Prophylaxis of Atrial Fibrillation After Noncardiac Thoracic Surgery

Surgical Issues for Operable Early-Stage Non-Small-Cell Lung Cancer

Surgical care for early stage non-small-cell lung cancer continuously evolves with new procedures, techniques and care pathways. The most obvious recent change was the transition to minimally invasive procedures, but numerous other aspects of care have also been refined to improve safety and tolerability. These care advancements are essential as we move into an era with increased early detection as a result of screening and greater indications for the use of adjuvant and neoadjuvant strategies.

Impact of Minimally Invasive Esophagectomy in Post-Operative Atrial Fibrillation and Long-Term Mortality in Patients Among Esophageal Cancer

Aims:

Postoperative Atrial fibrillation (POAF) after esophagectomy may prolong stay in intensive care and increase risk of perioperative complications. A minimally invasive approach is becoming the preferred option for esophagectomy, yet its implications for POAF risk remains unclear. The association between POAF and minimally invasive esophagectomy (MIE) was examined in this study.

Methods:

We used a dataset of 575 patients who underwent esophagectomy. Multivariate logistic regression analysis was performed to examine the association between MIE and POAF. A cox proportional hazards model was applied to assess the long-term mortality (MIE vs open esophagectomy, OE).

Results:

Of the 575 patients with esophageal cancer, 62 developed POAF. MIE was negatively associated with the occurrence of POAF (Odds ratio: 0.163, 95%CI: 0.033-0.801). No significant difference was observed in long-term mortality (Odds ratio: 2.144, 95%CI: 0.963-4.775).

Conclusions:

MIE may reduced the incidence of POAF without compromising the survival of patients with esophageal cancer. Moreover, the specific mechanism of MIE providing this possible advantage needs to be determined by larger prospective cohort studies with specific biomarker information from laboratory tests.

[Effect of ultrasound-guided right stellate ganglion block on perioperative atrial fibrillation in patients undergoing lung lobectomy: a randomized controlled trial]

OBJECTIVE

To observe the effects of preoperative right stellate ganglion block on perioperative atrial fibrillation in patients undergoing lung lobectomy.

METHODS

Two hundred patients who underwent a scheduled lobectomy were randomly divided into the S and C groups. The S group was injected with 4mL of 0.2% ropivacaine under ultrasound guidance, and the C group did not receive stellate ganglion block. The patients underwent continuous ECG monitoring, and the incidences of atrial fibrillation and other types of arrhythmias were recorded from the start of surgery to 24hours after surgery.

RESULTS

The respective incidences of atrial fibrillation in the S group and the C group were 3% and 10% (p=0.045); other atrial arrhythmias were 20% and 38% (p=0.005); and ventricular arrhythmia were 28% and 39% (p=0.09).

CONCLUSIONS

The results of the study indicated that preoperative right stellate ganglion block can effectively reduce the incidence of intraoperative and postoperative atrial fibrillation.

Incidence, Management, Prevention and Outcome of Post-Operative Atrial Fibrillation in Thoracic Surgical Oncology

Atrial fibrillation (AF) is a common supraventricular arrhythmia, a recognized risk factor for ischemic stroke, as a potential driver for heart failure (HF). Cancer patients have an increased risk for AF, even not including any cancer-specific treatment, as surgery or chemotherapy. The mechanism is multifactorial, with inflammation and changes in autonomic tone as critical actors. Commonly, AF is a recurrent complication of the post-operative period in cancer surgery (especially thoracic). Recent papers confirmed a significant incidence of post-operative (non-cardiac surgery) AF (PAF), partially mitigated by the use of prophylactic (rate o rhythm control) treatments. A relevant difference, in terms of mean hospitalization time, emerges between patients developing PAF and those who do not, while long term impact remains a matter of debate, due to several potential confounding factors. Besides clinical predictors, structural (i.e., echocardiographic) and bio-humoral findings may help in risk prediction tasks. In this respect, pre-operative natriuretic peptides (NPs) concentrations are nowadays recognized as significant independent predictors of perioperative cardiovascular complications (including PAF), while elevated post-operative levels may further enhance risk stratification. The aim of the present paper is to trace the state of the art in terms of incidence, management, prevention, and outcome of PAF in the field of thoracic surgical oncology.

Non-Transfemoral Transcatheter Aortic Valve Replacement Approach is Associated with a Higher Risk of New-Onset Atrial Fibrillation: A Systematic Review and Meta-Analysis

BACKGROUND

New-onset atrial fibrillation (NOAF) is a frequent arrhythmic complication following transcatheter aortic valve replacement (TAVR). Choice of access routes for TAVR could be a factor that determines the risk of NOAF although the data is still not well-characterised. We aimed to assess the association between different access routes for TAVR (transfemoral versus non-transfemoral) and the risk of NOAF.

METHODS

A comprehensive literature review was performed through September 2018 using EMBASE and Medline. Eligible studies must compare the incidence of NOAF in patients without pre-existing atrial fibrillation who underwent TAVR. Relative risk (RR) and 95% confidence intervals (CI) were extracted from each study and combined together using the random-effects model, generic inverse variance method of DerSimonian and Laird.

RESULTS

Seven (7) retrospective studies with 18,425 patients who underwent TAVR (12,744 with the transfemoral approach and 5,681 with the non-transfemoral approach) met the eligibility criteria. After the procedures, 2,205 (12.0%) patients developed NOAF (656 [5.1%] patients in the transfemoral group and 1,549 [27.3%] patients in the non-transfemoral group). There was a significant association between the non-transfemoral approach and an increased risk of NOAF with the pooled RR of 2.94 (95%CI, 2.53-3.41; p < 0.00001). Subgroup analysis showed the highest risk of NOAF in the transapical subgroup with the pooled RR of 3.20 (95% CI, 2.69-3.80; I² 33%).

CONCLUSIONS

A significantly increased risk of NOAF following TAVR among those who underwent a non-transfemoral approach compared with transfemoral approach was observed in this meta-analysis.

Amiodarone for prevention of atrial fibrillation following esophagectomy

OBJECTIVES

Atrial fibrillation (AF) is a common complication after esophagectomy and is associated with symptoms, hemodynamic instability, prolonged hospital stay, and an increased incidence of mortality. Our objective was to determine the efficacy and safety of intravenous amiodarone for prophylaxis of postesophagectomy AF.

METHODS

In this retrospective cohort study, 309 patients who underwent esophagectomy formed the initial cohort. Following propensity score-matching, 110 patients who received prophylactic amiodarone 43.75 mg/hour via continuous intravenous infusion over 96 hours (total dose, 4200 mg) were matched to a control group of patients who did not undergo amiodarone prophylaxis (n = 110). The propensity score was obtained using a multivariate logistic regression model with amiodarone as the variable and the following covariates: age, sex, surgical approach, history of neoadjuvant chemotherapy and/or radiation, chronic obstructive pulmonary disease, heart failure, cardiovascular disease, alcohol use (>7 drinks/week), preadmission β-blockers discontinued during hospitalization, preoperative use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, preoperative use of corticosteroids, postoperative use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, postoperative use of corticosteroids, postoperative use of statins, and preoperative Charlson comorbidity index.

RESULTS

The incidence of AF requiring treatment due to rapid ventricular rate and symptoms was lower in the amiodarone group (17 out of 110 [15.5%] vs 32 out of 110 [29.1%]; odds ratio, 0.45; 95% confidence interval, 0.23-0.86; P = .015). There were no significant differences between the groups in median postoperative length of hospital stay, incidence of pulmonary complications, or mortality. The incidences of hypotension requiring treatment (42.7% vs 21.8%; P = .001), bradycardia (8.2% vs 0.0%; P = .002), and corrected QT interval prolongation (10.9% vs 0.0%; P ≤ .0001) were significantly higher in the amiodarone group.

CONCLUSIONS

Prophylactic intravenous amiodarone is associated with a reduction in the incidence of AF following esophagectomy, but is not associated with shorter postoperative length of hospital stay. Intravenous amiodarone for prophylaxis of postesophagectomy AF is associated with hypotension, bradycardia, and corrected QT interval prolongation.

Prophylaxis Against Atrial Fibrillation After General Thoracic Surgery: Trial Sequential Analysis and Network Meta-Analysis

BACKGROUND

Postoperative atrial fibrillation/flutter (POAF) is associated with significant morbidity and mortality after general thoracic surgery, but the need for and the best agent for prophylaxis remains obscure.

METHODS

A systematic literature search was performed to identify randomized controlled trials that compared regimens for POAF prophylaxis after general thoracic surgery. Random-effects meta-analyses with trial sequential analyses were performed to compare the effects of medical prophylaxis vs placebo/usual care. The risk of POAF among patients receiving various prophylactic regimens was subjected to Bayesian network meta-analysis.

RESULTS

Twenty-two trials (2,891 patients and 11 regimens) were included. Overall, medical prophylaxis reduced the incidence of POAF (OR, 0.33; 95% CI, 0.22-0.49) but not short-term mortality (OR, 0.85; 95% CI, 0.41-1.73). There was no significant difference in patient withdrawal due to adverse events (OR, 1.67; 95% CI, 0.67-4.16). Trial sequential analysis showed that as of 2012, sufficient evidence had accrued in support of the effectiveness of medical prophylaxis in reducing POAF after general thoracic surgery. In network meta-analysis, β-blockers, angiotensin-converting enzyme inhibitors, amiodarone, magnesium, and calcium channel blockers significantly reduced the risk of POAF compared with placebo/usual care. β-Blockers had the highest probability of being the most effective agents (OR, 0.12; 95% credible interval [CrI], 0.05-0.27; probability of being best, 77.7%; number needed to treat, 5.2).

CONCLUSIONS

The current literature supports the effectiveness and tolerability of medical prophylaxis and the superiority of β-blockers in preventing POAF after general thoracic surgery. β-Blockers are recommended, taking into consideration the status of the bronchopulmonary system.

Postoperative atrial fibrillation in liver transplantation

Postoperative atrial fibrillation (POAF) is common after major surgeries and is associated with increased morbidity and mortality. POAF after liver transplantation (LT) has not been reported. This study was undertaken to investigate the incidence, impact, and risk factors of POAF in LT patients. After IRB approval, LT between January 2006 and August 2013 at our center were retrospectively reviewed. POAF that occurred within 30 days after LT was included. Patients with and without POAF were compared and independent risk factors were identified by logistic regression. Of 1387 adults LT patients, 102 (7.4%) developed POAF during the study period. POAF was associated with significantly increased mortality, graft failure, acute kidney injury and prolonged hospital stay. Independent risk factors included age, body weight, MELD score, presence of previous history of AF, the vasopressors use prior to LT and pulmonary artery diastolic pressure at the end of LT surgery (odds ratios 2.0-7.2, all p < 0.05). A risk index of POAF was developed and patients with the high-risk index had more than 60% chance of developing POAF. These findings may be used to stratify patients and to guide prophylaxis for POAF in the posttransplant period.

Incidence, severity and perioperative risk factors for atrial fibrillation following pulmonary resection

OBJECTIVES

Postoperative atrial fibrillation (PAF) occurs commonly following pulmonary resection. Our aims were to quantify the incidence and severity of PAF using the Thoracic Morbidity & Mortality classification system, and identify risk factors for PAF.

METHODS

All consecutive patients undergoing pulmonary resection at a single centre (January 2008 - April 2010) were enrolled. PAF was defined as postoperative, electrocardiographically documented and requiring initiation of pharmacological therapy. Univariate and multivariate analyses of risk factors associated with the development of PAF were conducted.

RESULTS

The incidence of PAF was 11.8% (n = 43) of 363 pulmonary resections (open: n = 173; 47.7%; video-assisted: n = 177; 48.8%; converted: n = 13; 3.6%): sublobar (n = 93; 25.6%), lobectomy (n = 237; 65.3%), bilobectomy (n = 7; 1.9%) and pneumonectomy (n = 24; 6.6%). Twenty-eight cases (65.1%) were uncomplicated/transient, and 15 cases (34.9%) were complicated/persistent PAF, defined as lasting for >7 days (40.0%), requiring cardioversion (13.3%), vasopressors (33.3%), in-hospital use of anticoagulants (46.7%) and/or anticoagulants on discharge (26.7%). Patients with PAF had increased mean lengths of hospital stay (10.5 days vs 6.9 days; P = 0.04). Peak onset of PAF occurred 2.5 (standard deviation (SD) ± 1.3) days after pulmonary resection, lasting for 1.8 ± 2.8 (mean, ±SD) days. Multivariate analysis identified (relative risk; 95% confidence interval): age ≥70 years (2.3; 1.1-5.1), history of angioplasty/stents/angina (4.0; 1.4-11.3), thoracotomy (3.6; 1.4-9.3), conversion to open thoracotomy (16.5; 2.2-124.0) and extent of surgery/stage (7.1; 1.0-49.4) as predictors of PAF.

CONCLUSIONS

While the majority of PAF is uncomplicated and transient, one-third of cases lead to persistence or major intervention. Age, coronary artery disease and extent of surgery/stage increase the risk of PAF following pulmonary resection. Identifying patients with elevated risk may lead to targeted prophylaxis to reduce the incidence of PAF.

A review of enhanced recovery for thoracic anaesthesia and surgery

During the past decade, there has been a dramatic increase in the number of thoracic surgical procedures carried out in the UK. The current financial climate dictates that more efficient use of resources is necessary to meet escalating demands on healthcare. One potential means to achieve this is through the introduction of enhanced recovery protocols, designed to produce productivity savings by driving reduction in length of stay. These have been promoted by government bodies in a number of surgical specialties, including colorectal, gynaecological and orthopaedic surgery. This review focuses on aspects of peri-operative care that might be incorporated into such a programme for thoracic anaesthesia, for which an enhanced recovery programme has not yet been introduced in the UK, and a review of the literature specific to this area of practice has not been published before. We performed a comprehensive search for published work relating to the peri-operative management and optimisation of patients undergoing thoracic surgery, and divided these into appropriate areas of practice. We have reviewed the specific interventions that may be included in an enhanced recovery programme, including: pre-optimisation; minimising fasting time; thrombo-embolic prophylaxis; choice of anaesthetic and analgesic technique and surgical approach; postoperative rehabilitation; and chest drain management. Using the currently available evidence, the design and implementation of an enhanced recovery programme based on this review in selected patients as a package of care may reduce morbidity and length of hospital stay, thus maximising utilisation of available resources.