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Kim JA, Najam US, Ternes CMP, Marashly Q, Chelu MG. Clinical Outcomes of Early Rhythm or Rate Control for New Onset Atrial Fibrillation Following Transcatheter Aortic Valve Replacement. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07577-x. [PMID: 38869743 DOI: 10.1007/s10557-024-07577-x] [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] [Accepted: 05/08/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND New onset atrial fibrillation (NOAF) is a common occurrence after transcatheter aortic valve replacement (TAVR) and portends a poorer prognosis. The optimal strategy for managing NOAF in this population is uncertain. METHODS This retrospective cohort study utilized deidentified patient data from the TriNetX Research Network. Patients with TAVR and NOAF were stratified into a rhythm control cohort if they were treated with antiarrhythmics, received AF ablation, or underwent cardioversion within 1 year of AF diagnosis. A rate control cohort was similarly defined by the absence of rhythm control strategies and treatment with a beta blocker, calcium channel blocker, or digoxin. After 1:1 propensity score matching, the Kaplan-Meier survival analysis and Cox proportional hazard ratios (HRs) were used to compare outcomes at 7 years of follow-up. RESULTS We identified 569 patients in each cohort following propensity matching. At 7 years, the primary composite outcome of all-cause death, myocardial infarction, cerebrovascular accident, and heart failure hospitalization was not significantly different between the rhythm and rate control cohorts (HR 0.99, 95% CI 0.83-1.18). The individual components of the primary outcome in addition to all-cause hospitalization were also similar between the groups. CONCLUSIONS Similar outcomes were seen among patients receiving an early rhythm or rate control strategy to manage NOAF after TAVR. The attenuated benefits of an early rhythm control strategy observed in this setting may be due to the overall high burden of comorbidities and advanced age of these patients.
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Affiliation(s)
- Jitae A Kim
- Division of Cardiovascular Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 875 Ellicott Street Suite 7030, Buffalo, NY, 14203, USA.
| | - Usman S Najam
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Caique M P Ternes
- Postgraduate Program in Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Qussay Marashly
- Department of Cardiology, Montefiore Medical Center, New York, NY, USA
| | - Mihail G Chelu
- Department of Internal Medicine, Division of Cardiology, Baylor College of Medicine, Houston, TX, USA
- Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX, USA
- Texas Heart Institute at Baylor St. Luke's Medical Center, Houston, TX, USA
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2
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Bowdish ME, Gelijns AC, Bagiella E. Response Regarding: "Clinical Implication to Predict New-Onset Atrial Fibrillation After Cardiac Surgery". J Surg Res 2024; 298:394-395. [PMID: 38627112 DOI: 10.1016/j.jss.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 02/21/2024] [Indexed: 06/03/2024]
Affiliation(s)
- Michael E Bowdish
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
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3
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Ma C, Wu S, Liu S, Han Y. Chinese guidelines for the diagnosis and management of atrial fibrillation. Pacing Clin Electrophysiol 2024; 47:714-770. [PMID: 38687179 DOI: 10.1111/pace.14920] [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: 11/22/2023] [Accepted: 11/30/2023] [Indexed: 05/02/2024]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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Affiliation(s)
- Changsheng Ma
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shulin Wu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shaowen Liu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Yaling Han
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
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4
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Bibo L, Goldblatt J, Cohen R, Merry C, Larbalestier R. Coronary artery bypass grafting in octogenarians: an Australian experience. ANZ J Surg 2024; 94:1065-1070. [PMID: 38361308 DOI: 10.1111/ans.18902] [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: 12/04/2021] [Revised: 10/18/2023] [Accepted: 01/30/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND The aims of this study were to describe early and mid-term morbidity and mortality in octogenarian patients undergoing CABG, to determine if outcomes are comparable to younger patients undergoing the same procedure. METHODS We conducted a retrospective analysis of the first 901 patients who underwent cardiac surgery at a large newly established tertiary hospital in Western Australia from February 2015 to September 2019. Inclusion criteria involved all patients undergoing coronary artery bypass grafting. Exclusion criteria included patients who underwent concomitant valve or aortic procedure. RESULTS From a cohort of 901 patients, 37 octogenarian patients underwent CABG. Octogenarian patients had a higher rate of post-operative transfusion 35.1% versus 21.4% (P = 0.048), a higher rate of post-op acute kidney injury 40.5% versus 17.2% (P < 0.0001), a higher rate of post-operative atrial arrythmia requiring treatment 40.5% versus 22.5% (P = 0.011) and higher rate of return to theatre (13.5% versus 4.7%, P = 0.018), with bleeding/tamponade being the most likely reason (10.8% versus 2.7%). Octogenarian patients had a longer post-operative length of stay (LOS) with a median LOS of 10 versus 7 days (P < 0.0001). There was no increase in hospital readmission rate, in-hospital mortality or 1 year mortality in octogenarian patients. 24-month and 36-month survivals were 95.2% and 89.6% in octogenarians and 95.3% and 91.5% in the younger group. CONCLUSIONS Despite an increase in post-operative morbidity and LOS, there was no difference in hospital readmission, in-hospital mortality or 1 year mortality in octogenarian patients who underwent CABG. CABG is safe and remains an important management option for these patients.
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Affiliation(s)
- Liam Bibo
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Joshua Goldblatt
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Ryan Cohen
- School of Biomedical Science, University of Western Australia, Perth, Western Australia, Australia
- School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Chris Merry
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Robert Larbalestier
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
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5
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Lee S, Wallick D, Khrestian C, Juzbasich D, Laurita D, Rushing G, Sahadevan J. Nonpharmacologic rate control of postoperative atrial fibrillation in the canine sterile pericarditis model. J Cardiovasc Electrophysiol 2024; 35:1121-1128. [PMID: 38536760 PMCID: PMC11176034 DOI: 10.1111/jce.16260] [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] [Received: 12/15/2023] [Revised: 02/28/2024] [Accepted: 03/13/2024] [Indexed: 06/14/2024]
Abstract
INTRODUCTION Postoperative atrial fibrillation (POAF) is common following open heart surgery, and is associated with significant morbidity. Medications used for ventricular rate control of POAF may not be effective in controlling rapid ventricular rates during the postoperative period because of increased sympathetic tone. The purpose of this study was to develop nonpharmacologic rate control of POAF by atrioventricular node (AVN) fat pad stimulation using clinically available temporary pacing wires in the canine sterile pericarditis model. METHODS We studied 10 sterile pericarditis dogs in the closed-chest state on postoperative days 1-3. The AVN fat pad stimulation (amplitude 2-15 mA; frequency 20 Hz; pulse width 0.03-0.2 ms) was performed during sustained POAF (>5 min). We measured ventricular rate and inefficient ventricular contractions during sustained POAF and compared it with and without AVN fat pad stimulation. Also, the parameters of AVN fat pad stimulation to achieve a rate control of POAF were measured over the postoperative days. RESULTS Eleven episodes of sustained POAF were induced in 5/10 sterile pericarditis dogs in the closed-chest state on postoperative days 1-2. During POAF, the AVN fat pad stimulation decreased the ventricular rate from 178 ± 52 bpm to 100 ± 8 bpm in nine episodes. Nonpharmacologic rate control therapy successfully controlled the ventricular rate and eliminated inefficient ventricular contractions during POAF for the duration of the AVN fat pad stimulation. The AVN fat pad stimulation output remained relatively stable over the postoperative days. CONCLUSION During sustained POAF, nonpharmacologic rate control by AVN fat pad stimulation effectively and safely controlled rapid ventricular rates throughout the postoperative period.
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Affiliation(s)
- Seungyup Lee
- Departments of Medicine, Case Western Reserve University, Cleveland, OH
- Biomedical Engineering, Case Western Reserve University, Cleveland, OH
| | - Don Wallick
- Departments of Medicine, Case Western Reserve University, Cleveland, OH
| | - Celeen Khrestian
- Departments of Medicine, Case Western Reserve University, Cleveland, OH
| | - Dragan Juzbasich
- Departments of Medicine, Case Western Reserve University, Cleveland, OH
| | - Daniel Laurita
- Biomedical Engineering, Case Western Reserve University, Cleveland, OH
| | - Gregory Rushing
- Department of Surgery, Case Western Reserve University, Cleveland, OH
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Zhang D, Zhang Z, Zhen Y, Liu X, Fan X, Ye Z, Liu P. New-onset postoperative atrial fibrillation after pulmonary endarterectomy is associated with adverse outcomes. Front Surg 2024; 11:1380570. [PMID: 38872724 PMCID: PMC11169783 DOI: 10.3389/fsurg.2024.1380570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 05/10/2024] [Indexed: 06/15/2024] Open
Abstract
Background New-onset postoperative atrial fibrillation (POAF) is a common complication after pulmonary thromboendarterectomy (PEA), yet the risk factors and their impact on prognosis remain poorly understood. This study aims to investigate the risk factors associated with new-onset POAF after PEA and elucidate its underlying connection with adverse postoperative outcomes. Methods A retrospective analysis included 129 consecutive chronic thromboembolic pulmonary hypertension (CTEPH) patients and 16 sarcoma patients undergoing PEA. Univariate and multivariate analyses were conducted to examine the potential effects of preoperative and intraoperative variables on new-onset POAF following PEA. Propensity score matching (PSM) was then employed to adjust for confounding factors. Results Binary logistic regression revealed that age (odds ratio [OR] = 1.041, 95% confidence interval [CI] = 1.008-1.075, p = 0.014) and left atrial diameter[LAD] (OR = 1.105, 95% CI = 1.025-1.191, p = 0.009) were independent risk factors for new-onset POAF after PEA. The receiver operating characteristic (ROC) curve indicated that the predictive abilities of age and LAD for new-onset POAF were 0.652 and 0.684, respectively. Patients with new-onset POAF, compared with those without, exhibited a higher incidence of adverse outcomes (in-hospital mortality, acute heart failure, acute kidney insufficiency, reperfusion pulmonary edema). Propensity score matching (PSM) analyses confirmed the results. Conclusion Advanced age and LAD independently contribute to the risk of new-onset POAF after PEA. Patients with new-onset POAF are more prone to adverse outcomes. Therefore, heightened vigilance and careful monitoring of POAF after PEA are warranted.
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Affiliation(s)
- Dingkai Zhang
- China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Zhaohua Zhang
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
- Department of Cardiovascular Surgery, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yanan Zhen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xiaopeng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xueqiang Fan
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Zhidong Ye
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Peng Liu
- China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
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7
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Balik M, Waldauf P, Maly M, Brozek T, Rulisek J, Porizka M, Sachl R, Otahal M, Brestovansky P, Svobodova E, Flaksa M, Stach Z, Horejsek J, Volny L, Jurisinova I, Novotny A, Trachta P, Kunstyr J, Kopecky P, Tencer T, Pazout J, Krajcova A, Duska F. Echocardiography predictors of sustained sinus rhythm after cardioversion of supraventricular arrhythmia in patients with septic shock. J Crit Care 2024; 83:154832. [PMID: 38759581 DOI: 10.1016/j.jcrc.2024.154832] [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: 03/05/2024] [Revised: 05/02/2024] [Accepted: 05/09/2024] [Indexed: 05/19/2024]
Abstract
PURPOSE The echocardiography parameters may predict the maintenance of sinus rhythm after cardioversion of a supraventricular arrhythmia (SVA). MATERIALS AND METHODS Patients in septic shock with onset of an SVA, normal to moderately reduced LV systolic function (EF_LV˃̳35%) and on a continuous noradrenaline of <1.0 μg/kg.min were included. Echocardiography was performed at the arrhythmia onset, 1 h and 4 h post cardioversion on an infusion of propafenone or amiodarone. RESULTS Cardioversion was achieved in 96% of the 209 patients within a median time of 6(1.8-15.6)h, 134(64.1%) patients experienced at least one SVA recurrence after cardioversion. At 4 h the left atrial emptying fraction (LA_EF, cut-off 38.4%, AUC 0.69,p˂0.001), and transmitral A wave velocity-time-integral (Avti, cut-off 6.8 cm, AUC 0.65,p = 0.001) showed as limited predictors of a single arrhythmia recurrence. The LA_EF 44(36,49)%, (p = 0.005) and the Avti 8.65(7.13,9.50)cm, (p < 0.001) were associated with sustained sinus rhythm and decreased proportionally to increasing numbers of arrhythmia recurrences (p < 0.001 and p = 0.007, respectively). The enlarged left atrial end-systolic diameter at the arrhythmia onset (p = 0.04) and elevated systolic pulmonary artery pressure at 4 h (p = 0.007) were weak predictors of multiple(˃3) recurrences. CONCLUSION The LA_EF and Avti are related to arrhythmia recurrences post-cardioversion suggesting potential guidance to the choice between rhythm and rate control strategies. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03029169, registered on 24th of January 2017.
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Affiliation(s)
- M Balik
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia.
| | - P Waldauf
- Department of Anaesthesiology and Intensive Care, 3(rd) Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Czechia
| | - M Maly
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - T Brozek
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - J Rulisek
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - M Porizka
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - R Sachl
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - M Otahal
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - P Brestovansky
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - E Svobodova
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - M Flaksa
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - Z Stach
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - J Horejsek
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - L Volny
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - I Jurisinova
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - A Novotny
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - P Trachta
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - J Kunstyr
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - P Kopecky
- Department of Anaesthesiology and Intensive Care, 1(st) Faculty of Medicine, Charles University and General University Hospital in Prague, Czechia
| | - T Tencer
- Department of Anaesthesiology and Intensive Care, 3(rd) Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Czechia
| | - J Pazout
- Department of Anaesthesiology and Intensive Care, 3(rd) Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Czechia
| | - A Krajcova
- Department of Anaesthesiology and Intensive Care, 3(rd) Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Czechia
| | - F Duska
- Department of Anaesthesiology and Intensive Care, 3(rd) Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Czechia
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Chatterjee S, Cangut B, Rea A, Salenger R, Arora RC, Grant MC, Morton-Bailey V, Hirji S, Engelman DT. Enhanced Recovery After Surgery Cardiac Society turnkey order set for prevention and management of postoperative atrial fibrillation after cardiac surgery: Proceedings from the American Association for Thoracic Surgery ERAS Conclave 2023. JTCVS OPEN 2024; 18:118-122. [PMID: 38690434 PMCID: PMC11056439 DOI: 10.1016/j.xjon.2024.02.008] [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: 11/06/2023] [Revised: 01/18/2024] [Accepted: 02/11/2024] [Indexed: 05/02/2024]
Abstract
Background Postoperative atrial fibrillation (POAF) is a prevalent complication following cardiac surgery that is associated with increased adverse events. Several guidelines and expert consensus documents have been published addressing the prevention and management of POAF. We aimed to develop an order set to facilitate widespread implementation and adoption of evidence-based practices for POAF following cardiac surgery. Methods Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for POAF. Orders derived from consistent class I or IIA or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently class I or IIA, class IIB, or supported by published evidence appear in italic type. Results Preoperatively, the recommendation is to screen patients for paroxysmal or chronic atrial fibrillation and initiate appropriate treatment based on individual risk stratification for the development of POAF. This may include the administration of beta-blockers or amiodarone, tailored to the patient's specific risk profile. Intraoperatively, surgical interventions such as posterior pericardiotomy should be considered in selected patients. Postoperatively, it is crucial to focus on electrolyte normalization, implementation strategies for rate or rhythm control, and anticoagulation management. These comprehensive measures aim to optimize patient outcomes and reduce the occurrence of POAF following cardiac surgery. Conclusions Despite the well-established benefits of implementing a multidisciplinary care pathway for POAF in cardiac surgery, its adoption and implementation remain inconsistent. We have developed a readily applicable order set that incorporates recommendations from existing guidelines.
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Affiliation(s)
- Subhasis Chatterjee
- Department of Surgery, Baylor College of Medicine and Texas Heart Institute, Houston, Tex
| | - Busra Cangut
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Amanda Rea
- Division of Cardiac Surgery, University of Maryland St Joseph Medical Center, Towson, Md
| | - Rawn Salenger
- Division of Cardiac Surgery, University of Maryland St Joseph Medical Center, Towson, Md
| | - Rakesh C. Arora
- Division of Cardiac Surgery, Department of Surgery, Harrington Heart and Vascular Institute, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Daniel T. Engelman
- Department of Surgery, Heart & Vascular Program, Baystate Health, University of Massachusetts Chan Medical, School–Baystate, Springfield, Mass
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Grayburn PA, Mack MJ, Manandhar P, Kosinski AS, Sannino A, Smith RL, Szerlip M, Vemulapalli S. Comparison of Transcatheter Edge-to-Edge Mitral Valve Repair for Primary Mitral Regurgitation Outcomes to Hospital Volumes of Surgical Mitral Valve Repair. Circ Cardiovasc Interv 2024; 17:e013581. [PMID: 38436084 DOI: 10.1161/circinterventions.123.013581] [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: 09/01/2023] [Accepted: 01/26/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Transcatheter edge-to-edge mitral valve (MV) repair (TEER) is an effective treatment for patients with primary mitral regurgitation at prohibitive risk for surgical MV repair (MVr). High-volume MVr centers and high-volume TEER centers have better outcomes than low-volume centers, respectively. However, whether MVr volume predicts TEER outcomes remains unknown. We hypothesized that high-volume MV surgical centers would have superior risk-adjusted outcomes for TEER than low-volume centers. METHODS We combined data from the American College of Cardiology/Society of Thoracic Surgeons Transcatheter Valve Therapy registry and the Society of Thoracic Surgeons adult cardiac surgery database. MVr was defined as leaflet resection or artificial chords with or without annuloplasty and was evaluated as a continuous variable and as predefined categories (<25, 25-49, and ≥50 MV repairs/year). A generalized linear mixed model was used to evaluate risk-adjusted in-hospital/30-day mortality, 30-day heart failure readmission, and TEER success (mitral regurgitation ≤2+ and gradient <5 mm Hg). RESULTS The study comprised 41 834 patients from 500 sites of which 332 (66.4%) were low, 102 (20.4%) intermediate, and 66 (13.2%) high-volume surgical centers (P<0.001). TEER success was 54.6% and was not statistically significantly different across MV surgical site volumes (P=0.4271). TEER mortality at 30 days was 3.5% with no significant difference across MVr volume on unadjusted (P=0.141) or adjusted (P=0.071) analysis of volume as a continuous variable. One-year mortality was 15.0% and was lower for higher MVr volume centers when adjusted for clinical and demographic variables (P=0.027). Heart failure readmission at 1 year was 9.4% and was statistically significantly lower in high-volume centers on both unadjusted (P=0.017) or adjusted (P=0.015) analysis. CONCLUSIONS TEER can be safely performed in centers with low volumes of MV repair. However, 1-year mortality and heart failure readmission are superior at centers with higher MVr volume.
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Affiliation(s)
- Paul A Grayburn
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
| | - Michael J Mack
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
| | | | | | - Anna Sannino
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
| | - Robert L Smith
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
| | - Molly Szerlip
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
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10
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MA CS, WU SL, LIU SW, HAN YL. Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. J Geriatr Cardiol 2024; 21:251-314. [PMID: 38665287 PMCID: PMC11040055 DOI: 10.26599/1671-5411.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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11
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Lala A, Louis C, Vervoort D, Iribarne A, Rao A, Taddei-Peters WC, Raymond S, Bagiella E, O'Gara P, Thourani VH, Badhwar V, Chikwe J, Jessup M, Jeffries N, Moskowitz AJ, Gelijns AC, Rodriguez CJ. Clinical Trial Diversity, Equity, and Inclusion: Roadmap of the Cardiothoracic Surgical Trials Network. Ann Thorac Surg 2024:S0003-4975(24)00200-5. [PMID: 38522771 DOI: 10.1016/j.athoracsur.2024.03.016] [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: 10/02/2023] [Revised: 02/15/2024] [Accepted: 03/06/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND There is a recognized lack of diversity among patients enrolled in cardiovascular interventional and surgical trials. Diverse patient representation in clinical trials is necessary to enhance generalizability of findings, which may lead to better outcomes across broader populations. The Cardiothoracic Surgical Trials Network (CTSN) recently developed a plan of action to increase diversity among participating investigators and trial participants and is the focus of this review. METHODS A review of literature and enrollment data from CTSN trials was conducted. RESULTS CTSN completed more than a dozen major clinical trials (2008-2022), enrolling >4000 patients, of whom 30% were women, 11% were non-White, and 5.6% were Hispanic. CTSN also completed trials of hospitalized patients with coronavirus disease 2019, wherein enrollment was more diverse, with 42% women, and 58% were Asian, Black, Hispanic, or from another underrepresented racial group. The discrepancy in diversity of enrollment between cardiac surgery trials and coronavirus disease trials highlights the need for a more comprehensive understanding of (1) the prevalence of underlying disease requiring cardiac interventions across broad populations, (2) differences in access to care and referral for cardiac surgery, and (3) barriers to enrollment in cardiac surgery trials. CONCLUSIONS Committed to diversity, CTSN's multifaceted action plan includes developing site-specific enrollment targets, collecting social determinants of health data, understanding reasons for nonparticipation, recruiting sites that serve diverse populations, emphasizing greater diversity among clinical trial teams, and implicit bias training. The CTSN will prospectively assess how these interventions influence enrollment as we work to ensure trial participants are more representative of the communities we serve.
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Affiliation(s)
- Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Clauden Louis
- Bostick Heart Center, Department of Cardiovascular and Thoracic Surgery, Winter Haven Hospital, BayCare Health System, Clearwater, Florida
| | - Dominique Vervoort
- Division of Cardiac Surgery and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Alexander Iribarne
- Department of Cardiothoracic Surgery, Staten Island University Hospital, Northwell Health, Staten Island, New York
| | - Aarti Rao
- Zena and Michael A. Wiener Cardiovascular Institute, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Wendy C Taddei-Peters
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Samantha Raymond
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Emilia Bagiella
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Patrick O'Gara
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Joanna Chikwe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Neal Jeffries
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Alan J Moskowitz
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Annetine C Gelijns
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Carlos J Rodriguez
- Department of Medicine (Cardiology), Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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12
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Abbasciano RG, Olivieri GM, Chubsey R, Gatta F, Tyson N, Easwarakumar K, Fudulu DP, Marsico R, Kofler M, Elshafie G, Lai F, Loubani M, Kendall S, Zakkar M, Murphy GJ. Prophylactic corticosteroids for cardiopulmonary bypass in adult cardiac surgery. Cochrane Database Syst Rev 2024; 3:CD005566. [PMID: 38506343 PMCID: PMC10952358 DOI: 10.1002/14651858.cd005566.pub4] [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] [Indexed: 03/21/2024]
Abstract
BACKGROUND Cardiac surgery triggers a strong inflammatory reaction, which carries significant clinical consequences. Corticosteroids have been suggested as a potential perioperative strategy to reduce inflammation and help prevent postoperative complications. However, the safety and effectiveness of perioperative corticosteroid use in adult cardiac surgery is uncertain. This is an update of the 2011 review with 18 studies added. OBJECTIVES Primary objective: to estimate the effects of prophylactic corticosteroid use in adults undergoing cardiac surgery with cardiopulmonary bypass on the: - co-primary endpoints of mortality, myocardial complications, and pulmonary complications; and - secondary outcomes including atrial fibrillation, infection, organ injury, known complications of steroid therapy, prolonged mechanical ventilation, prolonged postoperative stay, and cost-effectiveness. SECONDARY OBJECTIVE to explore the role of characteristics of the study cohort and specific features of the intervention in determining the treatment effects via a series of prespecified subgroup analyses. SEARCH METHODS We used standard, extensive Cochrane search methods to identify randomised studies assessing the effect of corticosteroids in adult cardiac surgery. The latest searches were performed on 14 October 2022. SELECTION CRITERIA We included randomised controlled trials in adults (over 18 years, either with a diagnosis of coronary artery disease or cardiac valve disease, or who were candidates for cardiac surgery with the use of cardiopulmonary bypass), comparing corticosteroids with no treatments. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more endpoints. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were all-cause mortality, and cardiac and pulmonary complications. Secondary outcomes were infectious complications, gastrointestinal bleeding, occurrence of new post-surgery atrial fibrillation, re-thoracotomy for bleeding, neurological complications, renal failure, inotropic support, postoperative bleeding, mechanical ventilation time, length of stays in the intensive care unit (ICU) and hospital, patient quality of life, and cost-effectiveness. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS This updated review includes 72 randomised trials with 17,282 participants (all 72 trials with 16,962 participants were included in data synthesis). Four trials (6%) were considered at low risk of bias in all the domains. The median age of participants included in the studies was 62.9 years. Study populations consisted mainly (89%) of low-risk, first-time coronary artery bypass grafting (CABG) or valve surgery. The use of perioperative corticosteroids may result in little to no difference in all-cause mortality (risk with corticosteroids: 25 to 36 per 1000 versus 33 per 1000 with placebo or no treatment; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.75 to 1.07; 25 studies, 14,940 participants; low-certainty evidence). Corticosteroids may increase the risk of myocardial complications (68 to 86 per 1000) compared with placebo or no treatment (66 per 1000; RR 1.16, 95% CI 1.04 to 1.31; 25 studies, 14,766 participants; low-certainty evidence), and may reduce the risk of pulmonary complications (risk with corticosteroids: 61 to 77 per 1000 versus 78 per 1000 with placebo/no treatment; RR 0.88, 0.78 to 0.99; 18 studies, 13,549 participants; low-certainty evidence). Analyses of secondary endpoints showed that corticosteroids may reduce the incidence of infectious complications (risk with corticosteroids: 94 to 113 per 1000 versus 123 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.76 to 0.92; 28 studies, 14,771 participants; low-certainty evidence). Corticosteroids may result in little to no difference in incidence of gastrointestinal bleeding (risk with corticosteroids: 9 to 17 per 1000 versus 10 per 1000 with placebo/no treatment; RR 1.21, 95% CI 0.87 to 1.67; 6 studies, 12,533 participants; low-certainty evidence) and renal failure (risk with corticosteroids: 23 to 35 per 1000 versus 34 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.69 to 1.02; 13 studies, 12,799; low-certainty evidence). Corticosteroids may reduce the length of hospital stay, but the evidence is very uncertain (-0.5 days, 0.97 to 0.04 fewer days of length of hospital stay compared with placebo/no treatment; 25 studies, 1841 participants; very low-certainty evidence). The results from the two largest trials included in the review possibly skew the overall findings from the meta-analysis. AUTHORS' CONCLUSIONS A systematic review of trials evaluating the organ protective effects of corticosteroids in cardiac surgery demonstrated little or no treatment effect on mortality, gastrointestinal bleeding, and renal failure. There were opposing treatment effects on cardiac and pulmonary complications, with evidence that corticosteroids may increase cardiac complications but reduce pulmonary complications; however, the level of certainty for these estimates was low. There were minor benefits from corticosteroid therapy for infectious complications, but the evidence on hospital length of stay was very uncertain. The inconsistent treatment effects across different outcomes and the limited data on high-risk groups reduced the applicability of the findings. Further research should explore the role of these drugs in specific, vulnerable cohorts.
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Affiliation(s)
| | | | - Rachel Chubsey
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Francesca Gatta
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Nathan Tyson
- Department of Cardiac Surgery, University Hospitals of Leicester, Leicester, UK
| | | | - Daniel P Fudulu
- Department of Cardiac Surgery, University Hospital Bristol NHS Trust, Bristol, UK
| | | | | | - Ghazi Elshafie
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Florence Lai
- Leicester Clinical Trials Unit, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | - Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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13
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Suero OR, Ali AK, Barron LR, Segar MW, Moon MR, Chatterjee S. Postoperative atrial fibrillation (POAF) after cardiac surgery: clinical practice review. J Thorac Dis 2024; 16:1503-1520. [PMID: 38505057 PMCID: PMC10944787 DOI: 10.21037/jtd-23-1626] [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: 10/24/2023] [Accepted: 01/18/2024] [Indexed: 03/21/2024]
Abstract
Postoperative atrial fibrillation (POAF) after cardiac surgery is associated with elevated morbidity and mortality. Although current prediction models have limited efficacy, several perioperative interventions can reduce patients' risk of POAF. These begin with preoperative medications, including beta-blockers and amiodarone. Moreover, patients should be screened for preexisting atrial fibrillation (AF) so that concomitant surgical ablation and left atrial appendage occlusion can be performed in appropriate candidates. Intraoperative interventions such as posterior pericardiectomy can reduce mediastinal fluid accumulation, which is a trigger for POAF. Furthermore, many preventive strategies for POAF are implemented in the immediate postoperative period. Initiating beta-blockers, amiodarone, or both is reasonable for most patients. Overdrive atrial pacing, colchicine, and steroids have been used by some, although the evidence base is less robust. For patients with POAF, rate-control and rhythm-control strategies have comparable outcomes. Decision-making regarding anticoagulation should recognize that the stroke risk associated with POAF appears to be lower than that for general nonvalvular AF. The evidence that oral anticoagulation reduces stroke risk is less clear for POAF patients than for patients with general nonvalvular AF. Given that POAF tends to be shorter-lived and is associated with greater bleeding risks in the perioperative period, decisions regarding anticoagulation should be individualized. Finally, wearable technology and machine learning algorithms for better predicting and managing POAF appear to be coming soon. These technologies and a comprehensive clinical program could meaningfully reduce the incidence of this common complication.
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Affiliation(s)
- Orlando R. Suero
- Divisions of Cardiovascular Anesthesia & Critical Care Medicine, Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
| | - Ahmed K. Ali
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Lauren R. Barron
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
| | - Matthew W. Segar
- Department of Cardiology, The Texas Heart Institute, Houston, TX, USA
| | - Marc R. Moon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
- Division of General Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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14
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Farha K, Gercek M, Gercek M, Mischlinger J, Rudolph V, Gummert JF, Saad C, Aboud A, Fox H. Sleep apnea in patients undergoing coronary artery bypass grafting: Impact on perioperative outcomes. J Sleep Res 2024:e14181. [PMID: 38410033 DOI: 10.1111/jsr.14181] [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: 12/11/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 02/28/2024]
Abstract
Sleep-disordered breathing is common in patients with coronary artery disease undergoing coronary artery bypass grafting. Sleep-disordered breathing is associated with increased perioperative morbidity, arrhythmias (e.g. atrial fibrillation) and mortality. This study investigated the impact of sleep-disordered breathing on the postoperative course after coronary artery bypass grafting, including development of atrial fibrillation. This prospective single-centre cohort study included adults undergoing coronary artery bypass grafting. All were screened for sleep-disordered breathing (polygraphy) and atrial fibrillation (electrocardiogram) preoperatively; those with known sleep-disordered breathing or atrial fibrillation were excluded. Endpoints included new-onset atrial fibrillation, duration of mechanical ventilation, time in the intensive care unit, and postoperative infection. Regression analysis was performed to identify associations between sleep-disordered breathing and these outcomes. A total of 508 participants were included (80% male, median age 68 years). The prevalence of any (apnea-hypopnea index ≥ 5 per hr), moderate (apnea-hypopnea index = 15-30 per hr) and severe (apnea-hypopnea index > 30 per hr) sleep-disordered breathing was 52.9%, 9.3% and 10.2%, respectively. All-cause 30-day mortality was 0.98%. After adjustment for age and sex, severe sleep-disordered breathing was associated with longer respiratory ventilation support (crude odds ratio [95% confidence interval] 5.28 [2.18-12.77]; p < 0.001) and higher postoperative infection rates (crude odds ratio 3.32 [1.45-7.58]; p < 0.005), but not new-onset atrial fibrillation or mortality. New-onset atrial fibrillation was significantly associated with postoperative infection and prolonged hospital stay. The significant associations between sleep-disordered breathing and several adverse outcomes after coronary artery bypass grafting support the need for preoperative sleep-disordered breathing screening in individuals undergoing cardiac surgery.
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Affiliation(s)
- Kassar Farha
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Mustafa Gercek
- Clinic for Cardiovascular Surgery, Herzzentrum Duisburg, Duisburg, Germany
| | - Muhammed Gercek
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Johannes Mischlinger
- Center for Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine & I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Volker Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Jan F Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Charbel Saad
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos, Lebanon
| | - Anas Aboud
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Henrik Fox
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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15
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Bowdish ME, Bagiella E, Giustino G, Atluri P, Alexander JH, Thourani VH, Gammie JS, DeRose JJ, Taddei-Peters WC, Jeffries NO, O'Gara PT, Moskowitz AJ, Gillinov M, Gelijns AC, Ailawadi G. Prospective Study of Risk Factors for Postoperative Atrial Fibrillation After Cardiac Surgery. J Surg Res 2024; 294:262-268. [PMID: 37931426 DOI: 10.1016/j.jss.2023.09.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/17/2023] [Accepted: 09/05/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION To examine risk factors for new-onset postoperative atrial fibrillation (POAF) after cardiac surgery. METHODS Patients enrolled in the Cardiothoracic Surgical Trials Network multicenter, randomized trial of rate control versus rhythm control for POAF were included. Predictors of POAF were determined using multivariable logistic regression. RESULTS Among the 2104 patients who were enrolled preoperatively, 695 developed POAF (33.0%). Rates of POAF were 28.1% after isolated coronary artery bypass grafting (CABG), 33.7% after isolated valve repair or replacement, and 47.3% after CABG plus valve repair or replacement. Baseline characteristics associated with an increased risk of POAF identified on multivariable analysis included older age (odds ratio [OR] 1.57; 95% confidence interval [CI] 1.42-1.73, per 10 y), White race or non-Hispanic ethnicity (OR 1.52; CI: 1.11-2.07), history of heart failure (OR 1.55; CI: 1.16-2.08), and history of hypothyroidism (OR 1.42; CI 1.04-1.94). The type of cardiac procedure was associated with an increased risk of POAF with both isolated valve repair or replacement (OR 1.33, CI 1.08-1.64) and combined CABG plus valve repair or replacement (OR 1.64, CI 1.24-2.17) having increased risk of POAF compared to isolated CABG. No preoperative cardiac medication was associated with POAF. CONCLUSIONS In this prospective cohort of patients, older age, a history of hypothyroidism, a history of heart failure, and valve repair or replacement, with or without CABG, and White non-Hispanic race were associated with an increased risk of POAF.
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Affiliation(s)
- Michael E Bowdish
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai Health, New York, New York
| | - Gennaro Giustino
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai Health, New York, New York
| | - Pavan Atluri
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John H Alexander
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Heart and Vascular Center, Piedmont Heart Institute, Atlanta, Georgia
| | - James S Gammie
- Division of Cardiac Surgery, Johns Hopkins Heart and Vascular Institute, Baltimore, Maryland
| | - Joseph J DeRose
- Department of Cardiothoracic and Vascular Surgery, Montefiore-Einstein Medical Center, New York, New York
| | - Wendy C Taddei-Peters
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland
| | - Neal O Jeffries
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Patrick T O'Gara
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Alan J Moskowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai Health, New York, New York
| | - Marc Gillinov
- Department of Thoracic & Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai Health, New York, New York.
| | - Gorav Ailawadi
- Cardiac Surgery, University of Michigan Health System, Ann Arbor, Michigan
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16
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Chatterjee S, Ad N, Badhwar V, Gillinov AM, Alexander JH, Moon MR. Anticoagulation for atrial fibrillation after cardiac surgery: Do guidelines reflect the evidence? J Thorac Cardiovasc Surg 2024; 167:694-700. [PMID: 37037415 DOI: 10.1016/j.jtcvs.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/25/2023] [Indexed: 04/12/2023]
Affiliation(s)
- Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex.
| | - Niv Ad
- Division of Cardiac Surgery, White Oak Medical Center, Adventist HealthCare, University of Maryland, Takoma Park, Md
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - John H Alexander
- Division of Cardiology, Duke University School of Medicine & Duke Clinical Research Institute, Durham, NC
| | - Marc R Moon
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
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17
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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.
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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
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18
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 156] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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19
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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20
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Elsheikh S, Hill A, Irving G, Lip GYH, Abdul-Rahim AH. Atrial fibrillation and stroke: State-of-the-art and future directions. Curr Probl Cardiol 2024; 49:102181. [PMID: 37913929 DOI: 10.1016/j.cpcardiol.2023.102181] [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: 10/23/2023] [Accepted: 10/28/2023] [Indexed: 11/03/2023]
Abstract
Atrial fibrillation (AF) and stroke remain a major cause of morbidity and mortality. The two conditions shared common co-morbidities and risk factors. AF-related strokes are associated with worse clinical outcomes and higher mortality compared to non-AF-related. Early detection of AF is vital for prevention. While various scores have been developed to predict AF in such a high-risk group, they are yet to incorporated into clinical guidelines. Novel markers and predictors of AF including coronary and intracranial arterial calcification have also been studied. There are also ongoing debates on the management of acute stroke in patients with AF, and those who experienced breakthrough stroke while on oral anticoagulants. We provided an overview of the complex interplay between AF and stroke, as well as the treatment and secondary prevention of stroke in AF. We also comprehensively discussed the current evidence and the ongoing conundrums, and highlighted the future directions on the topic.
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Affiliation(s)
- Sandra Elsheikh
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK.
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK
| | - Greg Irving
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Health Research Institute, Edge Hill University Faculty of Health and Social Care, Ormskirk, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK
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21
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Jackson JC, Molena D, Amar D. Evolving Perspectives on Esophagectomy Care: Clinical Update. Anesthesiology 2023; 139:868-879. [PMID: 37812764 PMCID: PMC10843679 DOI: 10.1097/aln.0000000000004720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Recent changes in perioperative care have led to new perspectives and important advances that have helped to improve outcomes among patients treated with esophagectomy for esophageal cancer.
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Affiliation(s)
- Jacob C. Jackson
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Daniela Molena
- Weill Cornell Medical College, New York, New York
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David Amar
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
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22
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Olanisa OO, Jain P, Khan QS, Vemulapalli AC, Elias AA, Yerramsetti MD, Nath TS. Which Is Better? Rate Versus Rhythm Control in Atrial Fibrillation: A Systematic Review. Cureus 2023; 15:e49869. [PMID: 38169694 PMCID: PMC10758588 DOI: 10.7759/cureus.49869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/03/2023] [Indexed: 01/05/2024] Open
Abstract
Atrial fibrillation (AF) is a common arrhythmia associated with significant morbidity and mortality. The optimal approach to managing AF, specifically rate control versus rhythm control, remains a topic of debate in clinical practice. This systematic review aims to compare the rate control and rhythm control strategies based on their clinical outcomes, quality of life, and adverse events associated with them. A comprehensive search was conducted using PubMed, Google Scholar, Science Direct, Research Gate, MEDLINE (Medical Literature Analysis and Retrieval System Online), Scopus, and Embase (Excerpta Medica dataBASE) databases. A total of 1657 research papers were identified through the search strategy, and after applying the eligibility criteria, 28 studies were selected for the analysis. The studies encompassed a range of methodologies, including randomized controlled trials, observational studies, and meta-analyses. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for study selection, data extraction, and analysis. The outcomes of interest included all: cause mortality, stroke, bleeding events, cardiovascular hospitalizations, quality of life, and adverse effects of treatment. Data were synthesized and presented in tables, charts, and forest plots for meta-analysis where appropriate. The results indicate that both rate control and rhythm control strategies have their own merits and limitations, with the outcomes varying based on patient characteristics and comorbidities. While rhythm control strategies may lead to better symptom control and improved quality of life, rate control strategies may be associated with lower risks of adverse events and complications. This systematic review provides a comprehensive overview of the current evidence regarding rate and rhythm control strategies in AF management, offering insights for clinical decision-making and highlighting the need for individualized treatment approaches.
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Affiliation(s)
- Olawale O Olanisa
- Internal Medicine, Trinity Health Grand Rapids, Grand Rapids, USA
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Payal Jain
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Qasim S Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Abanob A Elias
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Monica D Yerramsetti
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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23
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Gerçek M, Börgermann J, Gummert J, Gerçek M. Five-year-outcome of new-onset perioperative atrial fibrillation after left atrial appendage amputation concomitant with cardiac surgery. Clin Res Cardiol 2023; 112:1800-1811. [PMID: 37428220 PMCID: PMC10698101 DOI: 10.1007/s00392-023-02255-8] [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] [Received: 04/05/2023] [Accepted: 06/21/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Recent data demonstrated the benefit of left atrial appendage (LAA)-amputation in patients with atrial fibrillation (AF). However, the long-term impact of LAA-amputation for patients with new-onset perioperative atrial fibrillation (POAF) is still unknown. METHODS Patients with no history of AF undergoing coronary artery bypass grafting by off-pump technique (OPCAB) between 2014 and 2016 were retrospectively examined. Cohorts were divided by the concomitant execution of LAA-amputation. Propensity score (PS) matching was applied by all available baseline characteristics. The composite of all-cause mortality, stroke and rehospitalization in patients with POAF and patients maintaining sinus rhythm posed as the primary endpoint. RESULTS A total of 1522 patients were enrolled, of whom 1208 and 243 were included in the control and the LAA-amputation group, respectively and were matched to 243 patients in each group. In total, patients with POAF without LAA-amputation showed a significantly higher rate of the composite endpoint (17.3% vs 32.1%, p = 0.007). However, patients with LAA-amputation showed no significant difference in the composite endpoint (23.2% vs 26.7%, p = 0.57). The significantly higher occurrence of the composite endpoint was driven by all-cause mortality (p = 0.005) and rehospitalization (p = 0.029). Subgroup analysis revealed a CHA2DS2-VASc-score of ≥ 3 to be associated with the high rate of the primary endpoint (p = 0.004). CONCLUSION POAF is associated with a higher rate of the combined endpoint of all-cause mortality, stroke and rehospitalization. The composite endpoint in patients with LAA-amputation concomitant with OPCAB surgery developing new-onset POAF in a 5-year follow-up was not increased compared to a control cohort maintaining sinus rhythm. Five-year outcome of patients with POAF and LAA-amputation; 95% CI, 95% confidence interval, CPR, cardiopulmonary resuscitation, ECLS, extracorporeal life support, HR, hazard ratio, IABP, intra-aortic balloon pump, LAA, left atrial appendage, OPCAB, off-pump coronary artery bypass grafting, PAPs, systolic pulmonary artery pressure, SR, sinus rhythm, VT, ventricular tachycardia.
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Affiliation(s)
- Mustafa Gerçek
- Heart Center Duisburg, Clinic for Cardiac Surgery and Pediatric Cardiac Surgery, Gerrickstraße 21, 47137, Duisburg, Germany
| | - Jochen Börgermann
- Heart Center Duisburg, Clinic for Cardiac Surgery and Pediatric Cardiac Surgery, Gerrickstraße 21, 47137, Duisburg, Germany
| | - Jan Gummert
- Herz- und Diabeteszentrum NRW, Clinic for Thoracic and Cardiovascular Surgery, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Muhammed Gerçek
- Herz- und Diabeteszentrum NRW, Clinic for General and Interventional Cardiology/Angiology, Georgstraße 11, 32545, Bad Oeynhausen, Germany.
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24
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Welker CC, Ramakrishna H. Postoperative Atrial Fibrillation: Guidelines Revisited. J Cardiothorac Vasc Anesth 2023; 37:2413-2415. [PMID: 37573211 DOI: 10.1053/j.jvca.2023.07.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 07/29/2023] [Indexed: 08/14/2023]
Affiliation(s)
- Carson C Welker
- Department of Anesthesia and Perioperative Medicine (Welker and Ramakrishna), Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Department of Anesthesia and Perioperative Medicine (Welker and Ramakrishna), Mayo Clinic, Rochester, MN.
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25
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El-Battrawy I, Hamdani N, Akin I. Perioperative Atrial Fibrillation: Old Topic but Still a Black Box in Relevance and Management. Am J Cardiol 2023; 207:501-502. [PMID: 37778910 DOI: 10.1016/j.amjcard.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Ibrahim El-Battrawy
- Department of Cardiology and Angiology, Ruhr-University Bochum, Bochum, Germany; Institute for Research and Education, Department of Molecular and Experimental Cardiology, Ruhr-University Bochum, Bochum, Germany
| | - Nazha Hamdani
- Department of Cardiology and Angiology, Ruhr-University Bochum, Bochum, Germany; Institute for Research and Education, Department of Molecular and Experimental Cardiology, Ruhr-University Bochum, Bochum, Germany
| | - Ibrahim Akin
- Medical University Mannheim, Medical Faculty, Mannheim University, Heidelberg, Germany.
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26
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Balik M, Maly M, Brozek T, Rulisek J, Porizka M, Sachl R, Otahal M, Brestovansky P, Svobodova E, Flaksa M, Stach Z, Horejsek J, Volny L, Jurisinova I, Novotny A, Trachta P, Kunstyr J, Kopecky P, Tencer T, Pazout J, Belohlavek J, Duska F, Krajcova A, Waldauf P. Propafenone versus amiodarone for supraventricular arrhythmias in septic shock: a randomised controlled trial. Intensive Care Med 2023; 49:1283-1292. [PMID: 37698594 DOI: 10.1007/s00134-023-07208-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/21/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE Acute onset supraventricular arrhythmias can contribute to haemodynamic compromise in septic shock. Both amiodarone and propafenone are available interventions, but their clinical effects have not yet been directly compared. METHODS In this two-centre, prospective controlled parallel group double blind trial we recruited 209 septic shock patients with new-onset arrhythmia and a left ventricular ejection fraction above 35%. The patients were randomised in a 1:1 ratio to receive either intravenous propafenone (70 mg bolus followed by 400-840 mg/24 h) or amiodarone (300 mg bolus followed by 600-1800 mg/24 h). The primary outcomes were the proportion of patients who had sinus rhythm 24 h after the start of the infusion, time to restoration of the first sinus rhythm and the proportion of patients with arrhythmia recurrence. RESULTS Out of 209 randomized patients, 200 (96%) received the study drug. After 24 h, 77 (72.8%) and 71 (67.3%) were in sinus rhythm (p = 0.4), restored after a median of 3.7 h (95% CI 2.3-6.8) and 7.3 h (95% CI 5-11), p = 0.02, with propafenone and amiodarone, respectively. The arrhythmia recurred in 54 (52%) patients treated with propafenone and in 80 (76%) with amiodarone, p < 0.001. Patients with a dilated left atrium had better rhythm control with amiodarone (6.4 h (95% CI 3.5; 14.1) until cardioversion vs 18 h (95% CI 2.8; 24.7) in propafenone, p = 0.05). CONCLUSION Propafenone does not provide better rhythm control at 24 h yet offers faster cardioversion with fewer arrhythmia recurrences than with amiodarone, especially in patients with a non-dilated left atrium. No differences between propafenone and amiodarone on the prespecified short- and long-term outcomes were observed.
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Affiliation(s)
- Martin Balik
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic.
| | - Michal Maly
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Tomas Brozek
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Jan Rulisek
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Michal Porizka
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Robert Sachl
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Michal Otahal
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Petr Brestovansky
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Eva Svobodova
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Marek Flaksa
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Zdenek Stach
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Jan Horejsek
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Lukas Volny
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Ivana Jurisinova
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Adam Novotny
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Pavel Trachta
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Jan Kunstyr
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Petr Kopecky
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Tomas Tencer
- Department of Anesthesiology and Intensive Care, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Prague, Czech Republic
| | - Jaroslav Pazout
- Department of Anesthesiology and Intensive Care, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Prague, Czech Republic
| | - Jan Belohlavek
- 2nd Department of Medicine, Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Frantisek Duska
- Department of Anesthesiology and Intensive Care, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Prague, Czech Republic
| | - Adela Krajcova
- Department of Anesthesiology and Intensive Care, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Prague, Czech Republic
| | - Petr Waldauf
- Department of Anesthesiology and Intensive Care, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Prague, Czech Republic
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27
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Rong LQ, Di Franco A, Rahouma M, Dimagli A, Patel A, Lopes AJ, Walline M, Chan J, Chadow D, Olaria RP, Soletti GJ, Kim J, Devereux RB, Pryor KO, Girardi LN, Weinsaft JW, Gaudino M. Baseline Intraoperative Left Ventricular Diastolic Function Is Associated with Postoperative Atrial Fibrillation after Cardiac Surgery. Anesthesiology 2023; 139:602-613. [PMID: 37552082 PMCID: PMC10592238 DOI: 10.1097/aln.0000000000004725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND Detailed understanding of the association between intraoperative left atrial and left ventricular diastolic function and postoperative atrial fibrillation is lacking. In this post hoc analysis of the Posterior Left Pericardiotomy for the Prevention of Atrial Fibrillation after Cardiac Surgery (PALACS) trial, we aimed to evaluate the association of intraoperative left atrial and left ventricular diastolic function as assessed by transesophageal echocardiography (TEE) with postoperative atrial fibrillation. METHODS PALACS patients with available intraoperative TEE data (n = 402 of 420; 95.7%) were included in this cohort study. We tested the hypotheses that preoperative left atrial size and function, left ventricular diastolic function, and their intraoperative changes were associated with postoperative atrial fibrillation. Normal left ventricular diastolic function was graded as 0 and with lateral e' velocity 10 cm/s or greater. Diastolic dysfunction was defined as lateral e' less than 10 cm/s using E/e' cutoffs of grade 1, E/e' 8 or less; grade, 2 E/e' 9 to 12; and grade 3, E/e' 13 or greater, along with two criteria based on mitral inflow and pulmonary wave flow velocities. RESULTS A total of 230 of 402 patients (57.2%) had intraoperative diastolic dysfunction. Posterior pericardiotomy intervention was not significantly different between the two groups. A total of 99 of 402 patients (24.6%) developed postoperative atrial fibrillation. Patients who developed postoperative atrial fibrillation more frequently had abnormal left ventricular diastolic function compared to patients who did not develop postoperative atrial fibrillation (75.0% [n = 161 of 303] vs. 57.5% [n = 69 of 99]; P = 0.004). Of the left atrial size and function parameters, only delta left atrial area, defined as presternotomy minus post-chest closure measurement, was significantly different in the no postoperative atrial fibrillation versus postoperative atrial fibrillation groups on univariate analysis (-2.1 cm2 [interquartile range, -5.1 to 1.0] vs. 0.1 [interquartile range, -4.0 to 4.8]; P = 0.028). At multivariable analysis, baseline abnormal left ventricular diastolic function (odds ratio, 2.02; 95% CI, 1.15 to 3.63; P = 0.016) and pericardiotomy intervention (odds ratio, 0.46; 95% CI, 0.27 to 0.78, P = 0.004) were the only covariates independently associated with postoperative atrial fibrillation. CONCLUSIONS Baseline preoperative left ventricular diastolic dysfunction on TEE, not left atrial size or function, is independently associated with postoperative atrial fibrillation. Further studies are needed to test if interventions aimed at optimizing intraoperative left ventricular diastolic function during cardiac surgery may reduce the risk of postoperative atrial fibrillation. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Lisa Q. Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Mohammed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Aneri Patel
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Alexandra J. Lopes
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Maria Walline
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - June Chan
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - David Chadow
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | | | - Giovanni Jr. Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Jiwon Kim
- Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | - Richard B. Devereux
- Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | - Kane O. Pryor
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Leonard N. Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Jonathan W. Weinsaft
- Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
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28
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Gaudino M, Harik L, Redfors B, Sandner S, Alexander JH, Di Franco A, Dimagli A, Weinsaft J, Perezgrovas-Olaria R, Soletti GJ, Lau C, Mack C, Girardi L. The Effect of Posterior Pericardiotomy on the Incidence of Atrial Fibrillation After Cardiac Surgery-Extended Follow-Up study (PALACS-EF): rationale and design. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead118. [PMID: 38035038 PMCID: PMC10684294 DOI: 10.1093/ehjopen/oead118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/10/2023] [Accepted: 11/03/2023] [Indexed: 12/02/2023]
Abstract
Aims Postoperative atrial fibrillation (POAF) is the most common complication of cardiac surgery and has been associated with increased postoperative morbidity and hospital costs. The Posterior left pericardiotomy for the prevention of AtriaL fibrillation After Cardiac Surgery (PALACS) trial found that posterior pericardiotomy significantly reduced the incidence of POAF (17% vs. 32%, P < 0.001). We present the protocol for The Effect of Posterior Pericardiotomy on the Incidence of Atrial Fibrillation After Cardiac Surgery-Extended Follow-Up study (PALACS-EF): a prospective, extended follow-up of the original PALACS trial. The aim of PALACS-EF is to gain more data regarding the effect of posterior pericardiotomy on postdischarge clinical outcomes. The primary outcome is the time to the first occurrence of the composite of all-cause mortality or hospital cardiovascular readmission. The key secondary outcome is the time to the first occurrence of the composite of all-cause mortality and all-cause hospital readmission. Hospital readmission, myocardial infarction, stroke, transient ischaemic attack, heart failure, systemic embolism, or new arrhythmias with onset since 30-day follow-up will also be recorded. Methods and results All 420 patients enrolled in the PALACS trial will be included; extended follow-up will be conducted via telephone by blinded research personnel utilizing a standardized script to ensure uniformity and completeness of follow-up. If an event has occurred, documentation will be obtained, and an independent adjudication committee blinded to group assignment will adjudicate outcome events. Results will be reported when a median follow-up of 5 years is achieved. Conclusion PALACS-EF will provide data to answer the question of whether posterior pericardiotomy improves postdischarge outcomes in patients undergoing cardiac surgery, and it will provide information on the relationship between POAF and adverse postdischarge outcomes including mortality, hospitalization, heart failure, and stroke. Registration PALACS: NCT02875405, PALACS-EF: NCT05903222.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065, USA
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065, USA
| | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - John H Alexander
- Division of Cardiology, Department of Medicine, Duke Clinical Research Institute, Duke Health, Durham, NC, USA
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065, USA
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065, USA
| | - Jonathon Weinsaft
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065, USA
| | | | - Giovanni Jr Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065, USA
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065, USA
| | - Charles Mack
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065, USA
| | - Leonard Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065, USA
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An SJ, Davis D, Peiffer S, Gallaher J, Tignanelli CJ, Charles A. Arrhythmias in Critically Ill Surgical and Non-surgical Patients: A National Propensity-Matched Study. World J Surg 2023; 47:2668-2675. [PMID: 37524957 DOI: 10.1007/s00268-023-07129-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Arrhythmias are common in critically ill patients, though the impact of arrhythmias on surgical patients is not well delineated. We aimed to characterize mortality following arrhythmias in critically ill patients. METHODS We performed a propensity-matched retrospective analysis of intensive care unit (ICU) patients from 2007 to 2017 in the Cerner Acute Physiology and Chronic Health Evaluation database. We compared outcomes between patients with and without arrhythmias and those with and without surgical indications for ICU admission. We also modeled predictors of arrhythmias in surgical patients. RESULTS 467,951 patients were included; 97,958 (20.9%) were surgical patients. Arrhythmias occurred in 1.4% of the study cohorts. Predictors of arrhythmias in surgical patients included a history of cardiovascular disease (odds ratio [OR] 1.35, 95% confidence interval [CI95] 1.11-1.63), respiratory failure (OR 1.48, CI95 1.12-1.96), pneumonia (OR 3.17, CI95 1.98-5.10), higher bicarbonate level (OR 1.03, CI95 1.01-1.05), lower albumin level (OR 0.79, CI95 0.68-0.91), and vasopressor requirement (OR 27.2, CI95 22.0-33.7). After propensity matching, surgical patients with arrhythmias had a 42% mortality risk reduction compared to non-surgical patients (risk ratio [RR] 0.58, CI 95 0.43-0.79). Predicted probabilities of mortality for surgical patients were lower at all ages. CONCLUSIONS Surgical patients with arrhythmias are at lower risk of mortality than non-surgical patients. In this propensity-matched analysis, predictors of arrhythmias in critically ill surgical patients included a history of cardiovascular disease, respiratory complications, increased bicarbonate levels, decreased albumin levels, and vasopressor requirement. These findings highlight the differential effect of arrhythmias on different cohorts of critically ill populations.
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Affiliation(s)
- Selena J An
- Department of Surgery, University of North Carolina at Chapel Hill, 4001 Burnett Womack Building, CB 7050, Chapel Hill, NC, 27599, USA
| | - Dylane Davis
- School of Medicine, University of North Carolina at Chapel Hill, 1001 Bondurant Hall, CB 9535, Chapel Hill, NC, 27599, USA
| | - Sarah Peiffer
- Baylor College of Medicine, 1 Moursund St, Houston, TX, 77030, USA
| | - Jared Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, 4001 Burnett Womack Building, CB 7050, Chapel Hill, NC, 27599, USA
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, 11-132 Phillips-Wangensteen Bldg., 516 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, 4001 Burnett Womack Building, CB 7050, Chapel Hill, NC, 27599, USA.
- Department of Surgery, UNC School of Medicine, 4008 Burnett Womack Building, CB 7228, Chapel Hill, USA.
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Roeschl T, Hinrichs N, Hommel M, Pfahringer B, Balzer F, Falk V, O'Brien B, Ott SC, Potapov E, Schoenrath F, Meyer A. Systematic Assessment of Shock Severity in Postoperative Cardiac Surgery Patients. J Am Coll Cardiol 2023; 82:1691-1706. [PMID: 37852698 DOI: 10.1016/j.jacc.2023.08.031] [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: 04/27/2023] [Revised: 07/05/2023] [Accepted: 08/15/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The Society for Cardiovascular Angiography and Interventions (SCAI) shock classification has been shown to provide robust mortality risk stratification in a variety of cardiovascular patients. OBJECTIVES This study sought to evaluate the SCAI shock classification in postoperative cardiac surgery intensive care unit (CSICU) patients. METHODS This study retrospectively analyzed 26,792 postoperative CSICU admissions at a heart center between 2012 and 2022. Patients were classified into SCAI shock stages A to E using electronic health record data. Moreover, the impact of late deterioration (LD) as an additional risk modifier was investigated. RESULTS The proportions of patients in SCAI shock stages A to E were 24.4%, 18.8%, 8.4%, 35.5%, and 12.9%, and crude hospital mortality rates were 0.4%, 0.6%, 3.3%, 4.9%, and 30.2%, respectively. Similarly, the prevalence of postoperative complications and organ dysfunction increased across SCAI shock stages. After multivariable adjustment, each higher SCAI shock stage was associated with increased hospital mortality (adjusted OR: 1.26-16.59) compared with SCAI shock stage A, as was LD (adjusted OR: 8.2). The SCAI shock classification demonstrated a strong diagnostic performance for hospital mortality (area under the receiver operating characteristic: 0.84), which noticeably increased when LD was incorporated into the model (area under the receiver operating characteristic: 0.90). CONCLUSIONS The SCAI shock classification effectively risk-stratifies postoperative CSICU patients for mortality, postoperative complications, and organ dysfunction. Its application could, therefore, be extended to the field of cardiac surgery as a triage tool in postoperative care and as a selection criterion in research.
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Affiliation(s)
- Tobias Roeschl
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Charité-Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany.
| | - Nils Hinrichs
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Charité-Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Matthias Hommel
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Deutsches Herzzentrum der Charité (DHZC), Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Boris Pfahringer
- Deutsches Herzzentrum der Charité (DHZC), Centre for Cardiovascular Telemedicine, Berlin, Germany
| | - Felix Balzer
- Charité-Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Volkmar Falk
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany; Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology, Zürich, Switzerland
| | - Benjamin O'Brien
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Deutsches Herzzentrum der Charité (DHZC), Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany; St Bartholomew's Hospital and Barts Heart Centre, Department of Perioperative Medicine, London, United Kingdom
| | - Sascha Christoph Ott
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Deutsches Herzzentrum der Charité (DHZC), Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Evgenij Potapov
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Felix Schoenrath
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Alexander Meyer
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Charité-Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
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Pereira MDP, Lima EG, Pitta FG, Gowdak LHW, Mioto BM, Carvalho LNS, Darrieux FCDC, Mejia OAV, Jatene FB, Serrano CV. Rivaroxaban versus warfarin in postoperative atrial fibrillation: Cost-effectiveness analysis in a single-center, randomized, and prospective trial. JTCVS OPEN 2023; 15:199-210. [PMID: 37808050 PMCID: PMC10556832 DOI: 10.1016/j.xjon.2023.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/27/2023] [Accepted: 05/22/2023] [Indexed: 10/10/2023]
Abstract
Objectives Postoperative atrial fibrillation is the most common clinical complication after coronary artery bypass graft surgery. It is associated with a high risk of both stroke and death and increases the length of hospital stay and costs. This study aimed to evaluate anticoagulants in postoperative atrial fibrillation. Methods A single-center, randomized, prospective, and open-label study. The trial was conducted in Heart Institute at University of São Paulo, Brazil. Patients who developed postoperative atrial fibrillation were randomized to anticoagulation with rivaroxaban or warfarin plus enoxaparin bridging. The primary objective was the cost-effectiveness evaluated by quality-adjusted life years, using the SF-6D questionnaire. The secondary end point was the combination of death, stroke, myocardial infarction, thromboembolic events, infections, bleeding, readmissions, and surgical reinterventions. The safety end point was any bleeding using the International Society on Thrombosis and Haemostasis score. Follow-up period was 30 days after hospital discharge. Results We analyzed 324 patients and 53 patients were randomized. The median cost-effectiveness was $1423.20 in the warfarin group versus $586.80 in the rivaroxaban group (P = .002). The median cost was lower in the rivaroxaban group, $450.20 versus $947.30 (P < .001). The secondary outcome was similar in both groups, 44.4% in warfarin group versus 38.5% in the rivaroxaban group (P = .65). Bleeding occured in 25.9% in the warfarin group versus 11.5% in the rivaroxaban group (P = .18). Conclusions Rivaroxaban was more cost-effective when compared with warfarin associated with enoxaparin bridging in postoperative atrial fibrillation after isolated coronary artery bypass grafting.
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Affiliation(s)
- Marcel de Paula Pereira
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Eduardo Gomes Lima
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Fabio Grunspun Pitta
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Luís Henrique Wolff Gowdak
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Bruno Mahler Mioto
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Leticia Neves Solon Carvalho
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | | | - Omar Asdrubal Vilca Mejia
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Fabio Biscegli Jatene
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Carlos Vicente Serrano
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
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Guzelburc O, Zengin A, Karatas MB, Bayer Erdogan S, Emre A. Relationship between platelet mass index and postoperative atrial fibrillation after elective coronary artery bypass surgery: a retrospective study. Herz 2023; 48:309-315. [PMID: 36063167 DOI: 10.1007/s00059-022-05136-4] [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: 10/12/2021] [Revised: 07/06/2022] [Accepted: 08/08/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common complication after cardiac surgery. The pathogenesis of postoperative atrial fibrillation (POAF) is multifactorial and one of the known factors is inflammation. Platelet mass index (PMI) is an indicator of platelet activation and a better inflammatory marker than mean platelet volume (MPV). In this retrospective study, we investigated the relationship between POAF and PMI. METHODS The study included 848 consecutive patients (655 male and 193 female) who had elective isolated coronary artery by-pass grafting (CABG) or combined CABG and valvular surgery. Platelet count and MPV were measured from preoperative blood samples to calculate PMI. Post-operative atrial fibrillation was defined as irregular and fibrillatory P waves occurring 48-96 h after cardiac surgery and lasting at least 30 s. The PMI values in patients who developed POAF were compared with those in patients who did not develop POAF. RESULTS Patients who developed POAF had higher PMI values (2549.3 ± 1077.1) when compared with patients in sinus rhythm (2248.1 ± 683.4; p < 0.01). In multivariate regression analysis, age (OR: 1.05; 95% CI: 1.02-1.09; p = 0.01), left atrial diameter (OR: 1.05; 95% CI: 1.03-1.09; p = 0.02), hs-CRP (OR: 1.09; 95%CI: 1.05-1.13; p < 0.01), EuroSCORE II (OR: 1.27; 95% CI: 1.14-1.41; p < 0.01), and PMI (OR: 1.01; 95% CI: 1.001-1.02; p < 0.01) were independent predictors of POAF. In ROC analysis, PMI ≥ 2286 predicted POAF development with a sensitivity of 69% and a specificity of 58% (AUC: 0.66; p < 0.01) CONCLUSION: A significant relationship was found between preoperatively calculated PMI and POAF. We showed that PMI may be used to predict patients who are at high risk of developing POAF.
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Affiliation(s)
- Ozge Guzelburc
- Departmeant of Cardiology, Istanbul Dr Siyami Ersek Cardiovascular and Thoracic Surgery Training and Research Hospital Istanbul, Tıbbiye Cad. No:13 Selimiye, 34886, Üsküdar/İstanbul, Turkey.
| | - Ahmet Zengin
- Departmeant of Cardiology, Istanbul Dr Siyami Ersek Cardiovascular and Thoracic Surgery Training and Research Hospital Istanbul, Tıbbiye Cad. No:13 Selimiye, 34886, Üsküdar/İstanbul, Turkey
| | - Mehmet Baran Karatas
- Departmeant of Cardiology, Istanbul Dr Siyami Ersek Cardiovascular and Thoracic Surgery Training and Research Hospital Istanbul, Tıbbiye Cad. No:13 Selimiye, 34886, Üsküdar/İstanbul, Turkey
| | - Sevinc Bayer Erdogan
- Departmeant of Cardiology, Istanbul Dr Siyami Ersek Cardiovascular and Thoracic Surgery Training and Research Hospital Istanbul, Tıbbiye Cad. No:13 Selimiye, 34886, Üsküdar/İstanbul, Turkey
| | - Ayse Emre
- Departmeant of Cardiology, Istanbul Dr Siyami Ersek Cardiovascular and Thoracic Surgery Training and Research Hospital Istanbul, Tıbbiye Cad. No:13 Selimiye, 34886, Üsküdar/İstanbul, Turkey
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Banga S, Abela GS, Saltiel F, Fischell T, Kalavakunta JK, Sood A, Jolly G, Najib K, Al-Ali H, Qintar M, Bazil J, Singh Y, Gupta V. Management of Atrial Fibrillation Post Transcatheter Aortic Valve Implantation. Am J Cardiol 2023; 200:171-177. [PMID: 37329837 DOI: 10.1016/j.amjcard.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 05/01/2023] [Accepted: 05/16/2023] [Indexed: 06/19/2023]
Abstract
Atrial fibrillation (AF) is a common complication in patients who underwent transcatheter aortic valve implantation. Some of these patients have preexisting AF as well. The management of these patients is complex, especially after the procedure, when there is a sudden change in hemodynamics. There are no established guidelines about the management of the patients who underwent transcatheter aortic valve replacement with preexisting or new-onset AF. This review article discusses the management of these patients with rate and rhythm control strategies with medications. This article also highlights the role of newer oral anticoagulation medications and left atrial occlusion devices to prevent stroke after the procedure. We will also discuss new advances in the care of this patient population to prevent the occurrence of AF after transcatheter aortic valve implantation. In conclusion, this article is a synopsis of both pharmacologic and device interventions for the management of AF in patients who underwent transcatheter aortic valve replacement.
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Affiliation(s)
- Sandeep Banga
- Department of Cardiology, Sparrow Hospital, Michigan State University, Lansing, Michigan.
| | - George S Abela
- Department of Cardiology, Sparrow Hospital, Michigan State University, Lansing, Michigan
| | - Frank Saltiel
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Tim Fischell
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Jagadeesh K Kalavakunta
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Abhinav Sood
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - George Jolly
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Khalid Najib
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Haya Al-Ali
- Department of Physiology, Michigan State University, Lansing, Michigan
| | - Mohammed Qintar
- Department of Cardiology, Sparrow Hospital, Michigan State University, Lansing, Michigan
| | - Jason Bazil
- Department of Physiology, Michigan State University, Lansing, Michigan
| | - Yashbir Singh
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Vishal Gupta
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
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Girgis RE, Hadley RJ, Murphy ET. Pulmonary, circulatory and renal considerations in the early postoperative management of the lung transplant recipient. Glob Cardiol Sci Pract 2023; 2023:e202318. [PMID: 37575284 PMCID: PMC10422876 DOI: 10.21542/gcsp.2023.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/15/2023] [Indexed: 08/15/2023] Open
Abstract
Lung transplantation volumes and survival rates continue to increase worldwide. Primary graft dysfunction (PGD) and acute kidney injury (AKI) are common early postoperative complications that significantly affect short-term mortality and long-term outcomes. These conditions share overlapping risk factors and are driven, in part, by circulatory derangements. The prevalence of severe PGD is up to 20% and is the leading cause of early death. Patients with pulmonary hypertension are at a higher risk. Prevention and management are based on principles learned from acute lung injury of other causes. Targeting the lowest effective cardiac filling pressure will reduce alveolar edema formation in the setting of increased pulmonary capillary permeability. AKI is reported in up to one-half of lung transplant recipients and is strongly associated with one-year mortality as well as long-term chronic kidney disease. Optimization of renal perfusion is critical to reduce the incidence and severity of AKI. In this review, we highlight key early post-transplant pulmonary, circulatory, and renal perturbations and our center's management approach.
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Affiliation(s)
- Reda E. Girgis
- Richard DeVos Lung Transplant Program, Corewell Health West, Michigan State University, College of Human Medicine, Grand Rapids, Michigan, USA
| | - Ryan J. Hadley
- Richard DeVos Lung Transplant Program, Corewell Health West, Michigan State University, College of Human Medicine, Grand Rapids, Michigan, USA
| | - Edward T. Murphy
- Richard DeVos Lung Transplant Program, Corewell Health West, Michigan State University, College of Human Medicine, Grand Rapids, Michigan, USA
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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.
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Hassanabad AF, Deniset JF, Fedak PWM. Pericardial Inflammatory Mediators That Can Drive Postoperative Atrial Fibrillation in Cardiac Surgery Patients. Can J Cardiol 2023; 39:1090-1102. [PMID: 37301368 DOI: 10.1016/j.cjca.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023] Open
Abstract
Postoperative atrial fibrillation (POAF) is a common dysrhythmia that affects a significant number of patients undergoing cardiac surgery. Many studies aim to better understand this complex postsurgical complication by analysing circulating biomarkers in patients who develop POAF. More recently, the pericardial space was shown to contain inflammatory mediators that could trigger POAF. In this review we summarise recent studies that examine the immune mediators present in the pericardial space and their potential implications for the pathophysiology of POAF in cardiac surgery patients. Ongoing research in this area should better delineate the multifactorial etiology of POAF, where specific markers may be targeted to reduce the incidence of POAF and improve outcomes for this patient population.
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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
| | - Justin F Deniset
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Physiology and Pharmacology, 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.
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Jiang Z, Song L, Liang C, Zhang H, Liu L. Prediction model of atrial fibrillation recurrence after Cox-Maze IV procedure in patients with chronic valvular disease and atrial fibrillation based on machine learning algorithm. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2023; 48:995-1007. [PMID: 37724402 PMCID: PMC10930048 DOI: 10.11817/j.issn.1672-7347.2023.230018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVES Atrial fibrillation (AF) is a prevalent cardiac arrhythmia, and Cox-maze IV procedure (CMP-IV) is a commonly employed surgical technique for its treatment. Currently, the risk factors for atrial fibrillation recurrence following CMP-IV remain relatively unclear. In recent years, machine learning algorithms have demonstrated immense potential in enhancing diagnostic accuracy, predicting patient outcomes, and devising personalized treatment strategies. This study aims to evaluate the efficacy of CMP-IV on treating chronic valvular disease with AF, utilize machine learning algorithms to identify potential risk factors for AF recurrence, construct a CMP-IV postoperative AF recurrence prediction model. METHODS A total of 555 patients with AF combined with chronic valvular disease, who met the criteria, were enrolled from January 2012 to December 2019 from the Second Xiangya Hospital of Central South University and the Affiliated Xinqiao Hospital of the Army Medical University, with an average age of (57.95±7.96) years, including an AF recurrence group (n=117) and an AF non-recurrence group (n=438). Kaplan-Meier method was used to analyze the sinus rhythm maintenance rate, and 9 machine learning models were developed including random forest, gradient boosting decision tree (GBDT), extreme gradient boosting (XGBoost), bootstrap aggregating, logistic regression, categorical boosting (CatBoost), support vector machine, adaptive boosting, and multi-layer perceptron. Five-fold cross-validation and model evaluation indicators [including F1 score, accuracy, precision, recall, and area under the curve (AUC)] were used to evaluate the performance of the models. The 2 best-performing models were selected for further analyze, including feature importance evaluation and Shapley additive explanations (SHAP) analysis, identifying AF recurrence risk factors, and building an AF recurrence risk prediction model. RESULTS The 5-year sinus rhythm maintenance rate for the patients was 82.13% (95% CI 78.51% to 85.93%). Among the 9 machine learning models, XGBoost and CatBoost models performed best, with the AUC of 0.768 (95% CI 0.742 to 0.786) and 0.762 (95% CI 0.723 to 0.801), respectively. Feature importance and SHAP analysis showed that duration of AF, preoperative left ventricular ejection fraction, postoperative heart rhythm, preoperative neutrophil-to-lymphocyte ratio, preoperative left atrial diameter, preoperative heart rate, and preoperative white blood cell were important factors for AF recurrence. Conclusion: Machine learning algorithms can be effectively used to identify potential risk factors for AF recurrence after CMP-IV. This study successfuly constructs 2 prediction model which may enhance individualized treatment plans.
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Affiliation(s)
- Zenan Jiang
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha 410011.
| | - Long Song
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha 410011
| | - Chunshui Liang
- Department of Cardiovascular Surgery, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Hao Zhang
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha 410011
| | - Liming Liu
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha 410011.
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Ahmed M, Belley-Coté EP, Qiu Y, Belesiotis P, Tao B, Wolf A, Kaur H, Ibrahim A, Wong JA, Wang MK, Healey JS, Conen D, Devereaux PJ, Whitlock RP, Mcintyre WF. Rhythm vs. Rate Control in Patients with Postoperative Atrial Fibrillation after Cardiac Surgery: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:4534. [PMID: 37445569 DOI: 10.3390/jcm12134534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/24/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery; it is associated with morbidity and mortality. We undertook this review to compare the effects of rhythm vs. rate control in this population. METHODS We searched MEDLINE, Embase and CENTRAL to March 2023. We included randomized trials and observational studies comparing rhythm to rate control in cardiac surgery patients with POAF. We used a random-effects model to meta-analyze data and rated the quality of evidence using GRADE. RESULTS From 8,110 citations, we identified 8 randomized trials (990 patients). Drug regimens used for rhythm control included amiodarone in four trials, other class III anti-arrhythmics in one trial, class I anti-arrhythmics in four trials and either a class I or III anti-arrhythmic in one trial. Rhythm control compared to rate control did not result in a significant difference in length of stay (mean difference -0.8 days; 95% CI -3.0 to +1.4, I2 = 97%), AF recurrence within 1 week (130 events; risk ratio [RR] 1.1; 95%CI 0.6-1.9, I2 = 54%), AF recurrence up to 1 month (37 events; RR 0.9; 95%CI 0.5-1.8, I2 = 0%), AF recurrence up to 3 months (10 events; RR 1.0; 95%CI 0.3-3.4, I2 = 0%) or mortality (25 events; RR 1.6; 95%CI 0.7-3.5, I2 = 0%). Effect measures from seven observational studies (1428 patients) did not differ appreciably from those in randomized trials. CONCLUSIONS Although atrial fibrillation is common after cardiac surgery, limited low-quality data guide its management. Limited available evidence suggests no clear advantage to either rhythm or rate control. A large-scale randomized trial is needed to inform this important clinical question.
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Affiliation(s)
- Muneeb Ahmed
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8L 2X2, Canada
| | | | - Yuan Qiu
- Ottawa Heart Institute, University of Ottawa, Ottawa, ON K1Y 4W7, Canada
| | - Peter Belesiotis
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8L 2X2, Canada
| | - Brendan Tao
- Department of Medicine, University of British Columbia, Vancouver, BC V6T 1Z1, Canada
| | - Alex Wolf
- Department of Medicine, Western University, Hamilton, ON N6A 5C1, Canada
| | - Hargun Kaur
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8L 2X2, Canada
| | - Alex Ibrahim
- Department of Medicine, Western University, Hamilton, ON N6A 5C1, Canada
| | - Jorge A Wong
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8L 2X2, Canada
| | - Michael K Wang
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8L 2X2, Canada
| | - Jeff S Healey
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8L 2X2, Canada
| | - David Conen
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8L 2X2, Canada
| | | | - Richard P Whitlock
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8L 2X2, Canada
| | - William F Mcintyre
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8L 2X2, Canada
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Evtushenko A, Evtushenko V, Gusakova A, Suslova T, Varlamova Y, Zavadovskiy K, Lebedev D, Kutikhin A, Pavlyukova E, Mamchur S. Neurohumoral Markers of Cardiac Autonomic Denervation after Surgical Ablation of Long-Standing Persistent Atrial Fibrillation. Life (Basel) 2023; 13:1340. [PMID: 37374123 PMCID: PMC10300786 DOI: 10.3390/life13061340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Although the autonomic nervous system has an evident impact on cardiac electrophysiology and radiofrequency ablation (RFA) is the conventional technique for treating persistent atrial fibrillation, the specific effects of RFA have been insufficiently studied to date. Here, we investigated whether RFA affects neurohumoral transmitter levels and myocardial 123I-metaiodobenzylguanidine (123I-MIBG) uptake. To perform this task, we compared two groups of patients with acquired valvular heart disease: patients who had undergone surgical AF ablation and patients with sinus rhythm. The decrease in norepinephrine (NE) level in the coronary sinus had a direct association with the heart-to-mediastinum ratio (p = 0.02) and a negative correlation with 123I-MIBG uptake defects (p = 0.01). The NE level decreased significantly after the main surgery, both in patients with AF (p = 0.0098) and sinus rhythm (p = 0.0039). Furthermore, the intraoperative difference between the norepinephrine levels in the ascending aorta and coronary sinus (ΔNE) of -400 pg/mL was determined as a cut-off value to evaluate RFA efficacy, as denervation failed in all patients with ΔNE < -400 pg/mL. Hence, ΔNE can be utilized to predict the efficacy of the "MAZE-IV" procedure and to assess the risk of AF recurrence after RFA.
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Affiliation(s)
- Alexey Evtushenko
- Department of Cardiovascular Surgery, Research Institute for Complex Issues of Cardiovascular Diseases, 6 Sosnovy Boulevard, Kemerovo 650002, Russia; (A.E.); (S.M.)
| | - Vladimir Evtushenko
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya Street, Tomsk 634012, Russia
| | - Anna Gusakova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya Street, Tomsk 634012, Russia
| | - Tatiana Suslova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya Street, Tomsk 634012, Russia
| | - Yulia Varlamova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya Street, Tomsk 634012, Russia
| | - Konstantin Zavadovskiy
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya Street, Tomsk 634012, Russia
| | - Denis Lebedev
- Department of Cardiovascular Surgery, Research Institute for Complex Issues of Cardiovascular Diseases, 6 Sosnovy Boulevard, Kemerovo 650002, Russia; (A.E.); (S.M.)
| | - Anton Kutikhin
- Department of Cardiovascular Surgery, Research Institute for Complex Issues of Cardiovascular Diseases, 6 Sosnovy Boulevard, Kemerovo 650002, Russia; (A.E.); (S.M.)
| | - Elena Pavlyukova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya Street, Tomsk 634012, Russia
| | - Sergey Mamchur
- Department of Cardiovascular Surgery, Research Institute for Complex Issues of Cardiovascular Diseases, 6 Sosnovy Boulevard, Kemerovo 650002, Russia; (A.E.); (S.M.)
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Caspersen E, Guinot PG, Rozec B, Oilleau JF, Fellahi JL, Gaudard P, Lorne E, Mahjoub Y, Besnier E, Moussa MD, Mongardon N, Hanouz JL, Briant AR, Paul LPS, Tomadesso C, Parienti JJ, Descamps R, Denisenko A, Fischer MO. Comparison of landiolol and amiodarone for the treatment of new-onset atrial fibrillation after cardiac surgery (FAAC) trial: study protocol for a randomized controlled trial. Trials 2023; 24:353. [PMID: 37226174 DOI: 10.1186/s13063-023-07353-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Postoperative atrial fibrillation (PoAF) after cardiac surgery has a high incidence of 30%, but its management is controversial. Two strategies are recommended without evidence of a superiority of one against the other: rate control with beta-blocker or rhythm control with amiodarone. Landiolol is a new-generation beta-blocker with fast onset and short half-life. One retrospective, single-center study compared landiolol to amiodarone for PoAF after cardiac surgery with a better hemodynamic stability and a higher rate of reduction to sinus rhythm with landiolol, justifying the need for a multicenter randomized controlled trial. Our aim is to compare landiolol to amiodarone in the setting of PoAF after cardiac surgery with the hypothesis of a higher rate of reduction to sinus rhythm with landiolol during the 48 h after the first episode of POAF. METHODS The FAAC trial is a multicenter single-blind two parallel-arm randomized study, which planned to include 350 patients with a first episode of PoAF following cardiac surgery. The duration of the study is 2 years. The patients are randomized in two arms: a landiolol group and an amiodarone group. Randomization (Ennov Clinical®) is performed by the anesthesiologist in charge of the patient if PoAF is persistent for at least 30 min after correction of hypovolemia, dyskalemia, and absence of pericardial effusion on a transthoracic echocardiography done at bedside. Our hypothesis is an increase of the percentage of patients in sinus rhythm from 70 to 85% with landiolol in less than 48 h after onset of PoAF (alpha risk = 5%, power = 90%, bilateral test). DISCUSSION The FAAC trial was approved by the Ethics Committee of EST III with approval number 19.05.08. The FAAC trial is the first randomized controlled trial comparing landiolol to amiodarone for PoAF after cardiac surgery. In case of higher rate of reduction with landiolol, this beta-blocker could be the drug of choice used in this context as to reduce the need for anticoagulant therapy and reduce the risk of complications of anticoagulant therapy for patients with a first episode of postoperative atrial fibrillation after cardiac surgery. TRIAL REGISTRATION ClinicalTrials.gov NCT04223739. Registered on January 10, 2020.
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Affiliation(s)
- Edouard Caspersen
- Department of Anaesthesiology-Resuscitation and Perioperative Medicine, Normandy University, UNICAEN, Caen University Hospital, Normandy, Caen, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Intensive Care, Dijon University Hospital, Dijon, France
- University of Bourgogne and Franche-Comté, LNC UMR1231, Dijon, France
- INSERM, LNC UMR1231, Dijon, France
- LipSTIC LabEx, FCS Bourgogne-Franche Comté, Dijon, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laennec, CHU Nantes, Nantes, France
- Institut du Thorax, Université de Nantes, CHU Nantes, CNRS, INSERM, Nantes, France
| | - Jean-Ferréol Oilleau
- Department of Anesthesiology and Surgical Intensive Care Unit, Brest University Hospital, 29200, Brest, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, Lyon, France
- Faculté de Médecine Lyon Est, Université Claude-Bernard, Lyon 1, Lyon, France
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine Arnaud de Villeneuve, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Emmanuel Lorne
- Department of Anaesthesia and Critical Care Medicine, Clinique du Millénaire, Cedex 2, 34960, Montpellier, France
| | - Yazine Mahjoub
- Anesthesia and Critical Care Department, Amiens Hospital University, Amiens, France
| | - Emmanuel Besnier
- Department of Anesthesiology and Critical Care, Rouen University Hospital, Rouen, France
| | - Mouhamed Djahoum Moussa
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, F-59000, Lille, France
| | | | - Jean-Luc Hanouz
- Department of Anaesthesiology-Resuscitation and Perioperative Medicine, Normandy University, UNICAEN, Caen University Hospital, Normandy, Caen, France
| | - Anaïs R Briant
- Department of Biostatistics, Normandy University, UNICAEN, Caen University Hospital, Normandy, Caen, France
| | - Laure Peyro Saint Paul
- Department of Clinical Research and Innovation, Normandy University, UNICAEN, Caen University Hospital, Normandy, Caen, France
| | - Clémence Tomadesso
- Department of Clinical Research and Innovation, Normandy University, UNICAEN, Caen University Hospital, Normandy, Caen, France
| | - Jean-Jacques Parienti
- Department of Biostatistics, Normandy University, UNICAEN, Caen University Hospital, Normandy, Caen, France
| | - Richard Descamps
- Department of Anaesthesiology-Resuscitation and Perioperative Medicine, Normandy University, UNICAEN, Caen University Hospital, Normandy, Caen, France
| | - Alina Denisenko
- Department of Anaesthesiology-Resuscitation and Perioperative Medicine, Normandy University, UNICAEN, Caen University Hospital, Normandy, Caen, France
| | - Marc-Olivier Fischer
- Institut Aquitain du Coeur, Clinique Saint Augustin, Elsan, 114 Avenue d'Arès, 33074, Bordeaux Cedex, France.
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Gaudino M, Andreotti F, Kimura T. Current concepts in coronary artery revascularisation. Lancet 2023; 401:1611-1628. [PMID: 37121245 DOI: 10.1016/s0140-6736(23)00459-2] [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: 11/22/2022] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 05/02/2023]
Abstract
Coronary artery revascularisation can be performed surgically or percutaneously. Surgery is associated with higher procedural risk and longer recovery than percutaneous interventions, but with long-term reduction of recurrent cardiac events. For many patients with obstructive coronary artery disease in need of revascularisation, surgical or percutaneous intervention is indicated on the basis of clinical and anatomical reasons or personal preferences. Medical therapy is a crucial accompaniment to coronary revascularisation, and data suggest that, in some subsets of patients, medical therapy alone might achieve similar results to coronary revascularisation. Most revascularisation data are based on prevalently White, non-elderly, male populations in high-income countries; robust data in women, older adults, and racial and other minorities, and from low-income and middle-income countries, are urgently needed.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA.
| | - Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Osaka, Japan
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Chyou JY, Barkoudah E, Dukes JW, Goldstein LB, Joglar JA, Lee AM, Lubitz SA, Marill KA, Sneed KB, Streur MM, Wong GC, Gopinathannair R. Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e676-e698. [PMID: 36912134 DOI: 10.1161/cir.0000000000001133] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.
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43
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[The ECG in cardiac rehabilitation]. Herzschrittmacherther Elektrophysiol 2023; 34:3-9. [PMID: 36757476 DOI: 10.1007/s00399-023-00927-6] [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: 11/15/2022] [Accepted: 01/17/2023] [Indexed: 02/10/2023]
Abstract
The concept and the benefits of cardiac rehabilitation are well established and scientifically proven. In the context of shortened in-hospital stays and older patients receiving more complex interventions, complications of those procedures might occur during cardiac rehabilitation. This article discusses guideline-directed diagnosis and treatment of complications after transcatheter aortic valve replacement, especially delayed-onset heart block, post-operative atrial fibrillation, and acute coronary ischemia in the setting of pre-existent bundle branch block.
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Vorhofflimmern nach herzchirurgischen Eingriffen – Zusammenfassung der einer Metaanalyse. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2023. [DOI: 10.1007/s00398-023-00558-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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45
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Dönmez E, Özcan S, Mert B, Özkaynak B, Tuğrul S, Şahin İ, Okuyan E. A Retrospective Study to Evaluate the Association Between the Glasgow Prognostic Score and Atrial Fibrillation, Stroke, and Mortality at 30 Days and at 1 Year After Coronary Artery Bypass Graft Surgery. Med Sci Monit 2023; 29:e939283. [PMID: 36718108 PMCID: PMC9898998 DOI: 10.12659/msm.939283] [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] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The Glasgow prognostic score (GPS) consists of a combination of serum C-reactive protein and albumin levels as indicators of systematic inflammatory response and nutritional status, respectively. The present retrospective study aimed to evaluate the association between the GPS and atrial fibrillation, stroke, and mortality at 30 days and 1 year after coronary artery bypass graft (CABG) surgery. MATERIAL AND METHODS Patients with chronic coronary syndromes who underwent CABG surgery between 2012 and 2019 in a single center were included. Preoperative GPS was calculated. Then, patients were grouped according to postoperative atrial fibrillation (POAF) development. Further, groups were formed to evaluate the relationship between GPS and 30-day and 1-year cardiovascular mortality as well as stroke development. RESULTS Patients who developed POAF had higher GPS, higher European System for Cardiac Operative Risk Evaluation (EuroSCORE II) score, advanced age, lower angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) use, lower left ventricular ejection fraction, and were more likely to be female and to have a history of carotid artery disease (P<0.05, for all). Additionally, GPS, EuroSCORE II, advanced age, and lower left ventricular ejection fraction were detected as independent risk factors for POAF development. When adverse outcomes were assessed, cardiovascular mortality at 30 days or 1 year, and stroke development at 1 year, were more frequent in patients with POAF. Moreover, POAF development was found to be an independent risk factor for adverse outcomes. Also, GPS was established as an independent risk factor both for 30-day and 1-year cardiovascular mortality (P<0.0001 and P=0.001, respectively). CONCLUSIONS GPS is an easy-to-calculate score that has reasonable diagnostic accuracy in determining the risk of POAF and stroke as well as 30-day and 1-year cardiovascular mortality.
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Affiliation(s)
- Esra Dönmez
- Department of Cardiology, Bagcilar Training and Research Hospital, İstanbul, Turkey
| | - Sevgi Özcan
- Department of Cardiology, Bagcilar Training and Research Hospital, İstanbul, Turkey
| | - Bülent Mert
- Department of Cardiovascular Surgery, Bagcilar Training and Research Hospital, İstanbul, Turkey
| | - Berk Özkaynak
- Department of Cardiovascular Surgery, Bagcilar Training and Research Hospital, İstanbul, Turkey
| | - Sevil Tuğrul
- Department of Cardiology, Bagcilar Training and Research Hospital, İstanbul, Turkey
| | - İrfan Şahin
- Department of Cardiology, Bagcilar Training and Research Hospital, İstanbul, Turkey
| | - Ertuğrul Okuyan
- Department of Cardiology, Bagcilar Training and Research Hospital, İstanbul, Turkey
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Lee G, Tam DY, Fremes SE. Commentary: Until we take it seriously, the status quo of postoperative atrial fibrillation management will prevail. J Thorac Cardiovasc Surg 2023; 165:104-105. [PMID: 33985802 DOI: 10.1016/j.jtcvs.2021.04.034] [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: 04/13/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Grace Lee
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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Atrial fibrillation after cardiac surgery: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2023; 165:94-103.e24. [PMID: 33952399 DOI: 10.1016/j.jtcvs.2021.03.077] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/05/2021] [Accepted: 03/12/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE New-onset postoperative atrial fibrillation (POAF) after cardiac surgery is common, with rates up to 60%. POAF has been associated with early and late stroke, but its association with other cardiovascular outcomes is less known. The objective was to perform a meta-analysis of the studies reporting the association of POAF with perioperative and long-term outcomes in patients with cardiac surgery. METHODS We performed a systematic review and a meta-analysis of studies that presented outcomes for cardiac surgery on the basis of the presence or absence of POAF. MEDLINE, EMBASE, and the Cochrane Library were assessed; 57 studies (246,340 patients) were selected. Perioperative mortality was the primary outcome. Inverse variance method and random model were performed. Leave-one-out analysis, subgroup analyses, and metaregression were conducted. RESULTS POAF was associated with perioperative mortality (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.58-2.33), perioperative stroke (OR, 2.17; 95% CI, 1.90-2.49), perioperative myocardial infarction (OR, 1.28; 95% CI, 1.06-1.54), perioperative acute renal failure (OR, 2.74; 95% CI, 2.42-3.11), hospital (standardized mean difference, 0.80; 95% CI, 0.53-1.07) and intensive care unit stay (standardized mean difference, 0.55; 95% CI, 0.24-0.86), long-term mortality (incidence rate ratio [IRR], 1.54; 95% CI, 1.40-1.69), long-term stroke (IRR, 1.33; 95% CI, 1.21-1.46), and longstanding persistent atrial fibrillation (IRR, 4.73; 95% CI, 3.36-6.66). CONCLUSIONS The results suggest that POAF after cardiac surgery is associated with an increased occurrence of most short- and long-term cardiovascular adverse events. However, the causality of this association remains to be established.
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48
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Jiang Z, Song L, Liang C, Zhang H, Tan H, Sun Y, Guo R, Liu L. Machine learning-based analysis of risk factors for atrial fibrillation recurrence after Cox-Maze IV procedure in patients with atrial fibrillation and chronic valvular disease: A retrospective cohort study with a control group. Front Cardiovasc Med 2023; 10:1140670. [PMID: 37034340 PMCID: PMC10079913 DOI: 10.3389/fcvm.2023.1140670] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/13/2023] [Indexed: 04/11/2023] Open
Abstract
Objectives To evaluate the efficacy of the Cox-Maze IV procedure (CMP-IV) in combination with valve surgery in patients with both atrial fibrillation (AF) and valvular disease and use machine learning algorithms to identify potential risk factors of AF recurrence. Methods A total of 1,026 patients with AF and valvular disease from two hospitals were included in the study. 555 patients received the CMP-IV procedure in addition to valve surgery and left atrial appendage ligation (CMP-IV group), while 471 patients only received valve surgery and left atrial appendage ligation (Non-CMP-IV group). Kaplan-Meier analysis was used to calculate the sinus rhythm maintenance rate. 58 variables were selected as variables for each group and 10 machine learning models were developed respectively. The performance of the models was evaluated using five-fold cross-validation and metrics including F1 score, accuracy, precision, and recall. The four best-performing models for each group were selected for further analysis, including feature importance evaluation and SHAP analysis. Results The 5-year sinus rhythm maintenance rate in the CMP-IV group was 82.13% (95% CI: 78.51%, 85.93%), while in the Non-CMP-IV group, it was 13.40% (95% CI: 10.44%, 17.20%). The eXtreme Gradient Boosting (XGBoost), LightGBM, Category Boosting (CatBoost) and Random Fores (RF) models performed the best in the CMP-IV group, with area under the curve (AUC) values of 0.768 (95% CI: 0.742, 0.786), 0.766 (95% CI: 0.744, 0.792), 0.762 (95% CI: 0.723, 0.801), and 0.732 (95% CI: 0.701, 0.763), respectively. In the Non-CMP-IV group, the LightGBM, XGBoost, CatBoost and RF models performed the best, with AUC values of 0.738 (95% CI: 0.699, 0.777), 0.732 (95% CI: 0.694, 0.770), 0.724 (95% CI: 0.668, 0.789), and 0.716 (95% CI: 0.656, 0.774), respectively. Analysis of feature importance and SHAP revealed that duration of AF, preoperative left ventricular ejection fraction, postoperative heart rhythm, preoperative neutrophil-lymphocyte ratio, preoperative left atrial diameter and heart rate were significant factors in AF recurrence. Conclusion CMP-IV is effective in treating AF and multiple machine learning models were successfully developed, and several risk factors were identified for AF recurrence, which may aid clinical decision-making and optimize the individual surgical management of AF.
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Affiliation(s)
- Zenan Jiang
- Department of Cardiovascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, China
| | - Long Song
- Department of Cardiovascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, China
| | - Chunshui Liang
- Department of Cardiovascular Surgery, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Hao Zhang
- Department of Cardiovascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, China
| | - Haoyu Tan
- Department of Cardiovascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, China
| | - Yaqin Sun
- Department of Cardiovascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, China
| | - Ruikang Guo
- Department of Cardiovascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, China
| | - Liming Liu
- Department of Cardiovascular Surgery, the Second Xiangya Hospital of Central South University, Changsha, China
- Correspondence: Liming Liu
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Hussain ST, Kalimi R. Commentary: Atrial fibrillation after cardiac surgery: More than just a nuisance! J Thorac Cardiovasc Surg 2023; 165:106-107. [PMID: 33941372 DOI: 10.1016/j.jtcvs.2021.03.104] [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: 03/29/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Syed T Hussain
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY and Department of Cardiovascular and Thoracic Surgery, Northwell Health/South Shore University Hospital, Bay Shore, NY.
| | - Robert Kalimi
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY and Department of Cardiovascular and Thoracic Surgery, Northwell Health/South Shore University Hospital, Bay Shore, NY
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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: 7] [Impact Index Per Article: 7.0] [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.
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