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Halonen J, Kärkkäinen J, Jäntti H, Martikainen T, Valtola A, Ellam S, Väliaho E, Santala E, Räsänen J, Juutilainen A, Mahlamäki V, Vasankari S, Vasankari T, Hartikainen J. Prevention of Atrial Fibrillation After Cardiac Surgery: A Review of Literature and Comparison of Different Treatment Modalities. Cardiol Rev 2024; 32:248-256. [PMID: 36729126 DOI: 10.1097/crd.0000000000000499] [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] [Indexed: 02/03/2023]
Abstract
Atrial fibrillation is the most common arrhythmia to occur after cardiac surgery, with an incidence of 10% to 50%. It is associated with postoperative complications including increased risk of stroke, prolonged hospital stays and increased costs. Despite new insights into the mechanisms of atrial fibrillation, no specific etiologic factor has been identified as the sole perpetrator of the arrhythmia. Current evidence suggests that the pathophysiology of atrial fibrillation in general, as well as after cardiac surgery, is multifactorial. Studies have also shown that new-onset postoperative atrial fibrillation following cardiac surgery is associated with a higher risk of short-term and long-term mortality. Furthermore, it has been demonstrated that prophylactic medical therapy decreases the incidence of postoperative atrial fibrillation after cardiac surgery. Of note, the incidence of postoperative atrial fibrillation has not changed during the last decades despite the numerous preventive strategies and operative techniques proposed, although the perioperative and postoperative care of cardiac patients as such has improved.
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Affiliation(s)
- Jari Halonen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jussi Kärkkäinen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Helena Jäntti
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
- Centre for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - Tero Martikainen
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Antti Valtola
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Sten Ellam
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Eemu Väliaho
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Elmeri Santala
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jenni Räsänen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Auni Juutilainen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Visa Mahlamäki
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Sini Vasankari
- Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Tommi Vasankari
- The UKK Institute for Health Promotion Research, Tampere, Finland
- The Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Juha Hartikainen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
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Abstract
Atrial fibrillation occurs in 5-40% patients after coronary artery bypass graft surgery. Atrial fibrillation increases mortality and morbidity in the post-operative period. We sought to conduct a comprehensive review of literature focusing on pathophysiology, risk factors, prevention and treatment of post coronary artery bypass graft atrial fibrillation.
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Affiliation(s)
- Ashraf Mostafa
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
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Li MY, Chen HX, Hou HT, Wang J, Liu XC, Yang Q, He GW. Biomarkers and key pathways in atrial fibrillation associated with mitral valve disease identified by multi-omics study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:393. [PMID: 33842614 PMCID: PMC8033373 DOI: 10.21037/atm-20-3767] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Mitral valve disease (MVD)-associated atrial fibrillation (AF) is one of the most common arrhythmias with an increased risk of thromboembolic events. This study aimed to identify the molecular mechanisms and possible biomarkers for chronic AF in MVD by using multi-omics methods. Methods This prospective study enrolled patients with MVD (n=100) undergoing mitral valve replacement surgery. The patients were allocated into chronic AF and sinus rhythm (SR) groups. Plasma samples were collected preoperatively. Proteomics was performed with isobaric tags for relative and absolute quantitation (iTRAQ) to identify differential proteins (DPs) between the two groups. The selected DPs were then validated in a new cohort of patients by enzyme-linked immunosorbent assay (ELISA). A gas chromatography-mass spectrometer was used in the metabolomics study to identify differential metabolites (DMs). Bioinformatics analyses were performed to analyze the results. Results Among the 447 plasma proteins and 322 metabolites detected, 57 proteins and 55 metabolites, including apolipoprotein A-I (ApoA-I), apolipoprotein A-II (ApoA-II), LIM domain only protein 7 (LMO7), and vitronectin (VN) were differentially expressed between AF and SR patients. Bioinformatics analyses identified enriched pathways related to AF, including peroxisome proliferator-activated receptor alpha (PPARα), the renin angiotensin aldosterone system (RAAS), galactose, biosynthesis of unsaturated fatty acids, and linoleic acid metabolism. Conclusions Using integrated multi-omics technologies in MVD-associated AF patients, the present study, for the first time, revealed important signaling pathways, such as PPARα, as well as possible roles of other signaling pathways, including the RAAS and galactose metabolism to understand the molecular mechanism of MVD-associated AF. It also identified a large number of DPs and DMs. Some identified proteins and metabolites, such as ApoA-I, ApoA-II, LMO7, and VN, may be further developed as biomarkers for MVD-associated AF.
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Affiliation(s)
- Ming-Yang Li
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School, Peking Union Medical College, Beijing, China
| | - Huan-Xin Chen
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School, Peking Union Medical College, Beijing, China
| | - Hai-Tao Hou
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School, Peking Union Medical College, Beijing, China
| | - Jun Wang
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School, Peking Union Medical College, Beijing, China
| | - Xiao-Cheng Liu
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School, Peking Union Medical College, Beijing, China
| | - Qin Yang
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School, Peking Union Medical College, Beijing, China
| | - Guo-Wei He
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School, Peking Union Medical College, Beijing, China.,The Institute of Cardiovascular Diseases, Tianjin University, Tianjin, China.,Drug Research and Development Center, Wannan Medical College, Wuhu, China.,Department of Surgery, Oregon Health and Science University, Portland, OR, USA
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Hou HT, Xue LG, Zhou JY, Wang SF, Yang Q, He GW. Alteration of plasma trace elements magnesium, copper, zinc, iron and calcium during and after coronary artery bypass grafting surgery. J Trace Elem Med Biol 2020; 62:126612. [PMID: 32673943 DOI: 10.1016/j.jtemb.2020.126612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/12/2020] [Accepted: 07/02/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Dietary factors including trace elements contribute to the development of disorders including coronary artery diseases. Whether there are differences in concentrations of trace elements between on-pump and off-pump coronary artery bypass grafting (CABG) surgery remains unclear. The aim of this study was to investigate the differences in the plasma level of four trace elements Cu, Fe, Zn, magnesium (Mg), and calcium (Ca) during and after CABG between on-pump and off-pump procedure and the correlation between these trace elements and the development of postoperative AF. METHODS Fifty-three CABG patients using on-pump or off-pump methods were enrolled. The blood sample was taken before skin incision (T1), 4 h after skin incision (T2), postoperative day1 (T3), and day3 (T4) respectively. Plasma concentrations of Mg, Ca, Fe, Zn, and Cu were determined. RESULTS The plasma Mg concentration reached the highest level at T3 (0.94 ± 0.03 vs. 1.20 ± 0.03 mmol/L,P < 0.001) and completely recovered at T4 whereas Zn (11.28 ± 0.23 vs. 6.80 ± 0.20 mmol/L, P < 0.001) and Fe (10.97 ± 0.51 vs. 2.22 ± 0.1 μmol/L, P < 0.001) was lowest at T3 and partially recovered at T4. Cu was lowest at T2 (12.10 ± 0.33 vs. 9.62 ± 0.25 μmol/L, P < 0.001) then increased until T4. There were significant differences in Mg and Fe (P < 0.05), as well as Cu (P < 0.01) between on-pump and off-pump groups. No significant differences were detected between postoperative atrial fibrillation and sinus rhythm groups. CONCLUSIONS In CABG, Cu and Zn are significantly reduced and Cu is recovered at postoperative Day 1 but Zn takes longer to recover. Addition of Mg and Ca during CABG are sufficient to maintain the plasma concentration. However, supplementation of Cu and Zn during and after CABG may be necessary. Further, the correlation between these trace elements and postoperative AF is to be further determined.
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Affiliation(s)
- Hai-Tao Hou
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Lan-Gang Xue
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Jia-Yi Zhou
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Shi-Fu Wang
- Unit of Perfusion, Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Qin Yang
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Guo-Wei He
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China; Department of Cardiovascular Surgery, The First Affiliated Hospital, Zhejiang University, Hangzhou, China; School of Pharmacy, Wannan Medical College, Wuhu, China; Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA.
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Kawase Y, Ishii Y, Nishina D, Bessho R, Nitta T. Temporal Dispersion of Atrial Activation Causes Postoperative Atrial Fibrillation. J NIPPON MED SCH 2020; 87:197-203. [PMID: 31902857 DOI: 10.1272/jnms.jnms.2020_87-402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Spatial dispersion of atrial activation is a cause of postoperative atrial fibrillation (PoAF) after cardiac surgery. This study evaluated whether temporal dispersion of atrial activation causes PoAF after surgery in a clinical setting. METHODS Nineteen patients were enrolled. Postoperative atrial activation was evaluated by 24-hour Holter electrocardiography, with atrial pacing wires on the right atrium, for 5 days after cardiac surgery. No patient received antiarrhythmic drugs, including beta-blockers. The cycle length of 15 continuous atrial beats was measured at 4 time points: (i) earlier than 12 hours before PoAF, as a control, (ii) just before PoAF onset, (iii) during PoAF, and (iv) just before cessation of PoAF. Inhomogeneity of atrial activation was quantified by using the variation coefficient for a cycle length of 15 atrial beats during each phase. RESULTS The median inhomogeneity index of atrial activation (interquartile range) was 0.102 (0.046-0.136) in controls, 0.943 (0.582-1.610) just before PoAF onset (vs. control; p=0.009), 0.966 (0.631-1.117) during PoAF, and 0.471 (0.138-0.645) just before cessation of PoAF. CONCLUSIONS Dispersion of atrial activation significantly increased just before PoAF onset. Temporal dispersion of atrial activation is a precursory variation of PoAF.
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Affiliation(s)
| | - Yosuke Ishii
- Nippon Medical School Hospital, Cardiovascular Surgery
| | - Dai Nishina
- Nippon Medical School Chiba Hokusoh Hospital, Cardiovascular Surgery
| | - Ryuzo Bessho
- Nippon Medical School Chiba Hokusoh Hospital, Cardiovascular Surgery
| | - Takashi Nitta
- Nippon Medical School Hospital, Cardiovascular Surgery
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Palano F, Adduci C, Cosentino P, Silvetti G, Boldini F, Francia P. Assessing Atrial Fibrillation Substrates by P Wave Analysis: A Comprehensive Review. High Blood Press Cardiovasc Prev 2020; 27:341-347. [PMID: 32451990 DOI: 10.1007/s40292-020-00390-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 05/13/2020] [Indexed: 12/20/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia. Pharmacologic and non-pharmacologic rhythm control strategies impact on AF-related symptoms, while leaving largely unaffected the risk of stroke. Moreover, up to 20% of AF patients are asymptomatic during paroxysmal relapses of arrhythmia, thus underlying the need for early markers to identify at-risk patients and prevent cerebrovascular accidents. Indeed, non-invasive assessment of pre-clinical substrate changes that predispose to AF could provide early identification of at-risk patients and allow for tailored care paths. ECG-derived P wave analysis is a simple-to-use and inexpensive tool that has been successfully employed to detect AF-associated structural and functional atrial changes. Beyond standard electrocardiographic techniques, high resolution signal averaged electrocardiography (SAECG), by recording microvolt amplitude atrial signals, allows more accurate analysis of the P wave and possibly AF risk stratification. This review focuses on the evidence that support P wave analysis to assess AF substrates, predict arrhythmia relapses and guide rhythm-control interventions.
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Affiliation(s)
- Francesca Palano
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy.
| | - Carmen Adduci
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Pietro Cosentino
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Giacomo Silvetti
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Francesca Boldini
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Pietro Francia
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
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7
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Ruan Y, Robinson NB, Naik A, Silva M, Hameed I, Rahouma M, Oakley C, Di Franco A, Zamvar V, Girardi LN, Gaudino M. Effect of atrial pacing on post-operative atrial fibrillation following coronary artery bypass grafting: Pairwise and network meta-analyses. Int J Cardiol 2020; 302:103-107. [DOI: 10.1016/j.ijcard.2019.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/28/2019] [Accepted: 12/04/2019] [Indexed: 12/31/2022]
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Li XY, Hou HT, Chen HX, Liu XC, Wang J, Yang Q, He GW. Preoperative plasma biomarkers associated with atrial fibrillation after coronary artery bypass surgery. J Thorac Cardiovasc Surg 2020; 162:851-863.e3. [PMID: 32197906 DOI: 10.1016/j.jtcvs.2020.01.079] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/15/2020] [Accepted: 01/29/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Postoperative atrial fibrillation (POAF) is a common complication in coronary artery bypass grafting (CABG) procedures. This prospective study aimed to investigate predisposition of proteins and metabolites correlated to POAF after CABG and related cellular pathways. METHODS Preoperative plasma samples from patients undergoing CABG procedures were prospectively collected. After CABG, the patients were grouped to POAF or sinus rhythm (N = 170; n = 90 in the discovery set and n = 80 in the validation set). The plasma samples were analyzed using proteomics, metabolomics, and bioinformatics to identify the differential proteins and differential metabolites. The correlation between differential proteins and POAF was also investigated by multivariable regression analysis and receiver operator characteristic analysis. RESULTS In the POAF(+) group, 29 differential proteins and 61 differential metabolites were identified compared with the POAF(-) group. The analysis of integrated omics revealed that preoperative alteration of peroxisome proliferators-activated receptor α and glutathione metabolism pathways increased the susceptibility of POAF after CABG. There was a correlation between plasma levels of apolipoprotein-C3, phospholipid transfer protein, glutathione peroxidase 3, cholesteryl ester transfer protein, and POAF. CONCLUSIONS The present study for first time at multi-omics levels explored the mechanism of POAF and validated the results in a new cohort of patients, suggesting preexisting differential proteins and differential metabolites in the plasma of patients prone to POAF after CABG. Dysregulation of peroxisome proliferators-activated receptor α and glutathione metabolism pathways related to metabolic remodeling and redox imbalance-associated electrical remodeling may play a key role in the pathogenesis of POAF. Lower plasma phospholipid transfer protein, apolipoprotein-C3, higher cholesteryl ester transfer protein and glutathione peroxidase 3 levels are linked with POAF. These proteins/metabolites may be developed as biomarkers to predict POAF.
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Affiliation(s)
- Xin-Ya Li
- Center for Basic Medical Research and Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Hai-Tao Hou
- Center for Basic Medical Research and Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Huan-Xin Chen
- Center for Basic Medical Research and Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Xiao-Cheng Liu
- Center for Basic Medical Research and Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Jun Wang
- Center for Basic Medical Research and Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Qin Yang
- Center for Basic Medical Research and Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Guo-Wei He
- Center for Basic Medical Research and Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China; Department of Cardiac Surgery, The First Affiliated Hospital, Zhejiang University, Hangzhou, China; School of Pharmacy, Wannan Medical College, Wuhu, Anhui, China; Department of Surgery, Oregon Health and Science University, Portland, Ore.
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9
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Chen HX, Li MY, Jiang YY, Hou HT, Wang J, Liu XC, Yang Q, He GW. Role of the PPAR pathway in atrial fibrillation associated with heart valve disease: transcriptomics and proteomics in human atrial tissue. Signal Transduct Target Ther 2020; 5:4. [PMID: 32296022 PMCID: PMC6971265 DOI: 10.1038/s41392-019-0093-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 11/01/2019] [Indexed: 11/09/2022] Open
Affiliation(s)
- Huan-Xin Chen
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Ming-Yang Li
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Graduate School, Peking Union Medical College, Beijing, China
| | - Yi-Yao Jiang
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Hai-Tao Hou
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Jun Wang
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Xiao-Cheng Liu
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Qin Yang
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Guo-Wei He
- Center for Basic Medical Research & Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
- The First Affiliated Hospital of Zhejiang University, Hangzhou, and School of Pharmacy, Wannan Medical College, Wuhu, China.
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA.
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10
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Almassi GH, Hawkins RB, Bishawi M, Shroyer AL, Hattler B, Quin JA, Collins JF, Bakaeen FG, Ebrahimi R, Grover FL, Wagner TH. New-onset postoperative atrial fibrillation impact on 5-year clinical outcomes and costs. J Thorac Cardiovasc Surg 2019; 161:1803-1810.e3. [PMID: 31866082 DOI: 10.1016/j.jtcvs.2019.10.150] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/27/2019] [Accepted: 10/13/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The impact of new-onset postoperative atrial fibrillation (POAF) following coronary artery bypass grafting (CABG) surgery on long-term clinical outcomes and costs is not known. This subanalysis of the Veterans Affairs "Randomized On/Off Bypass Follow-up Study" compared 5-year outcomes and costs between patients with and without POAF. METHODS Of the 2203 veterans in the study, 100 with pre-CABG atrial fibrillation (93) or missing data (7) were excluded (4.8%). Unadjusted and risk-adjusted outcomes were compared between new-onset POAF (n = 551) and patients without POAF (n = 1552). Five-year clinical outcomes included mortality, major adverse cardiovascular events (MACE, comprising mortality, repeat revascularization, and myocardial infarction), MACE subcomponents, stroke, and costs. A stringent P value of ≤.01 was required to identify statistical significance. RESULTS Patients with POAF were older and had more complex comorbidities. Unadjusted 5-year all-cause mortality was 16.3% POAF versus 11.9% no-POAF, P = .008. Unadjusted cardiac-mortality was 7.4% versus 4.8%, P = .022. There were no differences between groups in any other unadjusted outcomes including MACE or stroke. After risk adjustment, there were no significant differences between groups in 5-year all-cause mortality (POAF odds ratio, 1.19; 99% confidence interval, 0.81-1.75) or cardiac mortality (odds ratio, 1.51, 99% confidence interval, 0.88-2.60). Adjusted first-year post-CABG costs were $15,300 greater for patients with POAF, but 2- through 5-year costs were similar. CONCLUSIONS No 5-year risk-adjusted outcome differences were found between patients with and without POAF after CABG. Although first-year costs were greater in patients with POAF, this difference did not persist in subsequent years.
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Affiliation(s)
- G Hossein Almassi
- Cardiothoracic Surgery, Zablocki Veterans Affairs Medical Center, Milwaukee, Wis; Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis.
| | - Robert B Hawkins
- Department of Surgery, Salem Veterans Affairs Medical Center, Salem, Va; Department of Surgery, University of Virginia, Charlottesville, Va
| | - Muath Bishawi
- Research Office, Northport Veterans Affairs Medical Center, Northport, NY; Department of Surgery, Duke University Medical Center, Durham, NC
| | - A Laurie Shroyer
- Research Office, Northport Veterans Affairs Medical Center, Northport, NY; Research Office, Departments of Surgery and Medicine, Rocky Mountain Regional VA Medical Center, Aurora, Colo
| | - Brack Hattler
- Research Office, Departments of Surgery and Medicine, Rocky Mountain Regional VA Medical Center, Aurora, Colo; Departments of Surgery and Medicine, University of Colorado Anschutz School of Medicine, Aurora, Colo
| | - Jacquelyn A Quin
- Department of Surgery, Veterans Affairs Boston Healthcare System, West Roxbury, Mass; Harvard Medical School, Boston, Mass
| | - Joseph F Collins
- Cooperative Studies Program Coordinating Center, Perry Point Veterans Affairs Medical Center, Perry Point, Md
| | - Faisal G Bakaeen
- Department of Surgery, Pittsburgh Veterans Affairs Medical Center, Pittsburgh, Pa; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ramin Ebrahimi
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, Calif; Department of Medicine, University of California Los Angeles, Los Angeles, Calif
| | - Frederick L Grover
- Research Office, Departments of Surgery and Medicine, Rocky Mountain Regional VA Medical Center, Aurora, Colo; Departments of Surgery and Medicine, University of Colorado Anschutz School of Medicine, Aurora, Colo
| | - Todd H Wagner
- Health Economics Resource Center, Palo Alto Veterans Affairs Medical Center, Menlo Park, Calif; Department of Surgery, Stanford University, Stanford, Calif
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Abstract
Purpose of Review An overview of recent literature regarding pathophysiology, risk factors, prophylaxis, and treatment of new-onset atrial fibrillation (AF) in post-cardiac surgical patients. Recent Findings AF is the most frequent adverse event after cardiac surgery with significant associated morbidity, mortality, and financial cost. Its causes are multifactorial, and models to stratify patients into risk categories are progressing but a consistent, evidence-based system has not yet been developed. Pharmacologic and surgical interventions to prevent and treat this complication have been an area of ongoing research and recent societal guidelines reflect this. Summary Inconsistencies remain surrounding how to best identify higher-risk AF patients, which interventions should be used to prevent and treat AF, and which patient groups should receive these interventions. The evidence for these available strategies and their place in contemporary guidelines are summarized.
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12
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Wu F, Wu Y, Tao W, Zhao H, Shen D. Preoperative P-wave duration as a predictor of atrial fibrillation after coronary artery bypass grafting: A prospective cohort study with meta-analysis. Int J Nurs Sci 2018; 5:151-156. [PMID: 31406817 PMCID: PMC6626247 DOI: 10.1016/j.ijnss.2018.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 03/03/2018] [Accepted: 04/02/2018] [Indexed: 11/28/2022] Open
Abstract
Objectives Methods Results Conclusion
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Affiliation(s)
- Fangqin Wu
- School of Nursing, Capital Medical University, Beijing, China
| | - Ying Wu
- School of Nursing, Capital Medical University, Beijing, China
- Corresponding author. School of Nursing, Capital Medical University, 10 You-an-men Wai Xi-tou-tiao, Feng-tai District, Beijing, 100069, China.
| | - Wenyan Tao
- School of Nursing, Capital Medical University, Beijing, China
| | - Haibo Zhao
- Heart Center, Beijing Chao-yang Hospital Affiliated to Capital Medical University, Beijing, China
| | - Dongyan Shen
- Heart Center, Beijing Jian-gong Hospital, Beijing, China
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13
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Abstract
New-onset atrial fibrillation (NOAF) is the most common perioperative complication of heart surgery, typically occurring in the perioperative period. NOAF commonly occurs in patients who are elderly, or have left atrial enlargement, or left ventricular hypertrophy. Various factors have been identified as being involved in the development of NOAF, and numerous approaches have been proposed for its prevention and treatment. Risk factors include diabetes, obesity, and metabolic syndrome. For prevention of NOAF, β-blockers and amiodarone are particularly effective and are recommended by guidelines. NOAF can be treated by rhythm/rate control, and antithrombotic therapy. Treatment is required in patients with decreased cardiac function, a heart rate exceeding 130 beats/min, or persistent NOAF lasting for ≥ 48 h. It is anticipated that anticoagulant therapies, as well as hemodynamic management, will also play a major role in the management of NOAF. When using warfarin as an anticoagulant, its dose should be adjusted based on PT-INR. PT-INR should be controlled between 2.0 and 3.0 in patients aged < 70 years and between 1.6 and 2.6 in those aged ≥ 70 years. Rate control combined with antithrombotic therapies for NOAF is expected to contribute to further advances in treatment and improvement of survival.
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Affiliation(s)
- Takeshi Omae
- Department of Anesthesiology and Pain Clinic, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan. .,Department of Anesthesiology and Pain Medicine, School of Medicine, Juntendo University, Tokyo, Japan.
| | - Eiichi Inada
- Department of Anesthesiology and Pain Medicine, School of Medicine, Juntendo University, Tokyo, Japan
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Raiten J, Patel PA, Gutsche J. Management of postoperative atrial fibrillation in cardiac surgery patients. Semin Cardiothorac Vasc Anesth 2016; 19:122-9. [PMID: 25975595 DOI: 10.1177/1089253214551283] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Postoperative atrial fibrillation (AF) is a common arrhythmia following cardiac surgery and contributes to patient morbidity, prolonged hospital stay, and increased financial costs. The risk of postoperative AF may increase based on patient characteristics or events that occur intraoperatively or postoperatively. An understanding of these risks may be helpful in identifying which patients would benefit from prevention strategies. Acute AF presentation may range from completely indolent to rapidly progressing hemodynamic instability. Patients without hemodynamic compromise can be managed conservatively with rate control or initiation of antiarrhythmic medications. Patients with significant hemodynamic instability should undergo direct current cardioversion. In the postoperative period, it is reasonable to initiate anticoagulation after 48 hours of sustained AF or frequent episodes of postoperative AF.
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Affiliation(s)
- Jesse Raiten
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Lomivorotov VV, Efremov SM, Pokushalov EA, Karaskov AM. New-Onset Atrial Fibrillation After Cardiac Surgery: Pathophysiology, Prophylaxis, and Treatment. J Cardiothorac Vasc Anesth 2016; 30:200-16. [DOI: 10.1053/j.jvca.2015.08.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Indexed: 01/13/2023]
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Postoperative atrial fibrillation is not pulmonary vein dependent: results from a randomized trial. Heart Rhythm 2015; 12:699-705. [PMID: 25595923 DOI: 10.1016/j.hrthm.2015.01.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Although often short-lived and self-limiting, postoperative atrial fibrillation (POAF) is a well-recognized postoperative complication of cardiac surgery and is associated with a 2-fold increase in cardiovascular mortality and morbidity. OBJECTIVE Our aim was to determine whether intraoperative bilateral pulmonary vein radiofrequency ablation decreases the incidence of POAF in patients undergoing coronary artery bypass grafting (CABG). METHODS A total of 175 patients undergoing CABG was prospectively randomized to undergo adjuvant bilateral radiofrequency pulmonary vein ablation in addition to CABG (group A; n = 89) or CABG alone (group B; n = 86). Intraoperative pulmonary vein isolation was confirmed by the inability to pace the heart via the pulmonary veins after ablation. All patients received postoperative β-blocker. RESULTS There was no difference in the incidence of POAF in the treatment group who underwent adjuvant pulmonary vein ablation (group A; 37.1%) compared with the control group who did not (group B; 36.1%) (P = .887). There were no differences in postoperative inotropic support, antiarrhythmic drug use, need for oral anticoagulation, and complication rates. The mean length of postoperative hospital stay was 8.2 ± 6.5 days in the ablation group and 6.7 ± 4.6 days in the control group (P < .001). CONCLUSION Adjuvant pulmonary vein isolation does not decrease the incidence of POAF or its clinical impact but increases the mean length of stay in the hospital. The mechanism of POAF does not appear to depend on the pulmonary veins.
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Centurión OA, Shimizu A. Rate Control Strategy Elevated To Primary Treatment For Atrial Fibrillation: Has The Last Word Already Been Spoken? J Atr Fibrillation 2014; 7:1152. [PMID: 27957133 DOI: 10.4022/jafib.1152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/21/2014] [Accepted: 12/22/2014] [Indexed: 11/10/2022]
Abstract
In the last decade, we were able to see the light shed by several trials and observational studies that dealt with the appropriate manner of treating patients with atrial fibrillation (AF). Recently the AF management by cardiologists has become more aggressive, in part because of an improved comprehension of this rhythm disturbance, as well as, the availability of new treatment strategies. Increasing awareness of AF as a disease rather than as an acceptable alternative to sinus rhythm has led to search for clear arguments to support a certain strategy as a gold standard. In this respect, the decision of whether to restore sinus rhythm, or to control the ventricular rate and allow AF to persist is of critical importance. The results of randomized, controlled trials addressing this matter shed some light on the proper way of treatment for these AF patients. The AFFIRM and RACE trials and their respective sub-studies showed surprising results. The vast majority of physicians were surprised to learn that the rate control strategy was elevated to the position of primary treatment for the AF management instead of the all-time recognized rhythm control approach to restoration and maintenance of sinus rhythm. The use of anticoagulants in the trials was different in the treatment strategies. There was a greater anticoagulant use in the rate control arm because of the belief that anticoagulation can be discontinued in the rhythm control arm when sinus rhythm was restored and maintained for one month. On the other hand, only pharmacological agents were used to maintain sinus rhythm in those trials, however, there is increasing evidence that AF ablation can restore and maintain sinus rhythm in a great proportion of patients. Indeed, there are some limitations and several interesting aspects of these trials and other studies that will be discussed. The last word has not been spoken yet.
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Affiliation(s)
- Osmar Antonio Centurión
- Cardiology Department. Clinic Hospital. Asunción National University. Division of Arrhythmias and Electrophysiology, Sanatorio Migone-Battilana, Asuncion, Paraguay. The Faculty of Health Sciences, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Akihiko Shimizu
- Cardiology Department. Clinic Hospital. Asunción National University. Division of Arrhythmias and Electrophysiology, Sanatorio Migone-Battilana, Asuncion, Paraguay. The Faculty of Health Sciences, Yamaguchi University School of Medicine, Yamaguchi, Japan
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Fernandes TM, Auger WR, Fedullo PF, Kim NH, Poch DS, Madani MM, Pretorius VG, Jamieson SW, Kerr KM. Baseline body mass index does not significantly affect outcomes after pulmonary thromboendarterectomy. Ann Thorac Surg 2014; 98:1776-81. [PMID: 25240778 DOI: 10.1016/j.athoracsur.2014.06.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 05/30/2014] [Accepted: 06/11/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Obesity is a common comorbidity of patients with chronic thromboembolic pulmonary hypertension referred for pulmonary thromboendarterectomy, yet the effect of obesity on pulmonary thromboendarterectomy outcomes has not been well described. METHODS We conducted a retrospective cohort study in which 476 consecutive operations over a 3.5-year period were examined to determine the effects of obesity on outcomes. Patients were grouped into four categories based on body mass index (BMI): less than 22 kg/m2, 22 to 30 kg/m2, 30 to 40 kg/m2, and more than 40 kg/m2. RESULTS There were important differences in baseline pulmonary hemodynamics, with obese patients having significantly lower pulmonary vascular resistances than nonobese patients. All patients achieved a significant reduction in pulmonary vascular resistance, although the improvement was greatest in the lower BMI groups. The overall in-hospital mortality was 0.8%, and there were no differences in risk among BMI groups. Among the BMI groups, there were no differences in incidence of postoperative complications, including atrial fibrillation (overall 24.8%), reperfusion lung injury (overall 23.1%), and surgical site infection (overall 4.4%) or in median lengths of stay (including ventilator days, intensive care unit days, and postoperative length of stay). CONCLUSIONS Pulmonary thromboendarterectomy outcomes have continued to improve, and this surgery can safely be completed in obese patients, previously deemed to be at high risk for poor outcomes.
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Affiliation(s)
- Timothy M Fernandes
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, California.
| | - William R Auger
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, California
| | - Peter F Fedullo
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, California
| | - Nick H Kim
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, California
| | - David S Poch
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, California
| | - Michael M Madani
- Division of Cardiothoracic Surgery, University of California, San Diego, San Diego, California
| | - Victor G Pretorius
- Division of Cardiothoracic Surgery, University of California, San Diego, San Diego, California
| | - Stuart W Jamieson
- Division of Cardiothoracic Surgery, University of California, San Diego, San Diego, California
| | - Kim M Kerr
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, California
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Abstract
Atrial fibrillation is the most commonly encountered arrhythmia after cardiac surgery. Although usually self-limiting, it represents an important predictor of increased patient morbidity, mortality, and health care costs. Numerous studies have attempted to determine the underlying mechanisms of postoperative atrial fibrillation (POAF) with varied success. A multifactorial pathophysiology is hypothesized, with inflammation and postoperative β-adrenergic activation recognized as important contributing factors. The management of POAF is complicated by a paucity of data relating to the outcomes of different therapeutic interventions in this population. This article reviews the literature on epidemiology, mechanisms, and risk factors of POAF, with a subsequent focus on the therapeutic interventions and guidelines regarding management.
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Hatam N, Aljalloud A, Mischke K, Karfis EA, Autschbach R, Hoffmann R, Goetzenich A. Interatrial conduction disturbance in postoperative atrial fibrillation: a comparative study of P-wave dispersion and Doppler myocardial imaging in cardiac surgery. J Cardiothorac Surg 2014; 9:114. [PMID: 24957051 PMCID: PMC4082174 DOI: 10.1186/1749-8090-9-114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 06/13/2014] [Indexed: 12/03/2022] Open
Abstract
Objective Disturbances of interatrial conduction have been proposed as one of the contributing mechanisms of postoperative atrial fibrillation (AF). P-wave dispersion has been recognized as a sensitive tool for detecting interatrial conduction disturbances. Doppler myocardial imaging (DMI) has been validated as a non-invasive tool to indirectly reflect electrical atrial activation and therefore is used in this study to detect possible interatrial electromechanical disturbances after cardiac surgery. Methods 30 patients (23 men, age 62 ± 1 years) admitted for coronary bypass surgery with no prior history of AF were included in this investigation. Echocardiography and electrocardiograms (ECG) were obtained on the day before and after surgery. In addition to standard echocardiography, DMI-loops were acquired from the apical window. The following time intervals were derived off-line from the free right atrial (RA), left atrial (LA) lateral and LA posterior wall: onset P-wave to start (P to A’start), to peak (P to A’peak) and to end of atrial deformation (total electromechanical activity). These intervals were compared to each other and to P-wave dispersion derived from the recorded ECGs. Results All patients were in sinus rhythm during their postoperative assessment, but 11 patients presented episodes of AF within the first three postoperative days. Atrial electromechanical activation was earliest in the RA and latest in the lateral LA. In patients with AF, P-wave dispersion was significantly prolonged postoperatively (mean: +18.6 ms; 95% confidence interval (CI): 12.1–25.2 ms; p < 0.001) compared to non-AF patients (mean: -2.4 ms; CI: -6.6–1.9 ms). P dispersion was closely correlated to P to A’start intervals (from RA to LA lat.: preop.: rho = 0.74, postop.: rho = 0.87; p < 0.001). Prolonged right to left conduction interval was associated with an elevated risk for AF (from RA to LA lat.: odds ratio 1.13 (CI:1.03-1.24); p: 0.007. Conclusion DMI enabled detection of interatrial conduction disturbances in concordance to findings of prolonged postoperative P-wave dispersion. Equally effective to P-wave dispersion, this simple and reproducible tool might help to early identify the risk for postoperative AF, thus extending the informative value of routine postoperative echocardiography.
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Affiliation(s)
- Nima Hatam
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital RWTH Aachen, Pauwelsstr 30, D-52074 Aachen, Germany.
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Bidar E, Maesen B, Nieman F, Verheule S, Schotten U, Maessen JG. A prospective randomized controlled trial on the incidence and predictors of late-phase postoperative atrial fibrillation up to 30 days and the preventive value of biatrial pacing. Heart Rhythm 2014; 11:1156-62. [PMID: 24657803 DOI: 10.1016/j.hrthm.2014.03.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is considered to be a transient arrhythmia in the first week after cardiac surgery. OBJECTIVE To determine the 30-day incidence and predictors of POAF and the value of postoperative overdrive biatrial pacing in the prevention of POAF. METHODS Patients (n = 148) without a history of atrial fibrillation undergoing aortic valve replacement or coronary artery bypass graft (CABG) were randomized into a pacing group (n = 75) and a control group. Patients were treated with standardized sotalol postoperatively. Rhythm was continuously monitored for 30 days by a transtelephonic event recorder. RESULTS POAF occurred in 73 (49.3%) patients, of whom 60 (40.5%) patients showed POAF during postoperative days (PODs) 0-5 and 37 (25%) patients during PODs 6-30. Prolonged aortic cross-clamp time was an important univariate predictor of 30-day and of late POAF (PODs 6-30; P = .017 and P = .03, respectively). Best-fit model analysis using 15 predetermined risk factors for POAF showed different positive interactive effects for early POAF (ie, baseline C-reactive protein levels with a history of myocardial infarction or low body mass index) and late POAF (ie, high body mass index, diabetes mellitus, baseline C-reactive protein, early POAF, creatinine levels, type of operation, smoking, and male gender). Biatrial pacing reduced the late POAF incidence in patients with aortic cross-clamp time >50 minutes (P = .006). CONCLUSION POAF is not limited to the first week after cardiac surgery but also occurs frequently in the postoperative month. It is desirable to regularly follow patients with POAF for atrial fibrillation recurrences after discharge.
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Affiliation(s)
- Elham Bidar
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Physiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Physiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Fred Nieman
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sander Verheule
- Department of Physiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ulrich Schotten
- Department of Physiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.
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Postoperative arrhythmias after cardiac surgery: incidence, risk factors, and therapeutic management. Cardiol Res Pract 2014; 2014:615987. [PMID: 24511410 PMCID: PMC3912619 DOI: 10.1155/2014/615987] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 10/16/2013] [Indexed: 01/16/2023] Open
Abstract
Arrhythmias are a known complication after cardiac surgery and represent a major cause of morbidity, increased length of hospital stay, and economic costs. However, little is known about incidence, risk factors, and treatment of early postoperative arrhythmias. Both tachyarrhythmias and bradyarrhythmias can present in the postoperative period. In this setting, atrial fibrillation is the most common heart rhythm disorder. Postoperative atrial fibrillation is often self-limiting, but it may require anticoagulation therapy and either a rate or rhythm control strategy. However, ventricular arrhythmias and conduction disturbances can also occur. Sustained ventricular arrhythmias in the recovery period after cardiac surgery may warrant acute treatment and long-term preventive strategy in the absence of reversible causes. Transient bradyarrhythmias may be managed with temporary pacing wires placed at surgery, but significant and persistent atrioventricular block or sinus node dysfunction can occur with the need for permanent pacing. We provide a complete and updated review about mechanisms, risk factors, and treatment strategies for the main postoperative arrhythmias.
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Bidar E, Bramer S, Maesen B, Maessen JG, Schotten U. Post-operative Atrial Fibrillation - Pathophysiology, Treatment and Prevention. J Atr Fibrillation 2013; 5:781. [PMID: 28496829 DOI: 10.4022/jafib.781] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 02/13/2013] [Accepted: 02/15/2013] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation occurring after cardiac surgery has been the subject of intensive research over the past decades. However, the incidence remains high, despite numerous preventive and treatment strategies. In addition, several reports show that the impact of post-operative atrial fibrillation (POAF) is high. It is an independent risk factor for mortality after several years. These findings make clear that the pathophysiology of POAF is not fully understood and POAF-associated risks to some extent might be underestimated. On the one hand, excessive triggers during the acute post operative phase after cardiac surgery might initiate AF even in atria with low vulnerability. On the other hand, many patients undergoing surgery have an atrial substrate at the time of operation promoting AF not only in the post-operative phase but also in the days and weeks thereafter. Progress in our understanding of the AF mechanisms in general has provided valuable insights into processes involved in atrial structural remodeling due to advanced age, hypertension, obesity, and congestive heart failure. These patient characteristics strongly contribute to cardiac disease, predict POAF and likely have an impact on the risk of thrombus formation in the weeks and months after cardiac surgery. For a better understanding of the mechanisms involved, it is important to not only recognize the occurrence of POAF by continuous monitoring after surgery, but also to identity the extent of atrial vulnerability to AF in these patients.
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Affiliation(s)
- E Bidar
- Dept. Physiology and electrophysiology, Maastricht University Medical Centre.,Dept. Cardiothoracic surgery, Maastricht University Medical Centre
| | - S Bramer
- Dept. Cardiothoracic surgery, OLVG hospital, Amsterdam
| | - B Maesen
- Dept. Physiology and electrophysiology, Maastricht University Medical Centre.,Dept. Cardiothoracic surgery, Maastricht University Medical Centre
| | - J G Maessen
- Dept. Physiology and electrophysiology, Maastricht University Medical Centre
| | - U Schotten
- Dept. Cardiothoracic surgery, Maastricht University Medical Centre
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Wang W, Buehler D, Wang X, Yuan X. Effectiveness of biatrial pacing in reducing early postoperative atrial fibrillation after the maze procedure. Interact Cardiovasc Thorac Surg 2013; 16:589-93. [PMID: 23403768 DOI: 10.1093/icvts/ivt019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Interatrial conduction abnormalities have an important role in the initiation of recurrent atrial fibrillation (AF) after the maze procedure. Biatrial pacing or single atrial pacing alters the site and timing of atrial depolarization and may improve restoration of sinus rhythm after the maze procedure. To further evaluate whether biatrial pacing is superior to single atrial or no pacing, we performed a randomized prospective study on 240 patients with a full maze procedure to compare the effectiveness with different pacing approaches in the postoperative period. METHODS Between 2002 and 2010, 240 patients undergoing mitral ± tricuspid valve surgery concomitant with the maze procedure were randomized into three equal groups: Group I using overdrive biatrial pacing, Group II utilizing single atrial pacing and Group III without pacing. The atria were paced continuously in Atrium paced, Atrium sensed, and pacemaker Inhibited in response to sensed beat (AAI) mode at a rate of 80 pulses per minute or 10 pulses above the underlying rate for 5 days. The endpoints were the onset of AF or discharge. RESULTS The incidence of recurrent postoperative atrial fibrillation was significantly less in Group I with 9 of 80 patients (11%) incurring atrial fibrillation compared with 23 of 80 patients (28%) in Group II (P < 0.01) and 29 of 80 patients in Group III (P < 0.01). The length of hospital stay and the mean costs of hospital stay were significantly lower in the biatrial pacing group (P < 0.05). CONCLUSIONS Biatrial overdrive pacing is well tolerated and more effective in preventing the early recurrence of atrial fibrillation after the maze procedure. The impacts of the long-term results with the maze procedure require further study.
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Affiliation(s)
- William Wang
- Department of Cardiac Surgery, Scripps Memorial Hospital, La Jolla, CA, USA.
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Arsenault KA, Yusuf AM, Crystal E, Healey JS, Morillo CA, Nair GM, Whitlock RP. Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery. Cochrane Database Syst Rev 2013; 2013:CD003611. [PMID: 23440790 PMCID: PMC7387225 DOI: 10.1002/14651858.cd003611.pub3] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Atrial fibrillation is a common post-operative complication of cardiac surgery and is associated with an increased risk of post-operative stroke, increased length of intensive care unit and hospital stays, healthcare costs and mortality. Numerous trials have evaluated various pharmacological and non-pharmacological prophylactic interventions for their efficacy in preventing post-operative atrial fibrillation. We conducted an update to a 2004 Cochrane systematic review and meta-analysis of the literature to gain a better understanding of the effectiveness of these interventions. OBJECTIVES The primary objective was to assess the effects of pharmacological and non-pharmacological interventions for preventing post-operative atrial fibrillation or supraventricular tachycardia after cardiac surgery. Secondary objectives were to determine the effects on post-operative stroke or cerebrovascular accident, mortality, cardiovascular mortality, length of hospital stay and cost of treatment during the hospital stay. SEARCH METHODS We searched the Cochrane Central Register of ControlLed Trials (CENTRAL) (Issue 8, 2011), MEDLINE (from 1946 to July 2011), EMBASE (from 1974 to July 2011) and CINAHL (from 1981 to July 2011). SELECTION CRITERIA We selected randomized controlled trials (RCTs) that included adult patients undergoing cardiac surgery who were allocated to pharmacological or non-pharmacological interventions for the prevention of post-operative atrial fibrillation or supraventricular tachycardia, except digoxin, potassium (K(+)), or steroids. DATA COLLECTION AND ANALYSIS Two review authors independently abstracted study data and assessed trial quality. MAIN RESULTS One hundred and eighteen studies with 138 treatment groups and 17,364 participants were included in this review. Fifty-seven of these studies were included in the original version of this review while 61 were added, including 27 on interventions that were not considered in the original version. Interventions included amiodarone, beta-blockers, sotalol, magnesium, atrial pacing and posterior pericardiotomy. Each of the studied interventions significantly reduced the rate of post-operative atrial fibrillation after cardiac surgery compared with a control. Beta-blockers (odds ratio (OR) 0.33; 95% confidence interval) CI 0.26 to 0.43; I(2) = 55%) and sotalol (OR 0.34; 95% CI 0.26 to 0.43; I(2) = 3%) appear to have similar efficacy while magnesium's efficacy (OR 0.55; 95% CI 0.41 to 0.73; I(2) = 51%) may be slightly less. Amiodarone (OR 0.43; 95% CI 0.34 to 0.54; I(2) = 63%), atrial pacing (OR 0.47; 95% CI 0.36 to 0.61; I(2) = 50%) and posterior pericardiotomy (OR 0.35; 95% CI 0.18 to 0.67; I(2) = 66%) were all found to be effective. Prophylactic intervention decreased the hospital length of stay by approximately two-thirds of a day and decreased the cost of hospital treatment by roughly $1250 US. Intervention was also found to reduce the odds of post-operative stroke, though this reduction did not reach statistical significance (OR 0.69; 95% CI 0.47 to 1.01; I(2) = 0%). No significant effect on all-cause or cardiovascular mortality was demonstrated. AUTHORS' CONCLUSIONS Prophylaxis to prevent atrial fibrillation after cardiac surgery with any of the studied pharmacological or non-pharmacological interventions may be favored because of its reduction in the rate of atrial fibrillation, decrease in the length of stay and cost of hospital treatment and a possible decrease in the rate of stroke. However, this review is limited by the quality of the available data and heterogeneity between the included studies. Selection of appropriate interventions may depend on the individual patient situation and should take into consideration adverse effects and the cost associated with each approach.
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Maaroos M, Halonen J, Kiviniemi V, Hartikainen J, Hakala T. Intravenous Metoprolol versus Biatrial Pacing in the Prevention of Atrial Fibrillation after Coronary Artery Bypass Surgery: A Prospective Randomized Open Trial. Scand J Surg 2012; 101:292-6. [DOI: 10.1177/145749691210100413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Aims: Atrial fibrillation (AF) is the most common arrhythmia after coronary arteryby pass surgery (CABG). Intravenous metoprolol and biatrial pacing have been reported to be effective in AF prophylaxis after cardiac surgery. The purpose of this trial was to compare the efficacy of intravenous metoprolol versus biatrial pacing combined with oral metoprolol in the prevention of AF after CABG. Methods: A single-centre prospective randomized open trial of 165 consecutive patients undergoing their first CABG. Patients were randomized to receive either intravenous metoprolol infusion 1–3 mg per hour or biatrial overdrive pacing and oral metoprolol (50–150mg) daily for 72 hours after CABG starting immediately after the surgery. AAI pacing with a pacing rate of 10 beats/minute above the baseline heart rate was used. Patients had continuous ECG-monitoring. The primaryend point was the first episode of AF. Results: The incidence of postoperative AF in the intravenous metoprolol and biatrial pacing groups did not differ from each other (14% vs. 18% respecively, p = 0.66). There was no difference in the time of AF on set between the groups (28.2 ± 16.2 h vs. 30.1 ± 21.2 h respectively, p = 0.8). Intravenous metoprolol infusion had to be temporarily interrupted for one hour in eleven patients because of hypotension or bradycardia. One case of bleeding from the left atria related to the pacemaker electrode wire was found. Conclusion: We found no difference in the incidence of AF between patients treated with intravenous metoprolol or the combination of biatrial pacing and oral metoprolol.
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Affiliation(s)
- M. Maaroos
- Heart Center of Kuopio University Hospital, Kuopio, Finland
- Hospital Cordia, Kuopio, Finland
| | - J. Halonen
- Heart Center of Kuopio University Hospital, Kuopio, Finland
| | - V. Kiviniemi
- IT Service Centre, University of Eastern Finland, Kuopio, Finland
| | - J. Hartikainen
- Heart Center of Kuopio University Hospital, Kuopio, Finland
| | - T. Hakala
- Department of Surgery, North Karelia Central Hospital, Joensuu, Finland
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Chua J, Schwarzenberger J, Mahajan A. Optimization of Pacing After Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2012; 26:291-301. [DOI: 10.1053/j.jvca.2011.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Indexed: 11/11/2022]
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Omae T, Kanmura Y. Management of postoperative atrial fibrillation. J Anesth 2012; 26:429-37. [PMID: 22274170 PMCID: PMC3375013 DOI: 10.1007/s00540-012-1330-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 01/09/2012] [Indexed: 11/24/2022]
Abstract
The impact of postoperative atrial fibrillation (PAF) on patient outcomes has prompted intense investigation into the optimal methods for prevention and treatment of this complication. In the prevention of PAF, β-blockers and amiodarone are particularly effective and are recommended by guidelines. However, their use requires caution due to the possibility of drug-related adverse effects. Aside from these risks, perioperative prophylactic treatment with statins seems to be effective for preventing PAF and is associated with a low incidence of adverse effects. PAF can be treated by rhythm control, heart-rate control, and antithrombotic therapy. For the purpose of heart rate control, β-blockers, calcium-channel antagonists, and amiodarone are used. In patients with unstable hemodynamics, cardioversion may be performed for rhythm control. Antithrombotic therapy is used in addition to heart-rate maintenance therapy in cases of PAF >48-h duration or in cases with a history of cerebrovascular thromboembolism. Anticoagulation is the first choice for antithrombotic therapy, and anticoagulation management should focus on maintaining international normalized ratio (INRs) in the 2.0–3.0 range in patients <75 years of age, whereas prothrombin-time INR should be controlled to the 1.6–2.6 range in patients ≥75 years of age. In the future, dabigatran could be used for perioperative management of PAF, because it does not require regular monitoring and has a quick onset of action with short serum half-life. Preventing PAF is an important goal and requires specific perioperative management as well as other approaches. PAF is also associated with lifestyle-related diseases, which emphasizes the ongoing need for appropriate lifestyle management in individual patients.
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Affiliation(s)
- Takeshi Omae
- Department of Anesthesiology, Fujimoto Hayasuzu Hospital, Miyakonojo, Miyazaki, Japan.
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Wang W, Buehler D, Feng XD, Zhang SY. Continuous biatrial pacing to prevent early recurrence of atrial fibrillation after the Maze procedure. J Thorac Cardiovasc Surg 2011; 142:989-94. [PMID: 21864856 DOI: 10.1016/j.jtcvs.2011.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Revised: 06/17/2011] [Accepted: 07/11/2011] [Indexed: 10/16/2022]
Abstract
OBJECTIVE It has been suggested that overdrive biatrial pacing may prevent the recurrence of atrial fibrillation after the Maze procedure. To further evaluate this hypothesis, we performed a randomized prospective study in 100 patients undergoing valve surgery concomitant with a full Maze procedure to determine the effectiveness of biatrial pacing in the postoperative period to reduce early recurrence of atrial fibrillation. METHOD Between January 2002 and December 2008, 100 patients undergoing mitral valve ± tricuspid valve surgery concomitant with the Maze procedure were randomized into 2 equal groups: the study group using overdrive biatrial pacing and a control group without pacing. One pacing wire was attached to the crista terminalis area of the right atrium, and the other pacing wire was attached to the Bachmann's bundle area located in the roof of the left atrium. The atria were paced continuously in AAI mode at a rate of 80 pulses per minute or 10 pulses above the underlying rate for 5 days. The end points were the onset of recurrent atrial fibrillation or discharge. RESULTS The incidence of recurrent postoperative atrial fibrillation was significantly less in the study group, with 6 of 50 patients (12%) incurring atrial fibrillation compared with 18 of 50 patients (36%) in the control group (P < .01). The length of hospital stay was significantly reduced in the study group (P < .01), and the mean costs of hospital stay were significantly lower in the control group (P < .05). CONCLUSIONS Biatrial overdrive pacing is well tolerated and more effective in preventing the early recurrence of atrial fibrillation after the Maze procedure. This therapy also results in shortened hospital stays and decreased hospital costs. However, the impacts of the long-term results in the Maze procedure require further study.
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Affiliation(s)
- William Wang
- Scripps Memorial Hospital, La Jolla, Calif, USA.
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ELKAYAM LIORU, KOEHLER JODIL, SHELDON TODDJ, GLOTZER TAYAV, ROSENTHAL LAWRENCES, LAMAS GERVASIOA. The Influence of Atrial and Ventricular Pacing on the Incidence of Atrial Fibrillation: A Meta-Analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 34:1593-9. [DOI: 10.1111/j.1540-8159.2011.03192.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS. 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol 2011; 57:e101-98. [PMID: 21392637 DOI: 10.1016/j.jacc.2010.09.013] [Citation(s) in RCA: 642] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Akbarzadeh F, Kazemi-Arbat B, Golmohammadi A, Pourafkari L. Biatrial pacing vs. intravenous amiodarone in prevention of atrial fibrillation after coronary artery bypass surgery. Pak J Biol Sci 2009; 12:1325-1329. [PMID: 20387748 DOI: 10.3923/pjbs.2009.1325.1329] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
This study was aimed to compare the results of post operative biatrial pacing and i.v. amiodarone in prevention of AF. In a single blind randomized clinical trial, 210 patients scheduled for elective CABG surgery were randomized either to receive overdrive biatrial pacing, i.v. amiodarone or no intervention. Incidence of AF postoperatively evaluated. Pacing was successful in 83% of patients and 80% of patients in amiodarone group could receive their drug. Twenty and one patients developed AF. Incidence of AF in pace, amiodarone and control group was 10.7, 5.3 and 17.9%, respectively (p = 0.08). Comparing incidence of AF between pacing and control group, the difference was not significant (p = 0.2), but the difference between amiodarone and control groups was significant statistically (p = 0.03). Patients who developed AF were older but their left ventricular ejection fraction was not different with patients without AF. The ICU stay was higher in patients with AF. Use of i.v. amiodarone was more effective than biatrial pacing in prevention of post operative AF and we recommend use of this drug in high risk patients.
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Affiliation(s)
- F Akbarzadeh
- Department of Cardiology, Shahid Madani Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Abstract
Atrial fibrillation (AF) is the most common arrhythmia, with an incidence of 17-33%, after coronary artery bypass grafting (CABG) and it increases the cost of operative treatment. beta-Blocker therapy reduces markedly the incidence of postoperative AF. The more effective preventive methods, e.g. amiodarone therapy or atrial pacing, are not cost-effective for all the patients. Thus, identification of patients at high risk of AF after CABG would be helpful. This review summarizes the predictors of postoperative AF and the current methods for risk stratification. In summary, identification of the patients at high risk of postoperative AF remains a challenge. The clinical usefulness of most of the conventional factors, e.g. age or history of AF, is low. Even attempts to build logistic regression models based on the pre- and intraoperative variables have failed to provide powerful predictors for postoperative AF after CABG. From the new predictors, the P-wave duration in signal-averaged ECG looks promising. Sensitivity and negative predictive value are high, positive predictive value remains low, which limits its usefulness. Contrary, even detailed analysis of standard 12-lead ECG or measure of heart rate variability has failed to provide useful information for risk stratification. A new method for risk stratification has been developed in our centre. The diagnostic accuracy of high-rate atrial pacing seems to be sufficient to identify a group of patients to whom prophylactic treatment could be proactively targeted. Further experience is, however, warranted to verify significance of this method in everyday clinical practice.
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Affiliation(s)
- Tapio Hakala
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland.
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Abstract
Atrial fibrillation is a common arrhythmia that occurs after cardiac surgery. It is associated with an increase in morbidity, length of hospital stay and mortality. Patients who are at higher risk of postoperative atrial fibrillation should receive prophylactic treatment. Atrial fibrillation usually resolves spontaneously after heart rate is controlled; however, if patients are highly symptomatic or hemodynamically unstable, sinus rhythm should be restored by electrical or pharmacologic cardioversion.
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Affiliation(s)
- Krit Jongnarangsin
- Division of Cardiovascular Medicine, Cardiovascular Center, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5853, USA
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36
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Abstract
Atrial fibrillation (AF) is the most common dysrhythmia that affects adults, with an estimated 2.2 million people diagnosed in the United States and 4.5 million in the European Union. The development of postoperative AF is associated with negative patient outcomes. This article provides critical care nurses with an understanding of the etiology of AF, risk factors associated with the development of it, and current treatment options for this dysrhythmia. In addition to the medical management of AF, an overview of preventive protocols, nursing implications, and patient education is provided.
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Echahidi N, Pibarot P, O’Hara G, Mathieu P. Mechanisms, Prevention, and Treatment of Atrial Fibrillation After Cardiac Surgery. J Am Coll Cardiol 2008; 51:793-801. [DOI: 10.1016/j.jacc.2007.10.043] [Citation(s) in RCA: 425] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Revised: 09/21/2007] [Accepted: 10/07/2007] [Indexed: 11/25/2022]
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Abstract
Atrial fibrillation is a common arrhythmia after cardiac surgery. It is associated with an increase in morbidity, length of hospital stay, and mortality. Patients who are at higher risk of postoperative atrial fibrillation should receive prophylactic treatment. Atrial fibrillation usually resolves spontaneously after heart rate is controlled; however, if patients are highly symptomatic or hemodynamically unstable, sinus rhythm should be restored by electrical or pharmacologic cardioversion. Patients with atrial fibrillation of more than 48 hours should receive antithrombotic therapy for thromboembolism prevention.
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Affiliation(s)
- Krit Jongnarangsin
- Division of Cardiovascular Medicine, University of Michigan, Veterans Affairs Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105-2399, USA
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Abstract
Atrial fibrillation is the most common arrhythmia occurring after heart surgery. Its prevalence after coronary artery bypass surgery is 17-33%. Atrial fibrillation requires additional treatment, lengthens hospitalization and increases the overall expenses of cardiac surgery. Atrial fibrillation can cause hemodynamic problems, predispose to congestive heart failure and increase the risk of stroke. Beta-blockers have been shown to effectively prevent atrial fibrillation, and beta-blockers should be a part of the medication of every patient undergoing cardiac surgery, if there are no contraindications. Amiodarone therapy can also be considered for especially high-risk patients.
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Affiliation(s)
- Hakala Tapio
- Department of Surgery, Knorth Karelia Central Hospital, Tikkamäentie 16, Joensuu, 80210, and Kuopio University Hospital, Finland
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40
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Abstract
BACKGROUND The prolongation of intraatrial and interatrial conduction time and the inhomogeneous propagation of sinus impulses are well known electrophysiologic characteristics in patients with paroxysmal atrial fibrillation (AF). Previous studies have demonstrated that individuals with a clinical history of paroxysmal AF show a significantly increased P-wave duration in 12-lead surface electrocardiograms (ECG) and signal-averaged ECG recordings. METHODS The inhomogeneous and discontinuous atrial conduction in patients with paroxysmal AF has recently been studied with a new ECG index, P-wave dispersion. P-wave dispersion is defined as the difference between the longest and the shortest P-wave duration recorded from multiple different surface ECG leads. Up to now the most extensive clinical evaluation of P-wave dispersion has been performed in the assessment of the risk for AF in patients without apparent heart disease, in hypertensives, in patients with coronary artery disease and in patients undergoing coronary artery bypass surgery. P-wave dispersion has proven to be a sensitive and specific ECG predictor of AF in the various clinical settings. However, no electrophysiologic study has proven up to now the suspected relationship between the dispersion in the atrial conduction times and P-wave dispersion. The methodology used for the calculation of P-wave dispersion is not standardized and more efforts to improve the reliability and reproducibility of P-wave dispersion measurements are needed. CONCLUSIONS P-wave dispersion constitutes a recent contribution to the field of noninvasive electrocardiology and seems to be quite promising in the field of AF prediction.
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Affiliation(s)
- P E Dilaveris
- State Department of Cardiology, Hippokration Hospital, Athens, Greece.
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Scherr K, Jensen L, Smith H, Kozak CL. Atrial fibrillation following cardiac surgery: a retrospective cohort series. ACTA ACUST UNITED AC 2006; 21:7-13. [PMID: 16522963 DOI: 10.1111/j.0197-3118.2006.04603.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Atrial fibrillation (AF) is a common postoperative complication of cardiac surgery, yet the prevention and treatment of postoperative AF remains controversial and varies among practitioners. The purpose of this study was to document the incidence and time of onset of postoperative AF in a cardiac surgical cohort, examine risk factors implicated in the occurrence of postoperative AF, and assess effectiveness of current treatment strategies implemented for postoperative AF. A retrospective health record review was conducted on 1078 adults following cardiac surgery. Data on demographic, preoperative, perioperative, and postoperative risk factors for postoperative AF, documented episodes of AF, and clinical outcomes were recorded. Overall incidence of postoperative AF was 39.6%: 57.6% after cardiac valve surgery, 69.3% after combined coronary artery bypass graft and valve surgery, and 33% after bypass graft surgery alone. The peak onset of postoperative AF occurred on the second postoperative day. Advancing age, history of AF, combined cardiac valve and coronary artery bypass graft surgery, and high Mg+2 levels on the third postoperative day were significant predictors of postoperative AF in this cohort. Length of hospitalization increased with the presence of postoperative AF. Findings corroborate that multiple factors play a role in the development of AF following cardiac surgery.
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Affiliation(s)
- Kimberly Scherr
- Cardiothoracic Intensive Care Unit, University of Alberta Hospital, Edmonton, Canada
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Matsumoto K, Ishikawa T, Sumita S, Matsushita K, Inoue N, Kobayashi T, Uchino K, Kimura K, Umemura S. Assessment of Atrial Regional Wall Motion Using Strain Doppler Imaging During Biatrial Pacing in the Bradycardia-Tachycardia Syndrome. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 29:220-5. [PMID: 16606387 DOI: 10.1111/j.1540-8159.2006.00326.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Biatrial pacing is expected to have preventive effects on atrial fibrillation. METHODS We evaluated atrial regional wall motion by strain Doppler imaging (SDI) in 6 patients (62.5 +/- 11.3 [SD] years), who suffered from atrial fibrillation, with an implanted biatrial pacemaker. SDI was performed and atrial regional wall motion was estimated during biatrial (BiA) and right atrial appendage (RAA) pacing. RESULTS There was no significant difference in the interval from the pacing spike to the peak strain of the atrium in the lateral right atrium (LRA) between BiA and RAA pacing. However, there was a significant difference in the septal atrium (SA) between BiA and RAA pacing (225.0 +/- 19.9 vs 267.2 +/- 15.7 ms, P < 0.0001) and in the lateral left atrium (LLA) between BiA and RAA pacing (216.7 +/- 21.6 vs 275.0 +/- 16.2 ms, P < 0.0001). There were significant differences in the time difference of peak strain between BiA and RAA pacing in each atrial segment (LRA-AS: 2.2 +/- 5.9 vs 45.0 +/- 11.9 ms, P = 0.0016, SA-LLA: -8.3 +/- 5.5 vs 7.8 +/- 2.7 ms, P < 0.0011, LRA-LLA: -6.1 +/- 3.9 vs 52.8 +/- 13.2 ms, P = 0.0002). There was no significant difference in the interval from the pacing spike to the inflection point of atrial strain (S-I) of LRA. However, there were significant differences in S-I of SA (83.9 +/- 24.1 vs 129.9 +/- 30.6 ms, P = 0.0086) and LLA (102.2 +/- 37.9 vs 166.1 +/- 13.4 ms, P = 0.0028). CONCLUSION BiA pacing improved the synchronicity of regional wall motion of both atrium.
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Affiliation(s)
- Katsumi Matsumoto
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University, Graduate School of Medicine, Yokohama, Japan.
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Ozin B, Sezgin A, Atar I, Gülmez O, Saritaş B, Gültekin B, Korkmaz ME, Yildirir A, Aşlamaci S, Müderrisoğlu H. Effectiveness of triple-site triggered atrial pacing for prevention of atrial fibrillation after coronary artery bypass graft surgery. Clin Cardiol 2006; 28:479-82. [PMID: 16274096 PMCID: PMC6654509 DOI: 10.1002/clc.4960281007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Recently, several temporary multisite pacing methods have been developed for prevention of postoperative atrial fibrillation (AF). HYPOTHESIS In this study, we evaluated the effect of triple-site temporary triggered pacing in the AAT mode on the development of AF in patients undergoing coronary artery bypass graft (CABG) at high risk for developing postoperative AF. METHODS A total of 70 patients undergoing CABG were randomly assigned either to pacing group (study group, n = 35 patients) or to no pacing group (control group, n = 35 patients). The external pacemaker was programmed to pace at the atrial triggered mode at a lower rate of 40 beats/min for 4 days. RESULTS Atrial fibrillation, defined as lasting > 30 s, occurred in 4 patients (11.4%) in the study group and in 16 patients (45.7%) in the control group (p = 0.003). Sustained AF, defined as AF lasting > 10 min, also was observed less frequently in the study group than in the control group (11.6 vs. 37.1%, p = 0.024). Triple-site triggered atrial pacing was observed to reduce the incidence of AF by 75% and the incidence of sustained AF by 69%. CONCLUSIONS We believe that multiple-site temporary pacing in the triggered mode is an effective way of preventing postoperative AF. This technique may be used especially in patients at high risk of developing AF.
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Affiliation(s)
- Bülent Ozin
- Department of Cardiology, Baskent University Hospital, Ankara, Turkey.
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Matsumoto K, Ishikawa T, Sumita S, Matsushita K, Kawasaki N, Kobayashi T, Uchino K, Kimura K, Umemura S. Beneficial effects of biatrial pacing on cardiac function in patients with bradycardia -- tachycardia syndrome. Circ J 2005; 69:831-6. [PMID: 15988109 DOI: 10.1253/circj.69.831] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Biatrial (BiA) pacing prevents atrial fibrillation. By an unknown mechanism. The purpose of this study was to use Doppler echocardiography to evaluate the hemodynamic effects during BiA pacing. METHODS AND RESULTS The subjects were 7 patients with bradycardia - tachycardia syndrome with an implanted pacemaker. Atrial pacing sites were the right atrial appendage (RAA) and coronary sinus. P wave duration during BiA pacing (123 +/-16 ms) was significantly shorter than during either RAA pacing (167+/-19 ms, p<0.05) or sinus rhythm (148+/-12 ms, p<0.05). Doppler echocardiography revealed a greater cardiac output during BiA pacing than during RAA pacing (4.1+/-1.1 vs 3.5+/-0.7 L/min, p=0.042). The Doppler waveform of transmitral flow indicated that the left ventricular contraction interrupted the atrial filling wave during RAA pacing. The interval between the end of the atrial filling wave of transmitral flow and the mitral valvular closing sound was significantly increased by BiA pacing compared with RAA pacing (56+/-65 vs 40+/-57 ms, p=0.047). CONCLUSION Cardiac hemodynamics were improved by BiA pacing and reduction of left atrial load may be one of the mechanisms.
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Affiliation(s)
- Katsumi Matsumoto
- Second Department of Internal Medicine, Yokohama City University School of Medicine, Yokohama, Japan.
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Bruce GK, Friedman PA. Device-based therapies for atrial fibrillation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2005; 7:359-70. [PMID: 16138955 DOI: 10.1007/s11936-005-0020-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Ablation of the atrioventricular conduction system and pacemaker implantation is the preferred procedure for patients with atrial fibrillation (AF) in whom a rate control strategy has been selected but in whom rate-controlling medications are intolerable or ineffective. Selection of standard right ventricular (RV) pacing versus biventricular pacing is individualized, based on the degree and etiology of left ventricular dysfunction. Atrial-based pacing is clearly preferable to ventricular-based pacing in patients with sick sinus syndrome, because it leads to a reduction in the development of AF. Emerging evidence indicates that excess RV pacing is deleterious, increasing AF, heart failure, and possibly mortality. Therefore, physiologic pacing with minimization of RV pacing is desirable. Atrial pacing algorithms that increase the frequency of atrial pacing have shown modest efficacy in the prevention of AF. Use of atrial pacing algorithms is reasonable for patients with a history of AF and standard bradycardia indications for permanent pacing in whom maintenance of sinus rhythm is desirable. Studies assessing novel and multiple site atrial pacing therapies have mixed results, without compelling evidence of clinically important benefit. The exceptions are biatrial and right atrial overdrive pacing immediately after cardiac surgery. Several studies have shown effective suppression of postoperative AF with their use. Device therapy (eg, atrial antitachycardia pacing and defibrillation) for the termination of AF is effective in reducing arrhythmia burden. However, improvement in clinically relevant end points is not established and indications are not clearly defined. If a patient lacks an indication for an implantable cardioverter-defibrillator, we do not offer atrial defibrillation as a treatment option. Atrial arrhythmias may be better prevented by programming to avoid ventricular pacing than by specific atrial interventions.
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Affiliation(s)
- Gregory K Bruce
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
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Abstract
Atrial fibrillation (AF) is one of the most frequent complications of cardiac surgery, affecting more than one third of patients. The mechanism of this arrhythmia is believed to be reentry. The electrophysiologic substrate may be preexisting or may develop due to heterogeneity of refractoriness after surgery. Multiple perioperative factors have been proposed to contribute to the latter, including operative trauma, inflammation, elevations in atrial pressure (including that due to left ventricular diastolic dysfunction), autonomic nervous system imbalance, metabolic and electrolyte imbalances, or myocardial ischemic damage incurred during the operation. Whether ectopic beats originating in the pulmonary veins explain at least some episodes of postoperative AF, as has been shown for nonsurgical patients with the arrhythmia, is of current interest as such sites could easily be isolated at the time of surgery. The development of postoperative AF is associated with a higher risk of operative morbidity, prolonged hospitalization, and increased hospital cost compared with that in patients remaining in sinus rhythm. Many factors have been identified as being associated with postoperative AF, but the most consistent variable across studies is increasing patient age. It is speculated that age-related pathologic changes in the atrium contribute to arrhythmia susceptibility. An important modifiable risk factor for postoperative AF is the failure to resume therapy with beta-adrenergic receptor blockers after surgery. The stratification of patients who are at higher risk for AF would focus preventative strategies on patients who are most likely to benefit from such therapy. Nonetheless, since postoperative AF often develops in patients with comorbidities who are predisposed to other complications and prolonged hospitalization, it is presently unclear whether the prevention of postoperative AF will result in improved patient outcomes, particularly shorter hospitalizations.
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Affiliation(s)
- Charles W Hogue
- Department of Anesthesiology, Washington University School of Medicine, 660 South Euclid Ave, Box 8054, St. Louis, MO 63110, USA.
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Abstract
New-onset atrial fibrillation (AF) occurs frequently after cardiac surgery. The utility of prophylactic atrial pacing to prevent AF following cardiac surgery has been investigated in a number of trials, but clinical guidelines for its use are lacking. Trials of prophylactic atrial pacing to prevent AF following cardiac surgery were identified by searching PubMed, the Cochrane database, selected medical journals, and references in selected articles. Nine randomized controlled trials were identified that addressed prophylactic atrial pacing after cardiac surgery to prevent AF. Prophylactic right atrial pacing and prophylactic left atrial pacing have yielded inconclusive results. Prophylactic biatrial pacing (BAP) reduced the incidence of AF significantly in four studies, reduced it nonsignificantly in one study, and had no effect in one study. On the basis of the literature that was reviewed and graded for quality, it was concluded that prophylactic atrial pacing to prevent AF after cardiac surgery is safe. We recommend that BAP be considered, particularly in patients who are at high risk for the development of postoperative AF.
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Affiliation(s)
- William H Maisel
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
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Abstract
The recommendations put forth in these guidelines for the management and prevention of atrial fibrillation (AF) after cardiac surgery are based on information available at the time of the final literature review. As a result, they will become dated as new information and results from new trials becomes available. The maintenance of clinical practice guidelines is an evolving process requiring the alteration of recommendations over time, based on new studies and new results. The current set of guidelines attempts not only to identify new therapeutic options for AF after cardiac surgery but also to develop a strategy to indicate how and when to update the guidelines themselves.
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Affiliation(s)
- Peter McKeown
- Department of Surgery, Veterans Affairs Medical Center Asheville, NC 28805, USA.
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Doi A, Takagi M, Toda I, Yoshiyama M, Takeuchi K, Yoshikawa J. Acute Hemodynamic Benefits of Bi-Atrial Atrioventricular Sequential Pacing With the Optimal Atrioventricular Delay. J Am Coll Cardiol 2005; 46:320-6. [PMID: 16022962 DOI: 10.1016/j.jacc.2005.04.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2004] [Revised: 04/11/2005] [Accepted: 04/14/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We evaluate the acute effects on hemodynamics of bi-atrial (BiA) pacing with the optimal atrioventricular (AV) delays, in comparison with high right atrial (HRA) pacing and coronary sinus (CS) pacing. BACKGROUND Bi-atrial pacing has been suggested as one of the alternative therapy for preventing the recurrence of atrial fibrillation (AF). There are, however, few reports on the hemodynamic effects of BiA pacing, and the results that exist are controversial. METHODS Twenty patients were paced from HRA, left lateral site of CS, and both sites with the optimal AV delays at 80 and 100 beats/min, in random order. After 5-min pacing, maximal P-wave duration in a 12-lead electrocardiogram, cardiac output (CO), pulmonary capillary wedge pressure (PCWP), and the transmitral flow pattern by transthoracic echocardiography were measured. RESULTS Compared with HRA and CS pacing, BiA pacing delivered the shortest P-wave duration (HRA: 130 +/- 14 ms, CS: 132 +/- 19 ms, and BiA: 94 +/- 8 ms, respectively, p < 0.001) and the most improvement in CO and PCWP (HRA: 3.63 +/- 0.67 l/min and 9.2 +/- 4.3 mm Hg, CS: 3.71 +/- 0.70 l/min and 8.8 +/- 3.4 mmHg, and BiA: 3.88 +/- 0.63 l/min and 8.0 +/- 3.1 mmHg, respectively, p < 0.01). Bi-atrial pacing also significantly increased the mitral flow time velocity integral and peak A-wave velocity by transthoracic echocardiography, compared with HRA and CS pacing (HRA: 7.6 +/- 1.4 cm and 68.8 +/- 12.2 cm/s, CS: 7.8 +/- 1.4 cm and 70.5 +/- 14.5 cm/s, and BiA: 8.2 +/- 1.2 cm and 76.3 +/- 14.2 cm/s, respectively, p < 0.01). Bi-atrial pacing most significantly decreased the intervals between the atrial pacing spike and the peak of A-wave (HRA: 180 +/- 28 ms, CS: 165 +/- 21 ms, and BiA: 157 +/- 19 ms, respectively, p < 0.01). These improvements in hemodynamics significantly correlated with interatrial conduction delay. CONCLUSIONS Bi-atrial pacing made the most significant improvements of hemodynamics. These benefits may be due to the improvements in interatrial conduction delay and atrial dyssynchrony.
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Affiliation(s)
- Atsushi Doi
- Department of Internal Medicine and Cardiology, Osaka City University Graduate School of Medicine, Osaka, Japan
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