitating complication after cardiac surgery, contributing to a considerable health- care cost. Extensive research has been conducted to study the underlying mechanisms and risk factors of AF in the perioperative period. Many options have been suggested to lower the incidence, and the concurrent cost in health resources. This review attempts to synthesize the large body of existing literature on AF, as well as expand and illustrate the available knowledge on its management strategies. The latter incorporates recent developments in the anesthesthetic approach as well as in the pharmacologic arsenal. In addition, the current review provides a tool for understanding the pathophysiology of AF and for reducing the occurrence after cardiac surgery. By using it, clinicians can manage patients with AF in the perioperative period of cardiac surgery and minimize the relatively high economic cost that accompanies it.
Collapse
Affiliation(s)
- Jeroen Boons
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium; Department of Intensive Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium.
| | - Stefaan Van Biesen
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium; Department of Intensive Care Medicine, OLVG-Hospital, Amsterdam, The Netherlands
| | - Tom Fivez
- Department of Intensive Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Marc Van de Velde
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, University of Leuven, Leuven, Belgium
| | - Layth Al Tmimi
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
31
|
Bruggmann C, Astaneh M, Lu H, Tozzi P, Ltaief Z, Voirol P, Sadeghipour F. Management of Atrial Fibrillation Following Cardiac Surgery: Observational Study and Development of a Standardized Protocol. Ann Pharmacother 2020; 55:830-838. [PMID: 33185128 DOI: 10.1177/1060028020973998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is the most common complication occurring after cardiac surgery. Guidelines for the management of this complication are scarce, often resulting in differences in treatment strategy use among patients. OBJECTIVE To evaluate the management of POAF in a cardiac surgery department, characterize the extent of its variability, and develop a standardized protocol. METHODS This was an observational retrospective study with data from patients who underwent cardiac surgeries with subsequent POAF between January 1, 2017, and June 1, 2018. We assessed the difference in the proportions of patients whose first POAF episodes were treated with a rate control (RaC) strategy, a rhythm control (RhC) strategy, and both among different hospital units. We also assessed the mean duration of POAF episodes, POAF recurrences, and the management of anticoagulation. RESULTS Data from 97 patients were included in this study. The POAF management strategy differed significantly among the 3 types of hospital units (P = 0.001). Considering all POAF episodes (including all recurrences), 83 of the 97 patients (85.6%) received amiodarone as part of the RhC strategy. Anticoagulation was used in 58 (59.8%) patients and was suboptimal according to the study criteria in 29.5% of the patients included. Based on these results, a hospital working group developed a standardized protocol for POAF management. CONCLUSIONS AND RELEVANCE POAF management was heterogeneous at our institution. This article highlights the need for clear practice guidelines based on large prospective studies to provide care according to best practices.
Collapse
Affiliation(s)
- Christel Bruggmann
- Pharmacy Department, University Hospital of Lausanne and University of Lausanne, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Switzerland
| | - Mahdieh Astaneh
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Switzerland
| | - Henri Lu
- Cardiology department, University Hospital of Lausanne and University of Lausanne, Switzerland
| | - Piergiorgio Tozzi
- Cardiac surgery department, University Hospital of Lausanne and University of Lausanne, Switzerland
| | - Zied Ltaief
- Intensive Care Unit, University Hospital of Lausanne and University of Lausanne, Switzerland
| | - Pierre Voirol
- Pharmacy Department, University Hospital of Lausanne and University of Lausanne, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Switzerland
| | - Farshid Sadeghipour
- Pharmacy Department, University Hospital of Lausanne and University of Lausanne, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Switzerland
| |
Collapse
|
32
|
Affiliation(s)
- Niall G Campbell
- Consultant in EP Cardiology, Wythenshawe Hospital, Manchester, United Kingdom
| | - Benjamin O'Brien
- Professor of Perioperative Medicine, Barts Heart Centre and William Harvey Research Institute, London, United Kingdom.
| |
Collapse
|
33
|
Buerge M, Magboo R, Wills D, Karpouzis I, Balmforth D, Cooper P, Roberts N, O'Brien B. Doing Simple Things Well: Practice Advisory Implementation Reduces Atrial Fibrillation After Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:2913-2920. [DOI: 10.1053/j.jvca.2020.06.078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/26/2020] [Indexed: 01/22/2023]
|
34
|
Gutsche JT, Grant MC, Kiefer JJ, Ghadimi K, Lane-Fall MB, Mazzeffi MA. The Year in Cardiothoracic Critical Care: Selected Highlights from 2019. J Cardiothorac Vasc Anesth 2020; 36:45-57. [PMID: 33051148 DOI: 10.1053/j.jvca.2020.09.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 11/11/2022]
Abstract
In 2019, cardiothoracic and vascular critical care remained an important focus and subspecialty. This article continues the annual series to review relevant contributions in postoperative critical care that may affect the cardiac anesthesiologist. Herein, the pertinent literature published in 2019 is explored and organized by organ system.
Collapse
Affiliation(s)
- J T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - M C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J J Kiefer
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - K Ghadimi
- Department of Anesthesiology and Critical Care, Duke University, Durham, NC
| | - M B Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - M A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
35
|
O'Brien B, Watkinson P. The Challenge of Untangling the Interdependencies Between Complications After Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:1791-1793. [PMID: 32217046 DOI: 10.1053/j.jvca.2020.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 02/20/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Benjamin O'Brien
- Barts Heart Centre and William Harvey Research Institute, London, United Kingdom; Outcomes Research Consortium, Cleveland Clinic, OH, USA.
| | - Peter Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
36
|
Augoustides JG. Engaged in Excellence - Travelling Onwards and Upwards with Expanding Horizons. J Cardiothorac Vasc Anesth 2020; 33:1487-1488. [PMID: 31088628 DOI: 10.1053/j.jvca.2019.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- John G Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
37
|
O'Brien B, Lip GYH. Generating Hypotheses Is Great, but at Some Point We Just Need to Do the Trials and Get the Answers. J Cardiothorac Vasc Anesth 2020; 34:1162-1164. [PMID: 32127271 DOI: 10.1053/j.jvca.2019.12.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 12/27/2019] [Indexed: 01/01/2023]
Affiliation(s)
- Benjamin O'Brien
- Barts Heart Centre and William Harvey Research Institute, London, United Kingdom; Outcomes Research Consortium, Cleveland Clinic, OH, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
38
|
Gudbjartsson T, Helgadottir S, Sigurdsson MI, Taha A, Jeppsson A, Christensen TD, Riber LPS. New-onset postoperative atrial fibrillation after heart surgery. Acta Anaesthesiol Scand 2020; 64:145-155. [PMID: 31724159 DOI: 10.1111/aas.13507] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/02/2019] [Accepted: 11/10/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND New-onset postoperative atrial fibrillation (poAF) complicates approximately 20-60% of all cardiac surgical procedures and is associated with an increased periprocedural mortality and morbitity, prolonged hospital stay, increased costs, and worse long-term survival. Unfortunately multiple advances in surgery and perioperative care over the last two decades have not led to a reduction in the incidence of poAF or associated complications in the daily clinical practice. METHODS A narrative review of the available literature was performed. RESULTS An extensive review of the pathophysiology of poAF following cardiac surgery, clinical, and procedural risk-factors is provided, as well as prophylactic measures and treatment. CONCLUSION Multiple strategies to prevent and manage poAF following heart surgery already exist. Our hope is that this review will facilitate more rigorous testing of prevention strategies, implementation of prophylaxis regimens as well as optimal treatment of this common and serious complication.
Collapse
Affiliation(s)
- Tomas Gudbjartsson
- Department of Cardiothoracic Surgery Landspitali University Hospital Reykjavik Iceland
- Faculty of Medicine University of Iceland Reykjavik Iceland
| | - Solveig Helgadottir
- Department of Cardiothoracic Surgery and Anaesthesia Uppsala University Hospital Uppsala Sweden
| | - Martin Ingi Sigurdsson
- Faculty of Medicine University of Iceland Reykjavik Iceland
- Department of Anaesthesia and Critical Care Landspitali University Hospital Reykjavik Iceland
| | - Amar Taha
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Department of Cardiothoracic Surgery Sahlgrenska University Hospital Gothenburg Sweden
| | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery Department of Clinical Medicine Aarhus University Hospital Aarhus Denmark
| | - Lars Peter Schoedt Riber
- Department of Cardiothoracic and Vascular Surgery, Department of Clinical Medicine Odense University Hospital, University of Southern Denmark Odense Denmark
| |
Collapse
|
39
|
O'Brien B, Muehlschlegel JD. A Penny Saved Should Be a Penny Earned. J Cardiothorac Vasc Anesth 2020; 34:898-899. [PMID: 31954617 DOI: 10.1053/j.jvca.2019.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/16/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Benjamin O'Brien
- Perioperative Medicine, Barts Heart Centre and William Harvey Research Institute, London, United Kingdom; Outcomes Research Consortium, Cleveland Clinic, OH, USA
| | - J Daniel Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| |
Collapse
|
40
|
Koh LY, Hwang NC. Serum Electrolyte Concentrations and Their Association With Postoperative Atrial Fibrillation: A Long-Standing Myth or Reality? J Cardiothorac Vasc Anesth 2020; 34:1160-1161. [PMID: 31901469 DOI: 10.1053/j.jvca.2019.11.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 11/29/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Li Ying Koh
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore.
| |
Collapse
|
41
|
Davis JD, Kovar AJ. The Cardiovascular Effects of Subclinical Thyroid Dysfunction. J Cardiothorac Vasc Anesth 2020; 34:35-38. [DOI: 10.1053/j.jvca.2019.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 08/13/2019] [Indexed: 01/07/2023]
|
42
|
Walter E, Heringlake M. Cost-Effectiveness Analysis of Landiolol, an Ultrashort-Acting Beta-Blocker, for Prevention of Postoperative Atrial Fibrillation for the Germany Health Care System. J Cardiothorac Vasc Anesth 2019; 34:888-897. [PMID: 31837963 DOI: 10.1053/j.jvca.2019.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/28/2019] [Accepted: 11/04/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Landiolol is an ultrashort-acting beta-blocker with high beta-1 receptor affinity and less blood pressure-lowering properties than other beta-blockers available for intravenous use in Germany. The present analysis aimed to determine whether perioperative treatment with landiolol in cardiac surgical patients is cost-effective under the conditions of the German Diagnosis-Related Groups health cost reimbursement system. DESIGN On the basis of clinical outcome data from a meta-analysis that included 622 patients from 7 randomized controlled trials, a decision-model was developed to determine the cost-effectiveness of landiolol versus standard-of-care (SoC). SETTING Hospital setting. PARTICIPANTS Hospital patients undergoing a representative mix of cardiac surgical procedures (MIX-CS) and isolated coronary artery bypass grafting (CABG). INTERVENTIONS Landiolol versus SoC in prevention of atrial fibrillation immediately after cardiac surgery. MEASUREMENTS AND MAIN RESULTS The model benefit was expressed in a reduction of postoperative atrial fibrillation (POAF) episodes and reduced complications. The model calculated total inpatient costs over the hospital length of stay. Costs from published sources were used for the German hospital perspective. SoC was associated with POAF rates of 36.0% to 39.2% and 24.4% to 30.1% in the MIX-CS and CABG populations, respectively. Patients with POAF had a higher morbidity and mortality. Estimated total costs for SoC patients in the MIX-CS and CABG groups were 28.792 € and 25.630 €, respectively. Landiolol reduced the incidence of POAF to 12.6% in the MIX-CS and 12.1% in the CABG groups. This was associated with a cost reduction of 2.209 € and 1.470 €. CONCLUSIONS This analysis suggests that preventing POAF with landiolol is highly cost-effective. Additional studies are needed to assess whether a comparable reduction in POAF and associated cost savings may be achieved using conventional intravenous beta-blockers or amiodarone.
Collapse
Affiliation(s)
- Evelyn Walter
- IPF Institute for Pharmaeconomic Research, Vienna, Austria.
| | - Matthias Heringlake
- Department of Anesthesiology and Intensive Care Medicine, University of Lübeck, Lübeck, Germany
| |
Collapse
|
43
|
Howitt SH, Grant SW, Campbell NG, Malagon I, McCollum C. Are Serum Potassium and Magnesium Levels Associated with Atrial Fibrillation After Cardiac Surgery? J Cardiothorac Vasc Anesth 2019; 34:1152-1159. [PMID: 31948890 DOI: 10.1053/j.jvca.2019.10.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/22/2019] [Accepted: 10/26/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Potassium and magnesium are frequently administered after cardiac surgery to reduce the risk of atrial fibrillation (AF). The evidence for this practice is unclear. This study was designed to evaluate the relationship between serum potassium and magnesium levels and AF after cardiac surgery. DESIGN Observational cohort study. SETTING A cardiac intensive care unit in the United Kingdom. PARTICIPANTS Patients undergoing cardiac surgery between January 2013 and November 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cardiac rhythm was assessed using continuous electrocardiogram (ECG) monitoring in 3,068 patients on the cardiac intensive care unit. Associations between serum potassium and magnesium concentrations extracted from hospital databases and postoperative AF were assessed using univariable and multivariable analyses. The association between electrolyte supplementation therapy and AF was also analyzed. AF developed within 72 hours of cardiac surgery in 545 (17.8%) of the 3,068 patients. After adjusting for logistic EuroSCORE, surgery type, cardiopulmonary bypass time and age, mean serum potassium concentration <4.5 mmol/L was associated with an increased risk of AF (odds ratio [OR] 1.43 (95% confidence interval (CI): 1.17-1.75), p < 0.001). Mean magnesium concentration <1.0 mmol/L was not associated with an increased risk of AF (OR 0.89, 0.71-1.13, p = 0.342), but the administration of magnesium was associated with increased risk of developing AF (OR 1.61, 1.33-1.96, p < 0.001). CONCLUSIONS Maintaining a serum potassium concentration ≥4.5 mmol/L after cardiac surgery may reduce the incidence of postoperative AF. Magnesium supplementation was associated with an increased risk of postoperative AF. Prospective randomized trials are required to clarify these associations.
Collapse
Affiliation(s)
- Samuel H Howitt
- Division of Cardiovascular Sciences, University of Manchester, ERC, Manchester University Hospitals Foundation Trust, Manchester, United Kingdom; Department of Cardiothoracic Anesthesia and Critical Care, Wythenshawe Hospital, Manchester University Hospitals Foundation Trust, Manchester, United Kingdom.
| | - Stuart W Grant
- Division of Cardiovascular Sciences, University of Manchester, ERC, Manchester University Hospitals Foundation Trust, Manchester, United Kingdom
| | - Niall G Campbell
- Division of Cardiovascular Sciences, University of Manchester, ERC, Manchester University Hospitals Foundation Trust, Manchester, United Kingdom
| | - Ignacio Malagon
- Division of Cardiovascular Sciences, University of Manchester, ERC, Manchester University Hospitals Foundation Trust, Manchester, United Kingdom; Department of Cardiothoracic Anesthesia and Critical Care, Wythenshawe Hospital, Manchester University Hospitals Foundation Trust, Manchester, United Kingdom
| | - Charles McCollum
- Division of Cardiovascular Sciences, University of Manchester, ERC, Manchester University Hospitals Foundation Trust, Manchester, United Kingdom
| |
Collapse
|
44
|
Khan MS, Yamashita K, Sharma V, Ranjan R, Selzman CH, Dosdall DJ. Perioperative Biomarkers Predicting Postoperative Atrial Fibrillation Risk After Coronary Artery Bypass Grafting: A Narrative Review. J Cardiothorac Vasc Anesth 2019; 34:1933-1941. [PMID: 31653497 DOI: 10.1053/j.jvca.2019.09.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 09/06/2019] [Accepted: 09/12/2019] [Indexed: 12/11/2022]
Abstract
Postoperative atrial fibrillation (POAF) after cardiac surgery remains a highly prevalent and costly condition that negatively impacts patient quality of life and survival. Numerous retrospective studies, meta-analysis, and review papers have been reported identifying POAF risk based on patients' risk factors and clinical biomarkers. In this narrative review, the authors report significant variations among selected pre- and perioperative biomarkers used to predict POAF incidence in patients without a history of atrial fibrillation (AF). POAF prediction based on B-type natriuretic peptide, N-terminal pro B-type natriuretic peptide, C-reactive protein, interleukin-6, creatinine, and plasminogen activator inhibitor-1 differs significantly among different studies, thereby limiting their clinical utility to predict POAF risk with high accuracy. Conversely, soluble vascular endothelial cells adhesion molecule-1, soluble CD40 ligand, Galectin-3, and aldosterone show promise for better POAF prediction. However, the current datasets for these selected biomarkers are not of sufficient size to validate the broad clinical application specifically for patients with no prior history of AF.
Collapse
Affiliation(s)
- Muhammad S Khan
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT
| | - Kennosuke Yamashita
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT; Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT
| | - Vikas Sharma
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT
| | - Ravi Ranjan
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT; Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT; Department of Bioengineering, University of Utah, Salt Lake City, UT
| | - Craig H Selzman
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT; Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT
| | - Derek J Dosdall
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT; Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT; Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT; Department of Bioengineering, University of Utah, Salt Lake City, UT.
| |
Collapse
|
45
|
Hui DS, Lee R. Treatment of postoperative atrial fibrillation: The long road ahead. J Thorac Cardiovasc Surg 2019; 159:1840-1843. [PMID: 31358335 DOI: 10.1016/j.jtcvs.2019.05.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/14/2019] [Accepted: 05/16/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Richard Lee
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Georgia, Augusta University, Augusta, Ga.
| |
Collapse
|
46
|
Abstract
Cardiac arrhythmias are common after cardiac surgery and have profound sequelae. Bradycardias are typically transient and have reversible causes; however, persistent atrioventricular block is an indicator for permanent pacemaker implantation after valvular surgery. Transcatheter aortic valve surgery is associated with even higher rates of permanent pacemaker implantation. Atrial fibrillation, the most common postoperative arrhythmia, is associated with ischemic stroke, myocardial infarction, congestive heart failure, and short-term mortality. Ventricular arrhythmias have extremely high in-hospital mortality, as well as long-term mortality for those who survive the initial event. Implantable cardioverter-defibrillators have been shown to reduce long-term mortality for these patients.
Collapse
|
47
|
Abstract
Purpose of Review An overview of recent literature regarding pathophysiology, risk factors, prophylaxis, and treatment of new-onset atrial fibrillation (AF) in post-cardiac surgical patients. Recent Findings AF is the most frequent adverse event after cardiac surgery with significant associated morbidity, mortality, and financial cost. Its causes are multifactorial, and models to stratify patients into risk categories are progressing but a consistent, evidence-based system has not yet been developed. Pharmacologic and surgical interventions to prevent and treat this complication have been an area of ongoing research and recent societal guidelines reflect this. Summary Inconsistencies remain surrounding how to best identify higher-risk AF patients, which interventions should be used to prevent and treat AF, and which patient groups should receive these interventions. The evidence for these available strategies and their place in contemporary guidelines are summarized.
Collapse
|
48
|
Kaplan JA. REMOVED: Plus Les Choses Changent Plus Elles Restent Les Mêmes. J Cardiothorac Vasc Anesth 2019; 33:1. [DOI: 10.1053/j.jvca.2018.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
49
|
Rasmussen BS. Atrial Fibrillation After Cardiac Surgery: Bringing Back the Focus on Patient Outcome. J Cardiothorac Vasc Anesth 2018; 33:27-28. [PMID: 30591179 DOI: 10.1053/j.jvca.2018.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Bodil Steen Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| |
Collapse
|