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Taha A, Martinsson A, Nielsen SJ, Rezk M, Pivodic A, Gudbjartsson T, Herrmann FEM, Bergfeldt LB, Jeppsson A. New-onset atrial fibrillation after coronary surgery and stroke risk: a nationwide cohort study. Heart 2024:heartjnl-2024-324573. [PMID: 39366738 DOI: 10.1136/heartjnl-2024-324573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 09/22/2024] [Indexed: 10/06/2024] Open
Abstract
BACKGROUND New-onset postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) increases ischaemic stroke risk, yet factors influencing this risk remain unclear. We sought to identify factors associated with 1-year ischaemic stroke risk, compare the CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes, previous Stroke/transient ischaemic attack (TIA), Vascular disease, Age 65-74 years, Sex category) and ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) scores' predictive abilities for ischaemic stroke, and assess oral anticoagulation (OAC) dispensing at discharge in patients with POAF. METHODS This nationwide cohort study used prospectively collected data from four mandatory Swedish national registries. All first-time isolated CABG patients who developed POAF during 2007-2020 were included. Multivariable logistic models were used to identify ischaemic stroke predictors and C-statistics to assess the predictive abilities of the CHA2DS2-VASc and ATRIA scores in patients without OAC. OAC dispensing patterns were described based on stroke-associated factors. RESULTS In total, 10 435 patients with POAF were identified. Out of those not receiving OAC (n=6903), 3.1% experienced an ischaemic stroke within 1 year. Advancing age (adjusted OR (aOR) 1.86 per 10-year increase, 95% CI 1.45 to 2.38), prior ischaemic stroke (aOR 18.56, 95% CI 10.05 to 34.28 at 60 years, aOR 5.95, 95% CI 3.78 to 9.37 at 80 years, interaction p<0.001), myocardial infarction (aOR 1.55, 95% CI 1.14 to 2.10) and heart failure (aOR 1.53, 95% CI 1.06 to 2.21) were independently associated with ischaemic stroke. The area under the receiver-operating characteristic curve was 0.72 (0.69-0.76) and 0.74 (0.70-0.78) for CHA2DS2-VASc and ATRIA, respectively (p=0.021). Altogether, 71.0% of patients with a stroke risk >2%/year, according to the CHA2DS2-VASc score, were not discharged on OAC. CONCLUSIONS Prior ischaemic stroke, advancing age, history of heart failure and myocardial infarction were associated with 1-year ischaemic stroke risk in patients with POAF after CABG. CHA2DS2-VASc and ATRIA scores predicted stroke risk with similar accuracy as in non-surgical atrial fibrillation cohorts. OAC dispense at discharge does not seem to reflect individual stroke risk.
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Affiliation(s)
- Amar Taha
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Goteborg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Andreas Martinsson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Goteborg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Susanne J Nielsen
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Goteborg, Sweden
- Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mary Rezk
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Goteborg, Sweden
- Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, University of Iceland, Reykjavik, Iceland
| | - Florian Ernst Martin Herrmann
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Goteborg, Sweden
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Munich, Germany
| | - Lennart B Bergfeldt
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Goteborg, Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Goteborg, Sweden
- Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, Banning AP, Budaj A, Buechel RR, Chiariello GA, Chieffo A, Christodorescu RM, Deaton C, Doenst T, Jones HW, Kunadian V, Mehilli J, Milojevic M, Piek JJ, Pugliese F, Rubboli A, Semb AG, Senior R, Ten Berg JM, Van Belle E, Van Craenenbroeck EM, Vidal-Perez R, Winther S. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J 2024; 45:3415-3537. [PMID: 39210710 DOI: 10.1093/eurheartj/ehae177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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3
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Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024; 45:3314-3414. [PMID: 39210723 DOI: 10.1093/eurheartj/ehae176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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van de Kar MRD, van Brakel TJ, Van't Veer M, van Steenbergen GJ, Daeter EJ, Crijns HJGM, van Veghel D, Dekker LRC, Otterspoor LC. Anticoagulation for post-operative atrial fibrillation after isolated coronary artery bypass grafting: a meta-analysis. Eur Heart J 2024; 45:2620-2630. [PMID: 38809189 DOI: 10.1093/eurheartj/ehae267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 03/26/2024] [Accepted: 04/16/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND AND AIMS This study aimed to evaluate clinical outcomes in patients developing post-operative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) and characterize variations in oral anticoagulation (OAC) use, benefits, and complications. METHODS A systematic search identified studies on new-onset POAF after CABG and OAC initiation. Outcomes included risks of thromboembolic events, bleeding, and mortality. Furthermore, a meta-analysis was conducted on these outcomes, stratified by the use or non-use of OAC. RESULTS The identified studies were all non-randomized. Among 1 698 307 CABG patients, POAF incidence ranged from 7.9% to 37.6%. Of all POAF patients, 15.5% received OAC. Within 30 days, thromboembolic events occurred at rates of 1.0% (POAF: 0.3%; non-POAF: 0.8%) with 2.0% mortality (POAF: 1.0%; non-POAF: 0.5%). Bleeding rates were 1.1% for POAF patients and 2.7% for non-POAF patients. Over a median of 4.6 years, POAF patients had 1.73 thromboembolic events, 3.39 mortality, and 2.00 bleeding events per 100 person-years; non-POAF patients had 1.14, 2.19, and 1.60, respectively. No significant differences in thromboembolic risks [effect size -0.11 (-0.36 to 0.13)] and mortality [effect size -0.07 (-0.21 to 0.07)] were observed between OAC users and non-users. However, OAC use was associated with higher bleeding risk [effect size 0.32 (0.06-0.58)]. CONCLUSIONS In multiple timeframes following CABG, the incidence of complications in patients who develop POAF is low. The use of OAC in patients with POAF after CABG is associated with increased bleeding risk.
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Affiliation(s)
- Mileen R D van de Kar
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
| | - Thomas J van Brakel
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
| | - Marcel Van't Veer
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Gijs J van Steenbergen
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
| | - Edgar J Daeter
- Department of Cardiothoracic Surgery, Antonius Hospital, Utrecht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology and Cardiovascular Research Centre Maastricht (CARIM), Maastricht UMC+, Maastricht, The Netherlands
| | - Dennis van Veghel
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
| | - Lukas R C Dekker
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Luuk C Otterspoor
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
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Aghakouchakzadeh M, Hosseini K, Haghjoo M, Mirzabeigi P, Tajdini M, Talasaz AH, Jalali A, Askarinejad A, Kohansal E, Hedayat B, Parvas E, Bozorgi A, Bagheri J, Givtaj N, Hadavand N, Hajighasemi A, Tafti SHA, Hosseini S, Sadeghipour P, Kakavand H. Empagliflozin to prevent post-operative atrial fibrillation in patients undergoing coronary artery bypass graft surgery: Rationale and design of the EMPOAF trial. Pacing Clin Electrophysiol 2024; 47:1087-1095. [PMID: 38946138 DOI: 10.1111/pace.15038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 05/31/2024] [Accepted: 06/18/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is one of the most common types of acute AF and can complicate the treatment course of approximately one third of patients undergoing cardiac surgery. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are among the newest antidiabetic drugs which can be therapeutic options for preventing POAF by different mechanisms. METHODS Empagliflozin to Prevent POAF (EMPOAF) is an interventional, investigator-initiated, double-blind, placebo-controlled, multicenter, randomized controlled trial which will be conducted in two referral teaching cardiology hospitals in Tehran. Four-hundred ninety-two adult patients who are scheduled for elective isolated coronary artery bypass graft (CABG) surgery will be randomly assigned to one of the groups of intervention (empagliflozin 10 mg daily) or placebo starting at least 3 days before surgery until discharge. Key exclusion criteria are a history of diabetes mellitus, AF, ketoacidosis, or recurrent urinary tract infections along with severe renal or hepatic impairment, unstable hemodynamics, and patients receiving SGLT2 inhibitors for another indication. The primary outcome will be the incidence of POAF. Key secondary endpoints will be the composite rate of life-threatening arrhythmias, postoperative acute kidney injury, hospitalization length, in-hospital mortality, stroke, and systemic embolization. Key safety endpoints will be the rate of life-threatening and/or genitourinary tract infections, hypoglycemia, and ketoacidosis. CONCLUSIONS EMPOAF will prospectively evaluate whether empagliflozin 10 mg daily can reduce the rate of POAF in patients undergoing elective CABG. Enrolment into this study has started by November 2023 and is expected to be ended before the end of 2025.
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Affiliation(s)
| | - Kaveh Hosseini
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Haghjoo
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Parastoo Mirzabeigi
- Department of Clinical Pharmacy and Pharmacoeconomics, Faculty of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | - Masih Tajdini
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Askarinejad
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Erfan Kohansal
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Behnam Hedayat
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Parvas
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Bozorgi
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jamshid Bagheri
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nader Givtaj
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Naser Hadavand
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | | | - Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Parham Sadeghipour
- Vascular Disease and Thrombosis Research Center, Rajaie Cardiovascular Medical and Research Institute, Tehran, Iran
| | - Hessam Kakavand
- Department of Clinical Pharmacy and Pharmacoeconomics, Faculty of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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6
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Zhang H, Zhang D, Qu J, Wang J, Rao C, Chen S, Zhao Y, Li H, Gao G, Liu S, Qian X, Zheng Z. Association of carotid duplex ultrasonography screening with stroke and mortality among patients undergoing coronary artery bypass grafting. J Vasc Surg 2024; 80:153-162.e4. [PMID: 38460766 DOI: 10.1016/j.jvs.2024.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/25/2024] [Accepted: 02/04/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVE Selection criteria for carotid duplex ultrasonography screening (DUS) before coronary artery bypass grafting (CABG) is primarily based on limited observational analysis, and the risks associated with carotid artery stenosis (CAS) detected by this approach to preoperative DUS are uncertain. This study aimed to determine the association of carotid DUS with stroke and mortality among patients undergoing CABG. METHODS Adult patients with coronary artery disease who underwent isolated CABG or CABG with concomitant valvular or congenital procedure were identified. CHA2DS2-VASc score was assessed before CABG, and patients were recorded as high risk if they had a score of 3 or higher. The primary outcomes were stroke and all-cause mortality. Secondary outcomes included ischemic stroke, non-ischemic stroke, transient ischemic attack, and cardiovascular mortality. RESULTS Among 8958 patients who underwent CABG, 70.9% (n = 6347) received carotid DUS preoperatively (low-risk, 57.3%; high-risk, 42.7%). In the low-risk cohort, there was no significant difference in the risk of stroke (20.7 per 1000 patient-years for CAS vs 13.1 per 1000 patient-years for no CAS; adjusted hazard ratio [aHR], 1.14; 95% confidence interval [CI], 0.78-1.68) or mortality (20.5 per 1000 patient-years for CAS vs 16.8 per 1000 patient-years for no CAS; aHR, 1.33; 95% CI, 0.97-1.83) at 15 years. In the high-risk cohort, CAS was associated with significantly higher risks of stroke at 30 days (433.2 vs 279.5 per 1000 patient-years; aHR, 1.92; 95% CI, 1.00-3.70) and mortality at 15 years (38.4 vs 32.7 per 1000 patient-years; aHR, 1.25; 95% CI, 1.01-1.57) compared with no CAS. CONCLUSIONS CAS did not impact the incidence of stroke or mortality in the low-risk cohort who underwent CABG. However, in the high-risk cohort, CAS was associated with a significant increase in the risks of 30-day stroke and 15-year mortality, indicating selective carotid DUS is necessarily recommended for these patients.
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Affiliation(s)
- Heng Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Danwei Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiac Surgery, Fujian Children's Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, People's Republic of China
| | - Jianyu Qu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jingjin Wang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Chenfei Rao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Sipeng Chen
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yan Zhao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Haojie Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Ge Gao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Sheng Liu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xiangyang Qian
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
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Jameie M, Rezaee M, Pashang M, Jalali A, Khalaji A, Behnoush AH, Fallahzadeh A, Sheikhy A, Masoudkabir F, Tafti HA, Momtahen S, Mansourian S, Hosseini K. Factors Affecting Late Atrial Fibrillation and Its Association With Coronary Artery Bypass Outcomes. Ann Thorac Surg 2024; 117:1145-1152. [PMID: 38360338 DOI: 10.1016/j.athoracsur.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/07/2024] [Accepted: 02/05/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Although predictors and outcomes of postoperative atrial fibrillation (POAF) are well studied, evidence is lacking concerning postdischarge late/recurrent atrial fibrillation (AF). This study evaluated factors affecting late/recurrent AF and its association with coronary artery bypass grafting (CABG) outcomes in a real-world setting. METHODS From 2012 through 2016, 5175 patients were included. Independent factors associated with late/recurrent AF were identified in a competing risk setting. Cox proportional hazard regression was used to evaluate the association between late/recurrent AF and study outcomes, consisting of all-cause mortality, major adverse cardio-cerebrovascular events, acute coronary syndrome, cerebrovascular events, and heart failure admissions. RESULTS During a median follow-up of 60 months (quartile 1-quartile 3, 59.3-60.7 months), late/recurrent AF developed in 85 patients (1.64%). Independent factors associated with late/recurrent AF were age (subdistribution hazard ratio [sHR], 1.04; 95% CI, 1.02-1.07), left-ventricular ejection fraction (sHR, 0.97; 95% CI, 0.95-0.99), length of stay (sHR, 1.02; 95% CI, 1.01-1.04), and POAF (sHR, 4.02; 95% CI, 2.50-6.45). Late/recurrent AF was not significantly associated with all-cause mortality and major adverse cardio-cerebrovascular events at unadjusted or adjusted levels (adjusted hazard ratio, 0.80 [95% CI, 0.50-1.28] and 0.74 [95% CI, 0.48-1.13], respectively). Nevertheless, it significantly increased the unadjusted risk of cerebrovascular events (hazard ratio, 2.28; 95% CI, 01.07-4.87), which disappeared after adjustments. CONCLUSIONS Patients with advanced age, a lower left-ventricular ejection fraction, and POAF are more likely to have late/recurrent clinical AF. Albeit counterintuitive, late/recurrent AF was not independently associated with worse midterm post-CABG outcomes. These observations need to be further elucidated in larger-scale studies and interpreted in the context of a developing country with limited resources for late AF surveillance.
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Affiliation(s)
- Mana Jameie
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Malihe Rezaee
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mina Pashang
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirmohammad Khalaji
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Behnoush
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Aida Fallahzadeh
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Sheikhy
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzad Masoudkabir
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Ahmadi Tafti
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahram Momtahen
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Soheil Mansourian
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
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Sajja LR. Six decades of cardiothoracic surgery: navigating new horizons, mending hearts with science and precision. Indian J Thorac Cardiovasc Surg 2024; 40:280-291. [PMID: 38681701 PMCID: PMC11045708 DOI: 10.1007/s12055-024-01719-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 05/01/2024] Open
Affiliation(s)
- Lokeswara Rao Sajja
- Division of Cardiothoracic Surgery, Star Hospitals, Road No. 10, Banjara Hills, Hyderabad, Telangana India 500034
- Division of Clinical Research in Cardiovascular Medicine/Surgery, Sajja Heart Foundation, Hyderabad, India 500073
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Krahn KM, Koshman SL, Wang T, Chen J, Bungard TJ, Zhou JS, Omar MA, Cowley EC. Anticoagulant Prescribing Patterns in New-Onset Atrial Fibrillation After Cardiac Surgery. Ann Thorac Surg 2024; 117:859-865. [PMID: 38081497 DOI: 10.1016/j.athoracsur.2023.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 11/08/2023] [Accepted: 11/20/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and is associated with an increased risk of thromboembolic stroke. Recommendations regarding the optimal anticoagulant, timing of initiation, and duration of therapy remain uncertain. METHODS Administrative databases were used to include adult patients who presented with POAF after cardiac surgery between January 1, 2015, and December 31, 2020. Key exclusion criteria included preexisting atrial fibrillation, mechanical valve replacement, or anticoagulant prescription fill within 6 months before the index admission. RESULTS A total of 3214 of patients were included, and 878 (27.3%) were prescribed an oral anticoagulant (OAC) on discharge, with 536 (61%) prescribed warfarin and 342 (39%) prescribed a direct OAC. More than half of the patients (56.1%) stopped their OAC by 6 months. There was no difference in stroke or systemic embolism at 30 days, 3 months, or 6 months between those with and without anticoagulation prescribed. However, those on any OAC had higher rates of any bleeding at all time points. CONCLUSIONS A minority of patients who presented with POAF after cardiac surgery were prescribed OAC, with warfarin being the most common agent. OAC initiation was associated with increased bleeding risk, warranting special consideration when assessing a patient's risk of stroke with the increased risk of bleeding, particularly in the postoperative period.
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Affiliation(s)
- Kaitlyn M Krahn
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sheri L Koshman
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Ting Wang
- Data and Research Services, Alberta Strategy for Patient Oriented Research Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - June Chen
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Tammy J Bungard
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Jian Song Zhou
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Mohamed A Omar
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Emily C Cowley
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada.
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10
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Campbell NG, Allen E, Evans R, Jamal Z, Opondo C, Sanders J, Sturgess J, Montgomery HE, Elbourne D, O’Brien B. Impact of maintaining serum potassium concentration ≥ 3.6mEq/L versus ≥ 4.5mEq/L for 120 hours after isolated coronary artery bypass graft surgery on incidence of new onset atrial fibrillation: Protocol for a randomized non-inferiority trial. PLoS One 2024; 19:e0296525. [PMID: 38478488 PMCID: PMC10936833 DOI: 10.1371/journal.pone.0296525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/20/2023] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND Atrial Fibrillation After Cardiac Surgery (AFACS) occurs in about one in three patients following Coronary Artery Bypass Grafting (CABG). It is associated with increased short- and long-term morbidity, mortality and costs. To reduce AFACS incidence, efforts are often made to maintain serum potassium in the high-normal range (≥ 4.5mEq/L). However, there is no evidence that this strategy is efficacious. Furthermore, the approach is costly, often unpleasant for patients, and risks causing harm. We describe the protocol of a planned randomized non-inferiority trial to investigate the impact of intervening to maintain serum potassium ≥ 3.6 mEq/L vs ≥ 4.5 mEq/L on incidence of new-onset AFACS after isolated elective CABG. METHODS Patients undergoing isolated CABG at sites in the UK and Germany will be recruited, randomized 1:1 and stratified by site to protocols maintaining serum potassium at either ≥ 3.6 mEq/L or ≥ 4.5 mEq/L. Participants will not be blind to treatment allocation. The primary endpoint is AFACS, defined as an episode of atrial fibrillation, flutter or tachycardia lasting ≥ 30 seconds until hour 120 after surgery, which is both clinically detected and electrocardiographically confirmed. Assuming a 35% incidence of AFACS in the 'tight control group', and allowing for a 10% loss to follow-up, 1684 participants are required to provide 90% certainty that the upper limit of a one-sided 97.5% confidence interval (CI) will exclude a > 10% difference in favour of tight potassium control. Secondary endpoints include mortality, use of hospital resources and incidence of dysrhythmias not meeting the primary endpoint (detected using continuous heart rhythm monitoring). DISCUSSION The Tight K Trial will assess whether a protocol to maintain serum potassium ≥ 3.6 mEq/L is non inferior to maintaining serum potassium ≥ 4.5 mEq/L in preventing new-onset AFACS after isolated CABG. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04053816. Registered on 13 August 2019. Last update 7 January 2021.
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Affiliation(s)
- Niall G. Campbell
- Faculty of Biology, Division of Cardiovascular Sciences, School of Medical Sciences, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Manchester Heart Institute, Manchester University Foundation NHS Trust, Manchester, United Kingdom
| | - Elizabeth Allen
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard Evans
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Zahra Jamal
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Charles Opondo
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Julie Sanders
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Joanna Sturgess
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Hugh E. Montgomery
- Division of Medicine and Institute for Sport, Exercise and Health, University College London, London, United Kingdom
| | - Diana Elbourne
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Benjamin O’Brien
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Berlin, Germany
- Department of Perioperative Medicine, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
- Outcomes Research Consortium, Cleveland, Ohio, United States of America
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11
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Nikolaou M, Pattakos G, Hitas C, Koniari K, Pitsis A, Iliopoulos D, Xintarakou Α, Vardas EP, Pattakos S, Tzeis S, Vardas P. Atrial fibrillation post CABG and the risk of arrhythmia recurrence: the AFRODITE study. Hellenic J Cardiol 2024:S1109-9666(24)00058-7. [PMID: 38453014 DOI: 10.1016/j.hjc.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/25/2024] [Accepted: 03/03/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND New-onset postoperative atrial fibrillation (POAF) after coronary artery bypass surgery (CABG) occurs with an incidence of 20-40%. The clinical relevance of POAF remains a concern, and the need for further studies regarding the clinical management of POAF is necessary. AIM The AFRODITE study, a prospective multicenter cohort study, had as its primary endpoint the evaluation of AF recurrence in patients post CABG over a one-year period. METHODS Two hundred twenty-eight patients aged >50 years who underwent isolated CABG were included in the study. Patients were stratified into two groups, POAF and non-POAF, and followed for 12 months for AF recurrence, hospitalizations, and death. RESULTS Two hundred twenty-eight patients (mean age 67 years, 88.6% male) were included in the study. 28.5% of patients experienced at least one episode of POAF during index hospitalization (POAF group) and were compared with the non-POAF group (n = 163). Multivariate stepwise logistic regression analysis showed that the strongest prognostic parameter for POAF was the CHA2DS2-VASc score (odds ratio = 1.61, p < 0.001). POAF patients had a worse in-hospital outcome, but the incidence of long-term AF recurrence was not statistically different (3.6% vs. 4.8%, p = 0.9). CONCLUSION Interestingly, a one-year prospective follow-up of patients in the study did not reveal significant differences between POAF and non-POAF patients. A notable finding was that patients with a higher CHA2DS2-VASc score were more likely to develop POAF.
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Affiliation(s)
- Maria Nikolaou
- Cardiology Department, Amalia Fleming General Hospital, Melissia, Attiki, Greece.
| | - Gregory Pattakos
- Second Department of Cardiac Surgery and Division of Transcatheter Heart Valves, HYGEIA Hospital, Athens, Greece.
| | - Christos Hitas
- Cardiology Department, Amalia Fleming General Hospital, Melissia, Attiki, Greece.
| | - Katerina Koniari
- Sixth Department of Cardiology, Hygeia Group Hospitals, Athens, Greece.
| | - Antoniοs Pitsis
- First Department of Cardiac Surgery, European Interbalkan Medical Center, Greece.
| | - Dimitrios Iliopoulos
- Fourth Department of Cardiac Surgery, Hygeia Hospital, Maroussi, Attiki, Greece.
| | - Αnastasia Xintarakou
- First Cardiology Department, Hippokration Hospital, National and Kapodistrian University of Athens, Greece.
| | - Emmanouil P Vardas
- Department of Cardiology, "G. Gennimatas" Athens General Hospital, Athens, Greece.
| | - Stratis Pattakos
- Second Department of Cardiac Surgery and Division of Transcatheter Heart Valves, HYGEIA Hospital, Athens, Greece.
| | - Stylianos Tzeis
- Cardiology Department, Mitera Hospital, Hygeia Group, Athens, Greece.
| | - Panagiotis Vardas
- Head of Heart Sector, Hygeia Group Hospitals, Hellenic Health Group, Athens, Greece.
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12
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Herrmann FEM, Taha A, Nielsen SJ, Martinsson A, Hansson EC, Juchem G, Jeppsson A. Recurrence of Atrial Fibrillation in Patients With New-Onset Postoperative Atrial Fibrillation After Coronary Artery Bypass Grafting. JAMA Netw Open 2024; 7:e241537. [PMID: 38451520 PMCID: PMC10921254 DOI: 10.1001/jamanetworkopen.2024.1537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 01/18/2024] [Indexed: 03/08/2024] Open
Abstract
Importance New-onset postoperative atrial fibrillation (POAF) occurs in approximately 30% of patients undergoing coronary artery bypass grafting (CABG). It is unknown whether early recurrence is associated with worse outcomes. Objective To test the hypothesis that early AF recurrence in patients with POAF after CABG is associated with worse outcomes. Design, Setting, and Participants This Swedish nationwide cohort study used prospectively collected data from the SWEDEHEART (Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) registry and 3 other mandatory national registries. The study included patients who underwent isolated first-time CABG between January 1, 2007, and December 31, 2020, and developed POAF. Data analysis was performed between March 6 and September 16, 2023. Exposure Early AF recurrence defined as an episode of AF leading to hospital care within 3 months after discharge. Main Outcomes and Measures The primary outcome was all-cause mortality. Secondary outcomes included ischemic stroke, any thromboembolism, heart failure hospitalization, and major bleeding within 2 years after discharge. The groups were compared with multivariable Cox regression models, with early AF recurrence as a time-dependent covariate. The hypothesis tested was formulated after data collection. Results Of the 35 329 patients identified, 10 609 (30.0%) developed POAF after CABG and were included in this study. Their median age was 71 (IQR, 66-76) years. The median follow-up was 7.1 (IQR, 2.9-9.0) years, and most patients (81.6%) were men. Early AF recurrence occurred in 6.7% of patients. Event rates (95% CIs) per 100 patient-years with vs without early AF recurrence were 2.21 (1.49-3.24) vs 2.03 (1.83-2.25) for all-cause mortality, 3.94 (2.92-5.28) vs 2.79 (2.56-3.05) for heart failure hospitalization, and 3.97 (2.95-5.30) vs 2.74 (2.51-2.99) for major bleeding. No association between early AF recurrence and all-cause mortality was observed (adjusted hazard ratio [AHR], 1.17 [95% CI, 0.80-1.74]; P = .41). In exploratory analyses, there was an association with heart failure hospitalization (AHR, 1.80 [95% CI, 1.32-2.45]; P = .001) and major bleeding (AHR, 1.92 [1.42-2.61]; P < .001). Conclusions and Relevance In this cohort study of early AF recurrence after POAF in patients who underwent CABG, no association was found between early AF recurrence and all-cause mortality. Exploratory analyses showed associations between AF recurrence and heart failure hospitalization, oral anticoagulation, and major bleeding.
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Affiliation(s)
- Florian E. M. Herrmann
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research) Partner Site Munich Heart Alliance, Munich, Germany
| | - Amar Taha
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Susanne J. Nielsen
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Martinsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Emma C. Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gerd Juchem
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
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13
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Suero OR, Ali AK, Barron LR, Segar MW, Moon MR, Chatterjee S. Postoperative atrial fibrillation (POAF) after cardiac surgery: clinical practice review. J Thorac Dis 2024; 16:1503-1520. [PMID: 38505057 PMCID: PMC10944787 DOI: 10.21037/jtd-23-1626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/18/2024] [Indexed: 03/21/2024]
Abstract
Postoperative atrial fibrillation (POAF) after cardiac surgery is associated with elevated morbidity and mortality. Although current prediction models have limited efficacy, several perioperative interventions can reduce patients' risk of POAF. These begin with preoperative medications, including beta-blockers and amiodarone. Moreover, patients should be screened for preexisting atrial fibrillation (AF) so that concomitant surgical ablation and left atrial appendage occlusion can be performed in appropriate candidates. Intraoperative interventions such as posterior pericardiectomy can reduce mediastinal fluid accumulation, which is a trigger for POAF. Furthermore, many preventive strategies for POAF are implemented in the immediate postoperative period. Initiating beta-blockers, amiodarone, or both is reasonable for most patients. Overdrive atrial pacing, colchicine, and steroids have been used by some, although the evidence base is less robust. For patients with POAF, rate-control and rhythm-control strategies have comparable outcomes. Decision-making regarding anticoagulation should recognize that the stroke risk associated with POAF appears to be lower than that for general nonvalvular AF. The evidence that oral anticoagulation reduces stroke risk is less clear for POAF patients than for patients with general nonvalvular AF. Given that POAF tends to be shorter-lived and is associated with greater bleeding risks in the perioperative period, decisions regarding anticoagulation should be individualized. Finally, wearable technology and machine learning algorithms for better predicting and managing POAF appear to be coming soon. These technologies and a comprehensive clinical program could meaningfully reduce the incidence of this common complication.
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Affiliation(s)
- Orlando R. Suero
- Divisions of Cardiovascular Anesthesia & Critical Care Medicine, Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
| | - Ahmed K. Ali
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Lauren R. Barron
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
| | - Matthew W. Segar
- Department of Cardiology, The Texas Heart Institute, Houston, TX, USA
| | - Marc R. Moon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
- Division of General Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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14
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Gautier A, Picard F, Ducrocq G, Elbez Y, Fox KM, Ferrari R, Ford I, Tardif JC, Tendera M, Steg PG. New-onset atrial fibrillation and chronic coronary syndrome in the CLARIFY registry. Eur Heart J 2024; 45:366-375. [PMID: 37634147 PMCID: PMC10834159 DOI: 10.1093/eurheartj/ehad556] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 07/13/2023] [Accepted: 08/20/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND AIMS Data on new-onset atrial fibrillation (NOAF) in patients with chronic coronary syndromes (CCS) are scarce. This study aims to describe the incidence, predictors, and impact on cardiovascular (CV) outcomes of NOAF in CCS patients. METHODS Data from the international (45 countries) CLARIFY registry (prospeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) were used. Among 29 001 CCS outpatients without previously reported AF at baseline, patients with at least one episode of AF/flutter diagnosed during 5-year follow-up were compared with patients in sinus rhythm throughout the study. RESULTS The incidence rate of NOAF was 1.12 [95% confidence interval (CI) 1.06-1.18] per 100 patient-years (cumulative incidence at 5 years: 5.0%). Independent predictors of NOAF were increasing age, increasing body mass index, low estimated glomerular filtration rate, Caucasian ethnicity, alcohol intake, and low left ventricular ejection fraction, while high triglycerides were associated with lower incidence. New-onset atrial fibrillation was associated with a substantial increase in the risk of adverse outcomes, with adjusted hazard ratios of 2.01 (95% CI 1.61-2.52) for the composite of CV death, non-fatal myocardial infarction, or non-fatal stroke, 2.61 (95% CI 2.04-3.34) for CV death, 1.64 (95% CI 1.07-2.50) for non-fatal myocardial infarction, 2.27 (95% CI 1.85-2.78) for all-cause death, 8.44 (95% CI 7.05-10.10) for hospitalization for heart failure, and 4.46 (95% CI 2.85-6.99) for major bleeding. CONCLUSIONS Among CCS patients, NOAF is common and is strongly associated with worse outcomes. Whether more intensive preventive measures and more systematic screening for AF would improve prognosis in this population deserves further investigation.
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Affiliation(s)
- Alexandre Gautier
- Department of Cardiology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials, INSERM U1148, Laboratory for Vascular Translational Science, 46 rue Henri Huchard, 75018 Paris, France
- Université Paris Cité, 85 boulevard Saint-Germain, 75006 Paris, France
| | - Fabien Picard
- Université Paris Cité, 85 boulevard Saint-Germain, 75006 Paris, France
- Department of Cardiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Gregory Ducrocq
- Department of Cardiology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials, INSERM U1148, Laboratory for Vascular Translational Science, 46 rue Henri Huchard, 75018 Paris, France
- Université Paris Cité, 85 boulevard Saint-Germain, 75006 Paris, France
| | - Yedid Elbez
- Signifience, 35 rue de l'Oasis, 92800 Puteaux, France
| | - Kim M Fox
- NHLI Imperial College, Dovehouse Street, London SW3 6LP, UK
| | - Roberto Ferrari
- Centro Cardiologico Universitario di Ferrara, University of Ferrara, Via Aldo Moro 8, 44124 Cona (FE) Italy, Scientific Department of Medical Trial Analysis (MTA), Via Antonio Riva 6, 6900, Lugano, Switzerland
| | - Ian Ford
- Robertson Centre for Biostatistics, Boyd Orr Building, University Avenue, University of Glasgow, Glasgow G12 8QQ, UK
| | - Jean-Claude Tardif
- Montreal Heart Institute, Université de Montreal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada
| | - Michal Tendera
- Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Ziolowa Street 45/47, 40-635 Katowice, Poland
| | - Philippe Gabriel Steg
- Department of Cardiology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials, INSERM U1148, Laboratory for Vascular Translational Science, 46 rue Henri Huchard, 75018 Paris, France
- Université Paris Cité, 85 boulevard Saint-Germain, 75006 Paris, France
- Institut Universitaire de France, 1 Rue Descartes, 75005 Paris, France
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15
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Chatterjee S, Ad N, Badhwar V, Gillinov AM, Alexander JH, Moon MR. Anticoagulation for atrial fibrillation after cardiac surgery: Do guidelines reflect the evidence? J Thorac Cardiovasc Surg 2024; 167:694-700. [PMID: 37037415 DOI: 10.1016/j.jtcvs.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/25/2023] [Indexed: 04/12/2023]
Affiliation(s)
- Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex.
| | - Niv Ad
- Division of Cardiac Surgery, White Oak Medical Center, Adventist HealthCare, University of Maryland, Takoma Park, Md
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - John H Alexander
- Division of Cardiology, Duke University School of Medicine & Duke Clinical Research Institute, Durham, NC
| | - Marc R Moon
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
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16
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Fanning JP, Campbell BCV, Bulbulia R, Gottesman RF, Ko SB, Floyd TF, Messé SR. Perioperative stroke. Nat Rev Dis Primers 2024; 10:3. [PMID: 38238382 DOI: 10.1038/s41572-023-00487-6] [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] [Accepted: 12/01/2023] [Indexed: 01/23/2024]
Abstract
Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.
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Affiliation(s)
- Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Anaesthesia & Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
- The George Institute for Global Health, Sydney, New South Wales, Australia.
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Bruce C V Campbell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | - Sang-Bae Ko
- Department of Neurology and Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Thomas F Floyd
- Department of Anaesthesiology & Pain Management, Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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17
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Yan H, Zhang J, Wu FQ, Du GF. Association Between Serum Levels of Nicotinamide-Adenine Dinucleotide Phosphate Oxidase 2 and the Development of Atrial Fibrillation After Isolated Coronary Artery Bypass Grafting: A Prospective Pilot Study. Biol Res Nurs 2024; 26:35-45. [PMID: 37347818 DOI: 10.1177/10998004231185295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
INTRODUCTION To investigate the levels of nicotinamide-adenine dinucleotide phosphate oxidase 2 (NOX2) in serum and pericardial drainage samples in the early stage after coronary artery bypass grafting (CABG) and determine whether NOX2 is predictive of postoperative atrial fibrillation (POAF). MATERIALS AND METHODS This prospective pilot study involved 152 adults without history of atrial fibrillation who underwent first-time elective isolated CABG. Serum and pericardial fluid samples were simultaneously obtained from patients at baseline and 4, 12, and 24 h post operation. NOX2 levels were determined using enzyme-linked immunosorbent assays. The heart rhythm of patients was continuously monitored through a Holter monitor until discharge. Logistic regression and receiver-operating characteristic (ROC) curve analyses were performed, as appropriate. RESULTS Fifty-one patients (33.6%) experienced in-hospital POAF. NOX2 concentration in serum and pericardial drainage samples was increased after surgery, reached its peak at 12 h, and gradually declined thereafter toward the baseline levels by 24 h. At 12 h, patients with POAF had higher levels of serum NOX2 than those without (3.96 ± 0.35 vs. 3.70 ± 0.75 μg/mL, respectively, p = 0.004). There were no discernible differences in pericardial NOX2 between the 2 groups. Multivariate analysis revealed that serum NOX2 at 12 h post operation was the strongest independent predictor of POAF (odds ratio: 2.179, 95% confidence interval: 1.084-4.377). The area under the ROC curve of the POAF predictive model was 0.732 (95% confidence interval: 0.654-0.801). CONCLUSION Serum NOX2 may be useful in the identification of POAF. Larger studies are warranted to substantiate these findings.
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Affiliation(s)
- Hui Yan
- School of Nursing, Capital Medical University, Beijing, China
| | - JiaYing Zhang
- School of Nursing, Capital Medical University, Beijing, China
| | - Fang Qin Wu
- School of Nursing, Capital Medical University, Beijing, China
| | - Gui Fang Du
- Department of Cardiovascular Surgery Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Klinkhammer B, Glotzer TV. Management of Arrhythmias in the Cardiovascular Intensive Care Unit. Crit Care Clin 2024; 40:89-103. [PMID: 37973359 DOI: 10.1016/j.ccc.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Arrhythmias in the cardiovascular intensive care unit (CVICU) can be difficult to manage because of the complex hemodynamic and respiratory states of critically ill patients. Treating physicians must be educated to prevent, diagnose, and treat a multitude of tachyarrhythmias and bradyarrhythmias. In this review article, the authors outline a pragmatic approach to patient assessment, arrhythmia diagnosis, and management of the most common arrhythmias seen in the CVICU.
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Affiliation(s)
- Brent Klinkhammer
- Division of Cardiac Electrophysiology, Hackensack University Medical Center, Hackensack, NJ 07601, USA; Hackensack Meridian School of Medicine, Hackensack, NJ 07601, USA
| | - Taya V Glotzer
- Division of Cardiac Electrophysiology, Hackensack University Medical Center, Hackensack, NJ 07601, USA; Hackensack Meridian School of Medicine, Hackensack, NJ 07601, USA.
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19
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Pakrad F, Shiri R, Mozayani Monfared A, Mohammadi Saleh R, Poorolajal J. Predictors of Premature Mortality Following Coronary Artery Bypass Grafting: An Iranian Single-Centre Study. Healthcare (Basel) 2023; 12:36. [PMID: 38200942 PMCID: PMC10779296 DOI: 10.3390/healthcare12010036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024] Open
Abstract
Modifiable risk factors play an important role in the premature mortality among patients undergoing coronary artery bypass grafting (CABG). The aim of this study was to examine the factors that influence the early death of patients who had CABG. We conducted a prospective cohort study and followed 2863 patients after their CABG, and collected data on their characteristics and blood tests. We used the Cox proportional hazards regression model in Stata, version 16, to identify the predictors of early mortality. Out of 2863 patients, 162 died during the follow-up period. The survival rate was 99.2% within the first three days after the surgery, 96.2% from the fourth day to the end of the first year, 94.9% at the end of the second year, and 93.6% at the end of the third year. After adjusting for confounding factors, we found that older age (hazard ratio [HR] 1.05, 95% CI 1.02, 1.08 for one year increase in age), obesity (HR 2.16, 95% CI 1.25, 3.72), ejection fraction < 50% (HR 1.61, 95% CI 1.06, 2.44), number of rehospitalizations (HR 2.63, 95% CI 1.35, 5.12 for two or more readmissions), history of stroke (HR 2.91, 95% CI 1.63, 5.21), living in rural areas (HR 1.58, 95% CI 1.06, 2.34), opium use (HR 2.08, 95% CI 1.40, 3.09), and impaired glomerular filtration rate increased the risk of early death after CABG, while taking a beta-blocker (HR 0.59, 95% CI 0.38, 0.91) reduced the risk. We conclude that modifiable risk factors such as excess body mass, high blood glucose, opium use, and kidney dysfunction should be monitored and managed in patients who had CABG to improve their survival outcomes.
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Affiliation(s)
- Fatemeh Pakrad
- Chronic Diseases (Home Care) Research Center, Hamadan University of Medical Sciences, Hamadan 6517838698, Iran;
| | - Rahman Shiri
- Finnish Institute of Occupational Health, 00032 Helsinki, Finland;
| | - Azadeh Mozayani Monfared
- Department of Cardiology, School of Medicine, Hamadan University of Medical Sciences, Hamadan 6517838736, Iran;
| | - Ramesh Mohammadi Saleh
- Department of Nursing, School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan 6517838698, Iran;
| | - Jalal Poorolajal
- Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan 6517838687, Iran
- Modeling of Noncommunicable Diseases Research Center, School of Public Health, Hamadan University of Medical Sciences, Hamadan 6517838687, Iran
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20
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Perezgrovas‐Olaria R, Alzghari T, Rahouma M, Dimagli A, Harik L, Soletti GJ, An KR, Caldonazo T, Kirov H, Cancelli G, Audisio K, Yaghmour M, Polk H, Toor R, Sathi S, Demetres M, Girardi LN, Biondi‐Zoccai G, Gaudino M. Differences in Postoperative Atrial Fibrillation Incidence and Outcomes After Cardiac Surgery According to Assessment Method and Definition: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2023; 12:e030907. [PMID: 37776213 PMCID: PMC10727249 DOI: 10.1161/jaha.123.030907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/22/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is the most frequent complication of cardiac surgery. Despite clinical and economic implications, ample variability in POAF assessment method and definition exist across studies. We performed a study-level meta-analysis to evaluate the influence of POAF assessment method and definition on its incidence and association with clinical outcomes. METHODS AND RESULTS A systematic literature search was conducted to identify studies comparing the outcomes of patients with and without POAF after cardiac surgery that also reported POAF assessment method. The primary outcome was POAF incidence. The secondary outcomes were in-hospital mortality, stroke, intensive care unit length of stay, and postoperative length of stay. Fifty-nine studies totaling 197 774 patients were included. POAF cumulative incidence was 26% (range: 7.3%-53.1%). There were no differences in POAF incidence among assessment methods (27%, [range: 7.3%-53.1%] for continuous telemetry, 27% [range: 7.9%-50%] for telemetry plus daily ECG, and 19% [range: 7.8%-42.4%] for daily ECG only; P>0.05 for all comparisons). No differences in in-hospital mortality, stroke, intensive care unit length of stay, and postoperative length of stay were found between assessment methods. No differences in POAF incidence or any other outcomes were found between POAF definitions. Continuous telemetry and telemetry plus daily ECG were associated with higher POAF incidence compared with daily ECG in studies including only patients undergoing isolated coronary artery bypass grafting. CONCLUSIONS POAF incidence after cardiac surgery remains high, and detection rates are variable among studies. POAF incidence and its association with adverse outcomes are not influenced by the assessment method and definition used, except in patients undergoing isolated coronary artery bypass grafting.
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Affiliation(s)
| | - Talal Alzghari
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNYUSA
| | - Mohammed Rahouma
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNYUSA
| | - Arnaldo Dimagli
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNYUSA
| | - Lamia Harik
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNYUSA
| | | | - Kevin R. An
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNYUSA
- Division of Cardiac Surgery, Department of SurgeryUniversity of TorontoONCanada
| | - Tulio Caldonazo
- Department of Cardiothoracic SurgeryFriedrich Schiller University JenaJenaGermany
| | - Hristo Kirov
- Department of Cardiothoracic SurgeryFriedrich Schiller University JenaJenaGermany
| | | | - Katia Audisio
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNYUSA
| | - Mohammad Yaghmour
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNYUSA
| | - Hillary Polk
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNYUSA
| | - Rajbir Toor
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNYUSA
| | - Swetha Sathi
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNYUSA
| | - Michelle Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Centre, Weill Cornell MedicineNew YorkNYUSA
| | | | - Giuseppe Biondi‐Zoccai
- Department of Medical‐Surgical Sciences and BiotechnologiesSapienza University of RomeLatinaItaly
- Mediterranea CardiocentroNaplesItaly
| | - Mario Gaudino
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNYUSA
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21
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Legare JF. Commentary: Post operative atrial fibrillation: Out of sight out of mind. J Thorac Cardiovasc Surg 2023; 166:1084-1085. [PMID: 34893328 DOI: 10.1016/j.jtcvs.2021.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/21/2022]
Affiliation(s)
- Jean-Francois Legare
- Department of Surgery, The New Brunswick Heart Center, Dalhousie Medicine New Brunswick, Saint John, New Brunswick, Canada.
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22
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Graczyk S, Grzeczka A, Pasławska U, Kordowitzki P. The Possible Influence of Vitamin D Levels on the Development of Atrial Fibrillation-An Update. Nutrients 2023; 15:2725. [PMID: 37375629 DOI: 10.3390/nu15122725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/07/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023] Open
Abstract
Atrial fibrillation (AF) is a severe and most common supraventricular arrhythmia in humans, which, if left untreated or treated ineffectively, can lead to ischemic stroke or heart failure. It has been suggested that serum vitamin D (VitD) deficiency may be one of the critical factors influencing the onset of AF, especially in the period after cardiac surgery, such as coronary artery bypass grafting. Several papers have indicated that VitD supplementation reduces the risk of AF, significantly reducing the proportion of patients between the control and study groups in both the pre- and postoperative periods. Factors that increase the risk of AF from VitD deficiency are also further indicated, and these are age, gender, weight, season or comorbidities. In addition, the cardiodepressive mechanism of VitD is not fully understood; however, it is suggested that it acts through at least two pathways. The first indicates a direct effect of VitD on atrial muscle degradation, while the second is related to the modulation of cardiovascular depression factors. Despite many reports showing correlations between no VitD concentrations on the development of AF, this topic is still widely debated and the results from these papers are still subject to doubt. Therefore, this review aims at describing in detail the problem of correlation between VitD deficiency and the development of AF associated mainly with the postoperative period, i.e., after cardiac surgery, especially pathogenesis, and results of this correlation, taking into account recent studies, limitations and future perspectives. Due to the fact that this is still a topical problem, we believe that the collection of the latest reports and a detailed description of the problem is most appropriate in this case.
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Affiliation(s)
- Szymon Graczyk
- Department of Biological and Veterinary Sciences, Faculty of Basic and Preclinical Sciences, Nicolaus Copernicus University, 87-100 Torun, Poland
| | - Arkadiusz Grzeczka
- Department of Biological and Veterinary Sciences, Faculty of Basic and Preclinical Sciences, Nicolaus Copernicus University, 87-100 Torun, Poland
| | - Urszula Pasławska
- Department of Biological and Veterinary Sciences, Faculty of Diagnostic and Clinical Sciences, Nicolaus Copernicus University, 87-100 Torun, Poland
| | - Pawel Kordowitzki
- Department of Biological and Veterinary Sciences, Faculty of Basic and Preclinical Sciences, Nicolaus Copernicus University, 87-100 Torun, Poland
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23
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Rong LQ, Di Franco A, Rahouma M, Dimagli A, Chan J, Lopes AJ, Kim J, Sanna T, Devereux RB, Delgado V, Weinsaft JW, Crea F, Alexander JH, Gillinov M, DiMaio JM, Pryor KO, Girardi L, Gaudino M. Postoperative pericardial effusion, pericardiotomy, and atrial fibrillation: An explanatory analysis of the PALACS trial. Am Heart J 2023; 260:113-123. [PMID: 36934978 PMCID: PMC10164079 DOI: 10.1016/j.ahj.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/06/2023] [Accepted: 03/12/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND In the Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery (PALACS) trial, posterior pericardiotomy was associated with a significant reduction in postoperative atrial fibrillation (POAF) after cardiac surgery. We aimed to investigate the mechanisms underlying this effect. METHODS We included PALACS patients with available echocardiographic data (n = 387/420, 92%). We tested the hypotheses that the reduction in POAF with the intervention was associated with 1) a reduction in postoperative pericardial effusion and/or 2) an effect on left atrial size and function. Spline and multivariable logistic regression analyses were used. RESULTS Most patients (n = 307, 79%) had postoperative pericardial effusions (anterior 68%, postero-lateral 51.9%). The incidence of postero-lateral effusion was significantly lower in patients undergoing pericardiotomy (37% vs 67%; P < .001). The median size of anterior effusion was comparable between patients with and without POAF (5.0 [IQR 3.0-7.0] vs 5.0 [IQR 3.0-7.5] mm; P = .42), but there was a nonsignificant trend towards larger postero-lateral effusion in the POAF group (5.0 [IQR 3.0-9.0] vs 4.0 [IQR 3.0-6.4] mm; P = .06). There was a non-linear association between postero-lateral effusion and POAF at a cut-off at 10 mm (OR 2.70; 95% CI 1.13, 6.47; P = .03) that was confirmed in multivariable analysis (OR 3.5, 95% CI 1.17, 10.58; P = 0.02). Left atrial dimension and function did not change significantly after posterior pericardiotomy. CONCLUSIONS Reduction in postero-lateral pericardial effusion is a plausible mechanism for the effect of posterior pericardiotomy in reducing POAF. Measures to reduce postoperative pericardial effusion are a promising approach to prevent POAF.
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Affiliation(s)
- Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - June Chan
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | | | - Jiwon Kim
- Department of Cardiology/Medicine, Weill Cornell Medicine, New York, NY
| | - Tommaso Sanna
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Victoria Delgado
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology, Heart Institute, Hospital University Germans Trias i Pujol, Badalona, Spain
| | | | - Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - John Michael DiMaio
- Department of Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital, Plano, TX
| | - Kane O Pryor
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Leonard Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
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24
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Lotter K, Yadav S, Saxena P, Vangaveti V, John B. Predictors of atrial fibrillation post coronary artery bypass graft surgery: new scoring system. Open Heart 2023; 10:e002284. [PMID: 37316327 DOI: 10.1136/openhrt-2023-002284] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/23/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) following coronary artery bypass graft surgery (CABG) is common and results in significant increases in hospital stay and financial encumbrance. OBJECTIVE Determine and use the predictors of postoperative AF (POAF) following CABG to develop a new predictive screening tool. METHOD A retrospective case-control study evaluated 388 patients (98 developed POAF and 290 remained in sinus rhythm) who undertook CABG surgery at Townsville University Hospital between 2016 and 2017. The demographic profile, risk factors for AF including hypertension, age≥75 years, transient ischaemic attack or stroke, chronic obstructive pulmonary disease (HATCH) score, electrocardiography features and perioperative factors were determined. RESULTS Patients who developed POAF were significantly older. On univariate analysis HATCH score, aortic regurgitation, increased p-wave duration and amplitude in lead II and terminal p-wave amplitude in lead V1 were associated with POAF; as were increased cardiopulmonary bypass time (103.5±33.9 vs 90.6±26.4 min, p=0.001) and increased cross clamp time. On multivariate analysis age (p=0.038), p-wave duration ≥100 ms (p=0.005), HATCH score (p=0.049) and CBP Time ≥100 min (p=0.001) were associated with POAF. Receiver operating characteristic curve demonstrated that with a cut-off of ≥2 for HATCH score, POAF could be predicted with a sensitivity of 72.8% and a specificity of 34.7%. Adding p-wave duration in lead II >100 ms and cardiopulmonary bypass time >100 min to the HATCH score increased the sensitivity to 83.7% with a specificity of 33.1%. This was termed the HATCH-PC score. CONCLUSION Patients with HATCH scores ≥2, and those with p-wave duration >100 ms, or cardiopulmonary bypass time >100 min were at greater risk of developing POAF following CABG.
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Affiliation(s)
- Kian Lotter
- Intensive Care, Townsville Hospital and Health Service, Townsville, Queensland, Australia
- James Cook University Division of Tropical Health and Medicine, Townsville, Queensland, Australia
| | - Sumit Yadav
- James Cook University Division of Tropical Health and Medicine, Townsville, Queensland, Australia
- Cardiothoracic Surgery, Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Pankaj Saxena
- James Cook University Division of Tropical Health and Medicine, Townsville, Queensland, Australia
- Cardiothoracic Surgery, Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Venkat Vangaveti
- James Cook University Division of Tropical Health and Medicine, Townsville, Queensland, Australia
| | - Bobby John
- James Cook University Division of Tropical Health and Medicine, Townsville, Queensland, Australia
- Cardiology, Townsville Hospital and Health Service, Townsville, Queensland, Australia
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25
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Kota R, Gemelli M, Dimagli A, Suleiman S, Moscarelli M, Dong T, Angelini GD, Fudulu DP. Patterns of cytokine release and association with new onset of post-cardiac surgery atrial fibrillation. Front Surg 2023; 10:1205396. [PMID: 37325422 PMCID: PMC10266410 DOI: 10.3389/fsurg.2023.1205396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/17/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Postoperative Atrial Fibrillation (POAF) is a common complication of cardiac surgery, associated with increased mortality, stroke risk, cardiac failure and prolonged hospital stay. Our study aimed to assess the patterns of release of systemic cytokines in patients with and without POAF. Methods A post-hoc analysis of the Remote Ischemic Preconditioning (RIPC) trial, including 121 patients (93 males and 28 females, mean age of 68 years old) who underwent isolated coronary artery bypass grafting (CABG) and aortic valve replacement (AVR). Mixed-effect models were used to analyze patterns of release of cytokines in POAF and non-AF patients. A logistic regression model was used to assess the effect of peak cytokine concentration (6 h after the aortic cross-clamp release) alongside other clinical predictors on the development of POAF. Results We found no significant difference in the patterns of release of IL-6 (p = 0.52), IL-10 (p = 0.39), IL-8 (p = 0.20) and TNF-α (p = 0.55) between POAF and non-AF patients. Also, we found no significant predictive value in peak concentrations of IL-6 (p = 0.2), IL-8 (p = >0.9), IL-10 (p = >0.9) and Tumour Necrosis Factor Alpha (TNF-α)(p = 0.6), however age and aortic cross-clamp time were significant predictors of POAF development across all models. Conclusions Our study suggests no significant association exists between cytokine release patterns and the development of POAF. Age and Aortic Cross-clamp time were found to be significant predictors of POAF.
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Affiliation(s)
- Rahul Kota
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Marco Gemelli
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
| | - Arnaldo Dimagli
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
| | - Saadeh Suleiman
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
| | - Marco Moscarelli
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
| | - Tim Dong
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
| | - Gianni D. Angelini
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
| | - Daniel P. Fudulu
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
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26
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Sabbag A, Berkovich A, Raanani E, Volvovitch D, McIntyre WF, Kassif Y, Kogan A, Glikson M, Beinart R. Subclinical postoperative atrial fibrillation: a randomized trial. Front Cardiovasc Med 2023; 10:1153275. [PMID: 37304958 PMCID: PMC10248069 DOI: 10.3389/fcvm.2023.1153275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 05/02/2023] [Indexed: 06/13/2023] Open
Abstract
Background Postoperative atrial fibrillation (POAF) is the most common complication of cardiac surgery, requiring interventions and prolonging hospital stay. POAF is associated with increased mortality and a higher rate of systemic thrombo-embolism. The rates of recurrent AF, optimal follow-up and management remain unclear. We aimed to evaluate the incidence of recurrent atrial fibrillation (AF) events, during long term follow-up in patients with POAF following cardiac surgery. Methods Patients with POAF and a CHA2DS2-VASc score of ≥2 were randomized in a 2:1 ratio to either implantation of a loop recorder (ILR) or ECG monitoring using periodic Holters. Participants were followed prospectively for 2 years. The primary end point was the occurrence of AF longer than 5 min. Results The final cohort comprised of 22 patients, of whom 14 received an ILR. Over a median follow up of 25.7 (IQR of 24.7-44.4) months, 8 patients developed AF, representing a cumulative annualized risk of AF recurrence of 35.7%. There was no difference between ILR (6 participants, 40%) and ECG/Holter (2 participants, 25% p = 0.917). All 8 patients with AF recurrence were treated with oral anticoagulation. There were no cases of mortality, stroke or major bleeding. Two patients underwent ILR explantation due to pain at the implantation site. Conclusions The rate of recurrent AF in patients with POAF after cardiac surgery and a CHA2DS2-VASc score of ≥2 is approximately 1 in 3 when followed systematically. Further research is need to assess the role of ILRs in this population.
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Affiliation(s)
- Avi Sabbag
- Davidai Arrhythmia Center, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Berkovich
- Davidai Arrhythmia Center, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ehud Raanani
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiac Surgery, Sheba Medical Center, Ramat Gan, Israel
| | - David Volvovitch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiac Surgery, Sheba Medical Center, Ramat Gan, Israel
| | - William F. McIntyre
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Yigal Kassif
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiac Surgery, Sheba Medical Center, Ramat Gan, Israel
| | - Alexander Kogan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiac Surgery, Sheba Medical Center, Ramat Gan, Israel
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Roy Beinart
- Davidai Arrhythmia Center, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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27
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Samadifar Z, Aslanabadi N, Kazemi Arbat B, Separham A, Javanshir E. Comparison of the Efficacy of Atorvastatin and Rosuvastatin in Preventing Atrial Fibrillation after Coronary Artery Bypass Grafting: A Double-Blind Randomized Comparative Trial. J Tehran Heart Cent 2023; 18:115-121. [PMID: 37637286 PMCID: PMC10459339 DOI: 10.18502/jthc.v18i2.13321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 08/03/2023] [Indexed: 08/29/2023] Open
Abstract
Background Atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterized by disorganized atrial activity and subsequent mechanical atrial failure. Postoperative AF is a frequent complication of coronary artery bypass grafting (CABG). Although there is evidence of decreased AF after CABG with statin usage, information is scarce regarding a direct comparison between atorvastatin and rosuvastatin. The present study was conducted to compare the efficacy of rosuvastatin and atorvastatin in preventing post-CABG AF. Methods The present double-blind randomized comparative clinical trial selected CABG candidates with stable ischemic heart disease or acute coronary syndromes. Atorvastatin (40 mg per day) or rosuvastatin (20 mg per day) was prescribed 1 week before surgery, and the outcomes were compared. Results Two-hundred patients, 100 cases in each group, completed the study. Twenty-five patients in each group were female, and the mean age was 59.30±8.42 years in the rosuvastatin group and 60.13±9.40 years in the atorvastatin group (P=0.513). The frequency of AF was 31% in the atorvastatin group and 27% in the rosuvastatin group (P=0.534). No significant differences existed between the groups concerning the length of hospital and ICU stay (P=0.333 and P=0.161) and in-hospital and 3-month mortality (P=0.315 and P=0.648). A subgroup analysis of only patients with stable ischemic heart disease could not detect a significant difference between the study groups in any of the investigated outcomes. Our logistic regression analysis showed an association only between age and the incidence of AF after CABG (OR, 1.12; 95% CI, 1.05 to 1.20; P<0.01). Conclusion Rosuvastatin and atorvastatin are similar concerning the prevention of post-CABG AF, but there is a need for future well-designed multicenter studies on this topic.
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Affiliation(s)
- Zahra Samadifar
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Naser Aslanabadi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Babak Kazemi Arbat
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ahmad Separham
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Elnaz Javanshir
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Ansari SA, Dhaliwal JSS, Ansari Y, Ghosh S, Khan TMA. The Role of Vitamin D Supplementation Before Coronary Artery Bypass Grafting in Preventing Postoperative Atrial Fibrillation in Patients With Vitamin D Deficiency or Insufficiency: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e36496. [PMID: 37090368 PMCID: PMC10119034 DOI: 10.7759/cureus.36496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/25/2023] Open
Abstract
This study aims to evaluate the role of preoperative vitamin D supplementation before coronary artery bypass grafting (CABG) surgery in preventing postoperative atrial fibrillation (POAF) in vitamin D deficient or insufficient patients. Three randomized controlled trials (RCTs) comprising 448 subjects were selected after a detailed search was conducted on PubMed, Cochrane CENTRAL, Scopus, and Embase in December 2022. Analysis was run using RevMan (version 5.4.1; Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014). The analysis collected risk ratio (RR) and 95% confidence interval (CI) data from the relevant studies, which were then pooled using a random effects model. A significance level of less than 0.05 (p<0.05) was considered significant. Our analysis showed that compared with the standard of care, preoperative vitamin D supplementation in vitamin D deficient and insufficient patients effectively reduced POAF after CABG surgery (RR=0.6, 95% CI=0.4-0.9, P=0.01). There was no significant difference in the duration of hospitalization between the vitamin D supplementation group compared with the control following CABG (mean difference -0.85, 95% CI -2.13 to 0.43, P = 0.19). This meta-analysis shows that preoperative vitamin D supplementation in vitamin D deficient and insufficient patients undergoing CABG can reduce the rate of POAF. As POAF is associated with many complications, providing vitamin D supplementation to individuals with a vitamin D deficiency undergoing CABG can improve long-term cardiovascular outcomes following surgery.
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Affiliation(s)
- Saad Ali Ansari
- Internal Medicine, University of California Riverside School of Medicine, Riverside, USA
| | | | - Yusra Ansari
- Internal Medicine, University of Kentucky College of Medicine, Bowling Green, USA
| | - Sudeshna Ghosh
- Internal Medicine, University of California Riverside School of Medicine, Riverside, USA
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Zhang RJZ, Yu XY, Wang J, Lv J, Zheng Y, Yu MH, Zang YR, Shi JW, Wang JH, Wang L, Liu ZG. A prediction model for new-onset atrial fibrillation following coronary artery bypass graft surgery: A multicenter retrospective study. Heliyon 2023; 9:e14656. [PMID: 37020944 PMCID: PMC10068116 DOI: 10.1016/j.heliyon.2023.e14656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 03/14/2023] [Accepted: 03/14/2023] [Indexed: 03/28/2023] Open
Abstract
Objective Developing and assessing a risk prediction model of postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG), and aims to provide a reference for the prediction and prevention. Design A retrospective case-control study. Setting Three major urban teaching and university hospitals and tertiary referral centers. Participants consecutive patients undergoing CABG. Interventions The study was retrospective and no interventions were administered to patients. Measurements and main results In the study, the overall new-onset POAF prevalence was approximately 28%. A prediction model for POAF with nine significant indicators was developed, and identified new predictors of POAF: left ventricular end diastolic diameter (LVEDD), intraoperative defibrillation, and intraoperative temporary pacing lead implantation. The model had good discrimination in both the derivation and validation cohorts, with the area under the receiver operating characteristic curves (AUCs) of 0.621 (95% CI = 0.602-0.640) and 0.616 (95% CI = 0.579-0.651), respectively, and showed good calibration. Compared with CHA2DS2-VASc, HATCH score, and the prediction model of POAF after CABG developed based on a small sample of clinical data from a single center in China, the model in this study had better discrimination. Conclusion We have developed and validated a new prediction model of POAF after CABG using multicenter data that can be used in the clinic for early identification of high-risk patients of POAF, and to help effectively prevent POAF in postoperative patients.
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Affiliation(s)
- Ren-Jian-Zhi Zhang
- Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School of Peking Union Medical College, Tianjin, 300457, China
| | - Xin-Yi Yu
- Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School of Peking Union Medical College, Tianjin, 300457, China
| | - Jing Wang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 6913114, China
| | - Jian Lv
- Department of Cardiovascular Surgery, Nanyang Central Hospital, Nanyang, 473005, China
| | - Yan Zheng
- First School of Clinical Medicine, Lanzhou University, Lanzhou, 730013, China
| | - Ming-Huan Yu
- Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School of Peking Union Medical College, Tianjin, 300457, China
| | - Yi-Rui Zang
- Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School of Peking Union Medical College, Tianjin, 300457, China
| | - Jian-Wei Shi
- Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School of Peking Union Medical College, Tianjin, 300457, China
| | - Jia-Hui Wang
- Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School of Peking Union Medical College, Tianjin, 300457, China
| | - Li Wang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 6913114, China
| | - Zhi-Gang Liu
- Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Graduate School of Peking Union Medical College, Tianjin, 300457, China
- Corresponding author.
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Dimagli A, Di Tommaso E, Bruno VD. Commentary: The importance of being predictable: Postoperative atrial fibrillation. J Thorac Cardiovasc Surg 2023; 165:1078-1079. [PMID: 34303536 DOI: 10.1016/j.jtcvs.2021.06.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Arnaldo Dimagli
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom.
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Skibniewski M, Venetsanos D, Ahlsson A, Batra G, Friberg Ö, Hofmann R, Janzon M, Karlsson LO, Lawesson SS, Nielsen SJ, Jeppsson A, Alfredsson J. Long-term antithrombotic therapy after coronary artery bypass grafting in patients with preoperative atrial fibrillation. A nationwide observational study from the SWEDEHEART registry. Am Heart J 2023; 257:69-77. [PMID: 36481448 DOI: 10.1016/j.ahj.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 05/11/2023]
Abstract
AIMS To provide data guiding long-term antithrombotic therapy after coronary artery by-pass grafting (CABG) in patients with preoperative atrial fibrillation (AF). METHODS AND RESULTS From the SWEDEHEART registry, we included all patients, between January 2006 and September 2016, with preoperative AF and CHA2DS2-VASC score ≥2, undergoing CABG. Based on dispensed prescriptions 12 to 18 months after CABG, patients were divided in 3 groups: use of platelet inhibitors (PI) only, oral anticoagulant (OAC) only or a combination of OAC + PI. Outcomes were: Major adverse cardiac and cerebrovascular events (MACCE, [all-cause death, myocardial infarction, or stroke]), net adverse clinical events (NACE, [MACCE or bleeding]) and the individual components of NACE. Inverse probability of treatment weighting was used to adjust for the non-randomized study design. Among 2,564 patients, 1,040 (41%) were treated with PI alone, 1,064 (41%) with OAC alone, and 460 (18%) with PI + OAC. Treatment with PI alone was associated with higher risk for MACCE (adjusted HR 1.43, 95% CI 1.09-1.88), driven by higher risk for stroke and MI, compared with OAC alone. Treatment with PI + OAC, was associated with higher risk for NACE (adjusted HR 1.40, 95% CI 1.06-1.85), driven by higher risk for bleeds, compared with OAC alone. CONCLUSION In this real-world observational study, a high proportion of patients with AF, undergoing CABG, did not receive a long-term OAC therapy. Treatment with OAC alone was associated with a net clinical benefit, compared with PI alone or PI + OAC.
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Affiliation(s)
- Mikolaj Skibniewski
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Dimitrios Venetsanos
- Division of Cardiology, Department of Medicine, Karolinska Institutet Solna and Karolinska University hospital, Stockholm, Sweden
| | - Anders Ahlsson
- Dept of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Gorav Batra
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Örjan Friberg
- Department of Health, Medicine and Caring Sciences and Department of Cardiothoracic and Vascular Surgery, Linköping University, Linköping, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Magnus Janzon
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Lars O Karlsson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Sofia Sederholm Lawesson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Susanne J Nielsen
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden.
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Liu Z, Deng Y, Wang X, Liu X, Zheng X, Sun G, Zhen Y, Liu M, Ye Z, Wen J, Liu P. Radiomics signature of epicardial adipose tissue for predicting postoperative atrial fibrillation after pulmonary endarterectomy. Front Cardiovasc Med 2023; 9:1046931. [PMID: 36698949 PMCID: PMC9869069 DOI: 10.3389/fcvm.2022.1046931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 12/19/2022] [Indexed: 01/12/2023] Open
Abstract
Purpose This study aimed to construct a radiomics signature of epicardial adipose tissue for predicting postoperative atrial fibrillation (POAF) after pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Methods We reviewed the preoperative computed tomography pulmonary angiography images of CTEPH patients who underwent PEA at our institution between December 2016 and May 2022. Patients were divided into training/validation and testing cohorts by stratified random sampling in a ratio of 7:3. Radiomics features were selected by using intra- and inter-class correlation coefficient, redundancy analysis, and Least Absolute Shrinkage and Selection Operator algorithm to construct the radiomics signature. The area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis (DCA) were used to evaluate the discrimination, calibration, and clinical practicability of the radiomics signature. Two hundred-times stratified five-fold cross-validation was applied to assess the reliability and robustness of the radiomics signature. Results A total of 93 patients with CTEPH were included in this study, including 23 patients with POAF and 70 patients without POAF. Five of the 1,218 radiomics features were finally selected to construct the radiomics signature. The radiomics signature showed good discrimination with an AUC of 0.804 (95%CI: 0.664-0.943) in the training/validation cohort and 0.728 (95% CI: 0.503-0.953) in the testing cohorts. The average AUC of 200 times stratified five-fold cross-validation was 0.804 (95%CI: 0.801-0.806) and 0.807 (95%CI: 0.798-0.816) in the training and validation cohorts, respectively. The calibration curve showed good agreement between the predicted and actual observations. Based on the DCA, the radiomics signature was found to be clinically significant and useful. Conclusion The radiomics signature achieved good discrimination, calibration, and clinical practicability. As a potential imaging biomarker, the radiomics signature of epicardial adipose tissue (EAT) may provide a reference for the risk assessment and individualized treatment of CTEPH patients at high risk of developing POAF after PEA.
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Affiliation(s)
- Zhan Liu
- Department of Cardiovascular Surgery, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Yisen Deng
- Department of Cardiovascular Surgery, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xuming Wang
- Department of Cardiovascular Surgery, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xiaopeng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xia Zheng
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Guang Sun
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Yanan Zhen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Min Liu
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Zhidong Ye
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jianyan Wen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China,*Correspondence: Jianyan Wen,
| | - Peng Liu
- Department of Cardiovascular Surgery, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China,Peng Liu,
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Jaakkola S, Paana T, Airaksinen J, Sipilä J, Kytö V. Association of CHA2DS2-VASc Score with Long-Term Incidence of New-Onset Atrial Fibrillation and Ischemic Stroke after Myocardial Infarction. J Clin Med 2022; 11:jcm11237090. [PMID: 36498665 PMCID: PMC9739941 DOI: 10.3390/jcm11237090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022] Open
Abstract
The CHA2DS2-VASc score is a reliable tool used to estimate the risk of ischemic stroke (IS) in patients with atrial fibrillation (AF). Few tools exist for the prediction of new-onset AF (NOAF) after myocardial infarction (MI) and its relation to IS. We studied the usefulness of CHA2DS2-VASc in predicting NOAF and IS in a long-term follow-up after MI. Consecutive MI patients without baseline AF (n = 70,922; mean age: 68.2 years), discharged from 20 hospitals in Finland during 2005−2018, were retrospectively studied using national registries. The outcomes of interest after discharge were NOAF- and IS-assessed with competing risk analyses at one and ten years. The median follow-up was 4.2 years. The median baseline CHA2DS2-VASc score was 3 (IQR 2−5). The likelihood of both NOAF and NOAF-related IS increased stepwise with this score at one and ten years (all p < 0.0001). The one-year-adjusted subdistribution hazard ratio (sHR) was 4.03 (CI 3.68−4.42) for NOAF in patients with CHA2DS2-VASc scores ≥6 points. The cumulative incidence of IS was 15.2% in patients with NOAF vs. 6.2% in patients without AF at 10 years after MI (adj. sHR 2.12; CI 1.98−2.28; p < 0.0001). Coronary artery bypass surgery was associated with a higher NOAF incidence compared to percutaneous coronary intervention (adj. sHR 1.87; CI 1.65−2.13; p < 0.0001 one year after MI). The CHA2DS2-VASc score is a simple tool used to estimate the long-term risk of NOAF and IS after MI in patients without baseline AF. Coronary bypass surgery is associated with an increased NOAF incidence after MI.
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Affiliation(s)
- Samuli Jaakkola
- Heart Center, Turku University Hospital, University of Turku, 20521 Turku, Finland
- Correspondence:
| | - Tuomas Paana
- Heart Center, Turku University Hospital, University of Turku, 20521 Turku, Finland
| | - Juhani Airaksinen
- Heart Center, Turku University Hospital, University of Turku, 20521 Turku, Finland
| | - Jussi Sipilä
- Department of Neurology, Siun Sote, North Karelia Central Hospital, 80210 Joensuu, Finland
| | - Ville Kytö
- Heart Center, Turku University Hospital, University of Turku, 20521 Turku, Finland
- Turku Clinical Research Center, Turku University Hospital, 20521 Turku, Finland
- Center for Population Health Research, Turku University Hospital, University of Turku, 20521 Turku, Finland
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Yang H, Yuan C, Yang J, Xiang H, Lan W, Tang Y. A novel predictive model for new-onset atrial fibrillation in patients after isolated cardiac valve surgery. Front Cardiovasc Med 2022; 9:949259. [PMID: 36247462 PMCID: PMC9556269 DOI: 10.3389/fcvm.2022.949259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPostoperative atrial fibrillation (POAF) is a severe complication after cardiac surgery and is associated with an increased risk of ischemic stroke and mortality. The main aim of this study was to identify the independent predictors associated with POAF after isolated valve operation and to develop a risk prediction model.MethodsThis retrospective observational study involved patients without previous AF who underwent isolated valve surgery from November 2018 to October 2021. Patients were stratified into two groups according to the development of new-onset POAF. Baseline characteristics and perioperative data were collected from the two groups of patients. Univariate and multivariate logistic regression analyses were applied to identify independent risk factors for the occurrence of POAF, and the results of the multivariate analysis were used to create a predictive nomogram.ResultsA total of 422 patients were included in the study, of which 163 (38.6%) developed POAF. The Multivariate logistic regression analysis indicated that cardiac function (odds ratio [OR] = 2.881, 95% confidence interval [CI] = 1.595–5.206; P < 0.001), Left atrial diameter index (OR = 1.071, 95%CI = 1.028–1.117; P = 0.001), Operative time (OR = 1.532, 95%CI = 1.095–2.141; P = 0.013), Neutrophil count (OR = 1.042, 95%CI = 1.006–1.08; P = 0.021) and the magnitude of fever (OR = 3.414, 95%CI = 2.454–4.751; P < 0.001) were independent predictors of POAF. The above Variables were incorporated, and a nomogram was successfully constructed with a C-index of 0.810. The area under the receiver operating characteristic curve was 0.817.ConclusionCardiac function, left atrial diameter index, operative time, neutrophil count, and fever were independent predictors of POAF in patients with isolated valve surgery. Establishing a nomogram model based on the above predictors helps predict the risk of POAF and may have potential clinical utility in preventive interventions.
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Affiliation(s)
- Heng Yang
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Chen Yuan
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Juesheng Yang
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Haiyan Xiang
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wanqi Lan
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Yanhua Tang
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- *Correspondence: Yanhua Tang,
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Akowuah E, Whitlock R. Evidence gaps pertaining to high-risk medications: Commentary on anticoagulation in new-onset postoperative atrial fibrillation. Heart Rhythm O2 2022; 3:333-334. [PMID: 36097455 PMCID: PMC9463701 DOI: 10.1016/j.hroo.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- Enoch Akowuah
- James Cook University Hospital, Middlesbrough, United Kingdom
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Talukder S, Dimagli A, Benedetto U, Gray A, Gerry S, Lees B, Krzych Ł, Gaudino M, Taggart DP, Flather M. Prognostic factors of 10-year mortality after coronary artery bypass graft surgery: a secondary analysis of the arterial revascularization trial. Eur J Cardiothorac Surg 2022; 61:1414-1420. [PMID: 35138360 PMCID: PMC9154348 DOI: 10.1093/ejcts/ezac043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/11/2022] [Accepted: 01/25/2022] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES The objective of this investigation was to determine the preoperative prognostic factors of long-term (10-year) mortality in patients treated with isolated coronary artery bypass graft surgery in the arterial revascularization trial (ART). METHODS A post hoc analysis of the ART was conducted. Cumulative 10-year mortality was estimated using the Kaplan-Meier method. Prospectively collected preoperative data were used to determine the prognostic factors of 10-year all-cause mortality in patients who participated in the ART (Cox proportional hazards model). RESULTS A total of 3102 patients who participated in the ART were included in the analysis. Ten-year follow-up was completed in 3040 patients (98%). A total of 644 patients (20.8%) had died by 10 years. Preoperative factors that were identified as statistically significant predictors of 10-year mortality in the multivariable analysis (all P ≤ 0.01) were: left ventricular ejection fraction, atrial fibrillation, age, diabetes, prior cerebrovascular event (stroke or transient ischaemic attack), serum creatinine and smoking status. The following variables were significantly associated in univariable models but did not retain significance in the multivariable model for mortality: non-Caucasian ethnicity, hypertension, peripheral vascular disease, chronic obstructive pulmonary disease and prior myocardial infarction. CONCLUSIONS Independent predictors of 10-year mortality in the ART were multifactorial. Several key independent predictors of 10-year mortality in the ART were identified including: heart function, renal function, cerebrovascular disease, age, atrial fibrillation, smoking status and diabetes. Understanding which preoperative variables influence long-term outcome after coronary artery bypass grafting may help to target treatments to those at higher risk to reduce mortality.
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Affiliation(s)
| | - Arnaldo Dimagli
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, UK
| | - Umberto Benedetto
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Stephen Gerry
- Centre of Statistics in Medicine, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Belinda Lees
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Łukasz Krzych
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - David P Taggart
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
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Friberg Ö. The Effect of Postoperative Atrial Fibrillation on Outcomes of Cardiac Surgery; Guilt or Association? Eur J Cardiothorac Surg 2022; 62:6593488. [PMID: 35639736 DOI: 10.1093/ejcts/ezac319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Örjan Friberg
- Dept of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Faculty of Medicine and Health, Örebro University, Sweden
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Taha A, Nielsen SJ, Franzén S, Rezk M, Ahlsson A, Friberg L, Björck S, Jeppsson A, Bergfeldt L. Stroke Risk Stratification in Patients With Postoperative Atrial Fibrillation After Coronary Artery Bypass Grafting. J Am Heart Assoc 2022; 11:e024703. [PMID: 35574947 PMCID: PMC9238552 DOI: 10.1161/jaha.121.024703] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The CHA2DS2‐VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, previous stroke or TIA [transient ischemic attack], vascular disease, age 65 to 74 years, sex category female; 2 indicates 2 points, otherwise 1 point) scoring system is recommended to guide decisions on oral anticoagulation therapy for stroke prevention in patients with nonsurgery atrial fibrillation. A score ≥1 in men and ≥2 in women, corresponding to an annual stroke risk exceeding 1%, warrants long‐term oral anticoagulation provided the bleeding risk is acceptable. However, in patients with new‐onset postoperative atrial fibrillation, the optimal risk stratification method is unknown. The aim of this study was therefore to evaluate the CHA2DS2‐VASc scoring system for estimating the 1‐year ischemic stroke risk in patients with new‐onset postoperative atrial fibrillation after coronary artery bypass grafting. Methods and Results All patients with new‐onset postoperative atrial fibrillation and without oral anticoagulation after first‐time isolated coronary artery bypass grafting performed in Sweden during 2007 to 2017 were eligible for this registry‐based observational cohort study. The 1‐year ischemic stroke rate at each step of the CHA2DS2‐VASc score was estimated using a Kaplan‐Meier estimator. Of the 6368 patients included (mean age, 69.9 years; 81% men), >97% were treated with antiplatelet drugs. There were 147 ischemic strokes during the first year of follow‐up. The ischemic stroke rate at 1 year was 0.3%, 0.7%, and 1.5% in patients with CHA2DS2‐VASc scores of 1, 2, and 3, respectively, and ≥2.3% in patients with a score ≥4. A sensitivity analysis, with the inclusion of patients on anticoagulants, was performed and supported the primary results. Conclusions Patients with new‐onset atrial fibrillation after coronary artery bypass grafting and a CHA2DS2‐VASc score <3 have such a low 1‐year risk for ischemic stroke that oral anticoagulation therapy should probably be avoided.
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Affiliation(s)
- Amar Taha
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska Academy University of Gothenburg Sweden
- Department of Cardiology Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Susanne J. Nielsen
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska Academy University of Gothenburg Sweden
- Department of Cardiothoracic Surgery Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Stefan Franzén
- Centre for Registries Region Västra Götaland Gothenburg Sweden
| | - Mary Rezk
- Department of Cardiothoracic Surgery Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Anders Ahlsson
- Department of Cardiothoracic Surgery Karolinska University Hospital Stockholm Sweden
| | - Leif Friberg
- Department of Clinical Sciences Karolinska Institute at Danderyd Hospital Stockholm Sweden
| | - Staffan Björck
- Centre for Registries Region Västra Götaland Gothenburg Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska Academy University of Gothenburg Sweden
- Department of Cardiothoracic Surgery Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Lennart Bergfeldt
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska Academy University of Gothenburg Sweden
- Department of Cardiology Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
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Mork C, Amacher SA, Gahl B, Koechlin L, Miazza J, Schaeffer T, Schmuelling L, Bremerich J, Berdajs D, Cueni N, Kühne M, Mueller C, Osswald S, Reuthebuch O, Schurr U, Sticherling C, Kopp Lugli A, Marsch S, Pargger H, Siegemund M, Eckstein F, Hollinger A, Santer D. Non-invasive evaluation of new-onset atrial fibrillation after cardiac surgery: a protocol for the BigMap study. ESC Heart Fail 2022; 9:2703-2712. [PMID: 35438261 PMCID: PMC9288739 DOI: 10.1002/ehf2.13902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 01/30/2022] [Accepted: 03/09/2022] [Indexed: 11/25/2022] Open
Abstract
Aims New‐onset atrial fibrillation (NOAF) is the most common complication after cardiac surgery, occurring in 25–50% of patients. It is associated with post‐operative stroke, increased mortality, prolonged hospital length of stay, and higher treatment costs. Previous small observational studies have identified the left atrium as a source of the electrical rotors and foci maintaining NOAF, but confirmation by a large prospective clinical study is still missing. The aim of the proposed study is to investigate whether the source of NOAF lies in the left atrium. The correct identification of NOAF‐maintaining structures in cardiac surgical patients might offer potential therapeutic targets for prophylactic perioperative ablation strategies. Methods and results This is a prospective single‐centre observational study of patients developing NOAF after cardiac surgery. The primary outcome is the description of NOAF‐maintaining structures within the atria. Key secondary outcomes include overall mortality, intensive care unit length of stay, hospital–ventilator‐free days, and proportion of persistent NOAF. In NOAF patients, the non‐invasive electrophysiological mapping will be conducted using a 252‐electrode electrocardiogram vest. After mapping, a low‐dose computed tomography scan of the chest will be performed to integrate the electrophysiological mapping results into a 3D picture of the heart. The study will include approximately 570 patients, of whom 30% (n = 170) are expected to develop NOAF. Sample size calculation revealed that 157 NOAF patients are necessary to assess the primary outcome. Patients will be tracked for a total of 5 years. Conclusions This is the largest prospective study to date describing the electrophysiological mechanisms of NOAF using non‐invasive mapping.
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Affiliation(s)
- Constantin Mork
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland.,Cardiovascular Research Institute (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Brigitta Gahl
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
| | - Luca Koechlin
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland.,Cardiovascular Research Institute (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jules Miazza
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
| | - Thibault Schaeffer
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
| | - Lena Schmuelling
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Jens Bremerich
- Department of Radiology, University Hospital Basel, Basel, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Denis Berdajs
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Nadine Cueni
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Michael Kühne
- Cardiovascular Research Institute (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Stefan Osswald
- Cardiovascular Research Institute (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Ulrich Schurr
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
| | - Christian Sticherling
- Cardiovascular Research Institute (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Andrea Kopp Lugli
- Medical Faculty of the University of Basel, Basel, Switzerland.,Intermediate Care Unit, University Hospital Basel, Basel, Switzerland
| | - Stephan Marsch
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Hans Pargger
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland.,Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Friedrich Eckstein
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Alexa Hollinger
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - David Santer
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
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Musa AF, Dillon J, Taib MEM, Yunus AM, Sanusi AR, Nordin MN, Smith JA. Incidence and Outcomes of Postoperative Atrial Fibrillation after Coronary Artery Bypass Grafting of a Randomized Controlled Trial: A Blinded End-of-cycle Analysis. Rev Cardiovasc Med 2022; 23:122. [PMID: 39076222 PMCID: PMC11273857 DOI: 10.31083/j.rcm2304122] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 07/31/2024] Open
Abstract
Objective The objective of this study is to analyse the incidence of postoperative atrial fibrillation (POAF), demography, post-operative outcomes including morbidity and mortality, length of Cardiac Intensive Care Unit (CICU) stay, High Dependency Unit (HDU) stay, and total hospital stay in patients undergoing coronary bypass grafting (CABG) at Institut Jantung Negana (IJN). Methods We conducted a prospective, randomised, controlled trial. We supplied the treatment group with Tocovid capsules and the control group with placebo containing palm superolein. Results Since January 2019, we have recruited the target population of 250 patients. However, the result is still blinded as we are still analysing blood samples for tocotrienol levels. 89.2% of patients completed the study with a 3.6% mortality and a 7.6% attrition rate. 35.2% of the patients developed POAF, the mean time being 46.06 ± 26.96 hours post-CABG. We did not observe any statistically significant difference when we compared left atrial size, New York Heart Association (NYHA) functional class, ejection fraction and premorbid history, besides EuroSCORE II (The European System for Cardiac Operative Risk Evaluation II) status except for older age group, right atrial size, and pleural effusion. There was also no difference in bypass time, cross clamp time or number of anastomoses. However, we noted a significant difference in death (p = 0.01) and renal failure requiring dialysis (p = 0.007) among patients with POAF; those patients also had a longer CICU stay (p = 0.005), HDU stay (p = 0.02), and total hospital stay (p = 0.001). Conclusions POAF is associated with a higher incidence of renal failure and death while it increases CICU, HDU, and total hospital stay. It remains to be seen whether Tocovid reduces POAF and its associated sequelae. Clinical Trial Registration NCT03807037 (Registered on 16 January 2019).
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Affiliation(s)
- Ahmad Farouk Musa
- Jeffrey Cheah School of Medicine & Health Sciences, Monash University Malaysia, 47500 Subang Jaya, Selangor, Malaysia
- Victorian Heart Institute, Monash University, 3168 Melbourne, Australia
| | - Jeswant Dillon
- Department of Cardiothoracic Surgery, National Heart Institute, 50400 Kuala Lumpur, Malaysia
| | - Mohamed Ezani Md Taib
- Department of Cardiothoracic Surgery, National Heart Institute, 50400 Kuala Lumpur, Malaysia
| | - Alwi Mohamed Yunus
- Department of Cardiothoracic Surgery, National Heart Institute, 50400 Kuala Lumpur, Malaysia
| | - Abdul Rais Sanusi
- Department of Cardiothoracic Surgery, National Heart Institute, 50400 Kuala Lumpur, Malaysia
| | - Mohd Nazeri Nordin
- Department of Cardiothoracic Surgery, National Heart Institute, 50400 Kuala Lumpur, Malaysia
| | - Julian A. Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, 3168 Melbourne, Australia
- Department of Cardiothoracic Surgery, Monash Health, 3168 Melbourne, Australia
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Blockage of transient receptor potential vanilloid 4 prevents postoperative atrial fibrillation by inhibiting NLRP3-inflammasome in sterile pericarditis mice. Cell Calcium 2022; 104:102590. [DOI: 10.1016/j.ceca.2022.102590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 02/06/2023]
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Campbell NG, Wollborn J, Fields KG, Lip GY, Ruetzler K, Muehlschlegel JD, O’Brien B. Inconsistent Methodology as a Barrier to Meaningful Research Outputs From Studies of Atrial Fibrillation After Cardiac Surgery. J Cardiothorac Vasc Anesth 2022; 36:739-745. [PMID: 34763979 PMCID: PMC9901359 DOI: 10.1053/j.jvca.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/19/2021] [Accepted: 10/08/2021] [Indexed: 02/08/2023]
Abstract
Atrial fibrillation after cardiac surgery (AFACS) is a serious postoperative complication. There is significant research interest in this field but also relevant heterogeneity in reported AFACS definitions and approaches used for its identification. Few data exist on the extent of this variation in clinical studies. The authors reviewed the literature since 2001 and included manuscripts reporting outcomes of AFACS in adults. They excluded smaller studies and studies in which patients did not undergo a sternotomy. The documented protocol in each manuscript was analyzed according to six different categories to determine how AFACS was defined, which techniques were used to identify it, and the inclusion and/or exclusion criteria. They also noted when a category was not described in the documented protocol. The authors identified 302 studies, of which 92 were included. Sixty-two percent of studies were randomized controlled trials. There was significant heterogeneity in the manuscripts, including the exclusion of patients with preoperative AF, the definition and duration of AF needed to meet the primary endpoint, the type of screening approach (continuous, episodic, or opportunistic), the duration of monitoring during the study period in days, the diagnosis with predefined electrocardiogram criteria, and the requirement for independent confirmation by study investigators. Furthermore, the definitions of these criteria frequently were not described. Consistent reporting standards for AFACS research are needed to advance scientific progress in the field. The authors here propose pragmatic standards for trial design and reporting standards. These include adequate sample size estimation, a clear definition of the AFACS endpoints, and a protocol for AFACS detection.
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Affiliation(s)
- Niall G. Campbell
- Division of Cardiovascular Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Jakob Wollborn
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - Kara G. Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kurt Ruetzler
- Anesthesiology Institute, Departments of Outcomes Research and General Anesthesiology, Cleveland Clinic, Cleveland, USA,Outcomes Research Consortium, Cleveland, USA
| | - Jochen D. Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - Benjamin O’Brien
- Outcomes Research Consortium, Cleveland, USA,Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany,Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Germany,Department of Perioperative Medicine, St Bartholomew’s Hospital, London, U.K
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Zhang J, Zhu C, Nie C, Song C, Zhang Y, Huang M, Zheng X, Lu J, Wang S, Huang X. Impact of Body Mass Index on Postoperative Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy Undergoing Septal Myectomy. J Am Heart Assoc 2022; 11:e023152. [PMID: 35043680 PMCID: PMC9238498 DOI: 10.1161/jaha.121.023152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Obesity is an established cardiovascular risk factor in patients with hypertrophic cardiomyopathy. Postoperative atrial fibrillation (POAF) is one of the most common complications after surgery in patients with obstructive hypertrophic cardiomyopathy (OHCM). We aimed to determine the impact of body mass index (BMI) on the occurrence of POAF in patients with OHCM who underwent septal myectomy. Methods and Results In all, 712 OHCM patients without previous atrial fibrillation who underwent septal myectomy were identified. Patients were stratified into 3 groups based on BMI. Of these, 224 (31.5%) had normal weight (BMI<24 kg/m2), 339 (47.6%) were overweight (BMI, 24 to <28 kg/m2), and 149 (20.9%) were obese (BMI≥28 kg/m2). Overweight and obese patients had increased levels of left atrial diameter (P<0.001) and left ventricular end-diastolic diameter (P<0.001), compared with patients with normal weight. Among 184 patients (25.8%) developing POAF, 32 cases (14.3%) occurred in the normal weight group, 100 cases (29.5%) occurred in the overweight group, and 52 cases (34.9%) occurred in the obese group (P<0.001). Logistic regression analysis indicated that overweight (odds ratio [OR]: 2.161, 95% CI, 1.333-3.503; P=0.002) or obesity (OR, 2.803; 95% CI, 1.589-4.944; P<0.001), age (OR, 1.037; 95% CI, 1.018-1.057; P<0.001), and left atrial diameter (OR, 1.060; 95% CI, 1.027-1.095; P<0.001) were independently associated with the occurrence of POAF in patients with OHCM. Conclusions Overweight and obesity are strong predictors of POAF in patients with OHCM. Strategies aimed at lowering BMI may be a potential way to prevent POAF.
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Affiliation(s)
- Jian Zhang
- Department of Cadre Ward Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Changsheng Zhu
- Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Changrong Nie
- Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Changpeng Song
- Department of Cadre Ward Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Yang Zhang
- Department of Cadre Ward Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Manyun Huang
- Department of Cadre Ward Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Xinxin Zheng
- Department of Cadre Ward Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Jie Lu
- Department of Cadre Ward Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Shuiyun Wang
- Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Xiaohong Huang
- Department of Cadre Ward Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing China
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6571148. [DOI: 10.1093/ejcts/ezac264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/31/2022] [Accepted: 04/15/2022] [Indexed: 11/14/2022] Open
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45
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Wang MK, Meyre PB, Heo R, Devereaux P, Birchenough L, Whitlock R, McIntyre WF, Peter Chen YC, Ali MZ, Biancari F, Butt JH, Healey JS, Belley-Côté EP, Lamy A, Conen D. Short-term and Long-term Risk of Stroke in Patients With Perioperative Atrial Fibrillation After Cardiac Surgery: Systematic Review and Meta-analysis. CJC Open 2022; 4:85-96. [PMID: 35072031 PMCID: PMC8767142 DOI: 10.1016/j.cjco.2021.09.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/12/2021] [Indexed: 11/24/2022] Open
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Fan K, Chen L, Liu F, Ding X, Yan P, Gao M, Yu W, Liu H, Yu Y. Predicting New-Onset Postoperative Atrial Fibrillation Following Isolated Coronary Artery Bypass Grafting: Development and Validation of a Novel Nomogram. Int J Gen Med 2022; 15:937-948. [PMID: 35115819 PMCID: PMC8801512 DOI: 10.2147/ijgm.s346339] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/07/2022] [Indexed: 01/23/2023] Open
Abstract
Objective To select variables associated with new-onset postoperative atrial fibrillation (POAF) following isolated coronary artery bypass grafting (CABG) and develop a nomogram for risk prediction in a Chinese population. Methods The study retrospectively enrolled 4854 consecutive patients undergoing isolated CABG from February 2018 to September 2019, they were divided into derivation cohort and validation cohort with a 3:1 ratio according to the order of operation date. In the derivation cohort, significant variables were selected by use of the multivariate logistic backward stepwise regression analysis and a nomogram model was built on the strength of the results. The model performance was assessed in terms of discrimination and calibration. Besides, we compared the discriminative ability for POAF of the nomogram with established prediction models (CHA2DS2-VASc and HATCH scores) in the two cohorts. Results POAF occurred in 1025 (28.2%) out of 3641 patients in the derivation cohort, and in 337 (27.8%) out of 1213 patients in the validation cohort. A nomogram, composed of eight prognostic variables, namely age, sex, heart rate, hypertension, left ventricular ejection fraction (LVEF) <50%, left atrial diameter (LAD) > 40mm, estimated glomerular filtration rate (eGFR) level, and on-pump surgery, was constructed from the derivation cohort. The nomogram had substantial discriminative ability in derivation and validation cohorts with the area under the receiver operating characteristic curves (AUCs) of 0.661 (95% confidence interval, 0.642–0.681) and 0.665 (95% confidence interval, 0.631–0.699), respectively, and showed well-fitted calibration curves. Compared with CHA2DS2-VASc, HATCH and POAF scores, respectively, the nomogram had superior discrimination performance. Conclusion We constructed a novel nomogram with improved accuracy for predicting the risk of POAF following isolated CABG, which might help clinicians predict individual probability of POAF and achieve effective prophylaxis.
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Affiliation(s)
- Kangjun Fan
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Liang Chen
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Fei Liu
- Department of Biology, Faculty of Science, Hong Kong Baptist College, Kowloon Tong, Hong Kong, People’s Republic of China
| | - Xiaohang Ding
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Pengyun Yan
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Mingxin Gao
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Wenyuan Yu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Hongli Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Yang Yu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
- Correspondence: Yang Yu, Tel +86-10-64456868, Fax +86-10-84005030, Email
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Tzoumas A, Nagraj S, Tasoudis P, Arfaras-Melainis A, Palaiodimos L, Kokkinidis DG, Kampaktsis PN. Atrial fibrillation following coronary artery bypass graft: Where do we stand? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:172-179. [PMID: 34949543 DOI: 10.1016/j.carrev.2021.12.006] [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] [Received: 11/01/2021] [Revised: 11/30/2021] [Accepted: 12/09/2021] [Indexed: 01/29/2023]
Abstract
Atrial fibrillation (AF) is the most common atrial arrhythmia following coronary artery bypass graft (CABG). Its prevalence is 15-45% and is associated with poor long-term prognosis. Risk factors can be patient-related, intraoperative, and/or postoperative. Therapeutic and preventive strategies have been developed to curtail AF burden. Cardioversion is recommended for unstable or symptomatic patients and rate control if asymptomatic. Anticoagulation is challenging with risk of thromboembolism and bleeding. However, patients should be anticoagulated after cardioversion or if AF persists >48 h and risk factors of stroke exist. A minimum of 4 weeks is recommended but longer duration should be considered in patients at high risk of stroke irrespective of recurrence of AF.
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Affiliation(s)
- Andreas Tzoumas
- Aristotle University of Thessaloniki, Thessaloniki 541 24, Greece
| | - Sanjana Nagraj
- Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham parkway S, The Bronx, NY, USA..
| | | | - Angelos Arfaras-Melainis
- Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham parkway S, The Bronx, NY, USA
| | - Leonidas Palaiodimos
- Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham parkway S, The Bronx, NY, USA
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, 333 Cedar St, New Haven, CT, USA
| | - Polydoros N Kampaktsis
- Division of Cardiology, New York University Langone Medical Center, 550 1st Ave, New York, NY, USA
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Karamnov S, O'Brien B, Muehlschlegel JD. A Wolf in Sheep's Skin? Postoperative Atrial Fibrillation After Cardiac Surgery and the Risk of Stroke and Mortality. J Cardiothorac Vasc Anesth 2021; 35:3565-3567. [PMID: 34518104 PMCID: PMC8819865 DOI: 10.1053/j.jvca.2021.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Sergey Karamnov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Benjamin O'Brien
- Departments of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Centre Berlin and Charité Universitätsmedizin Berlin
| | - Jochen D Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Musa AF, Dillon J, Md Taib ME, Yunus AM, Sanusi AR, Nordin MN, Smith JA. A double-blind randomised controlled trial on the effect of Tocovid, a tocotrienol-rich capsule on postoperative atrial fibrillation at the National Heart Institute, Kuala Lumpur: an interim blinded analysis. J Cardiothorac Surg 2021; 16:340. [PMID: 34819126 PMCID: PMC8611632 DOI: 10.1186/s13019-021-01721-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/06/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Post-operative atrial fibrillation (POAF) is associated with poorer outcomes, increased resource utilisation, morbidity and mortality. Its pathogenesis is initiated by systemic inflammation and oxidative stress. It is hypothesised that a potent antioxidant and anti-inflammatory agent such as tocotrienol, an isomer of Vitamin E, could reduce or prevent POAF. AIMS The aim of this study is to determine whether a potent antioxidative and anti-inflammatory agent, Tocovid, a tocotrienol-rich capsule, could reduce the incidence of POAF and affect the mortality and morbidity as well as the duration of ICU, HDU and hospital stay. METHODS This study was planned as a prospective, randomised, controlled trial with parallel groups. The control group received placebo containing palm superolein while the treatment group received Tocovid capsules. We investigated the incidence of POAF, the length of hospital stay after surgery and the health-related quality of life. RESULTS Recruitment commenced in January 2019 but the preliminary results were unblinded as the study is still ongoing. Two-hundred and two patients have been recruited out of a target sample size of 250 as of January 2021. About 75% have completed the study and 6.4% were either lost during follow-up or withdrew; 4% of participants died. The mean age group was 61.44 ± 7.30 years with no statistical difference between the groups, with males having a preponderance for AF. The incidence of POAF was 24.36% and the mean time for developing POAF was 55.38 ± 29.9 h post-CABG. Obesity was not a predictive factor. No statistically significant difference was observed when comparing left atrial size, NYHA class, ejection fraction and the premorbid history. The mean cross-clamp time was 71 ± 34 min and the mean bypass time was 95 ± 46 min, with no difference between groups. There was a threefold increase in death among patients with POAF (p = 0.008) and an increase in the duration of ICU stay (p = 0.01), the total duration of hospital stay (p = 0.04) and reintubation (p = 0.045). CONCLUSION A relatively low incidence rate of POAF was noted although the study is still ongoing. It remains to be seen if our prophylactic intervention using Tocovid would effectively reduce the incidence of POAF. Clinical Registration Number: US National Library of Medicine. Clinical Trials - NCT03807037. Registered on 16th January 2019. Link: https://clinicaltrials.gov/ct2/show/NCT03807037.
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Affiliation(s)
- Ahmad Farouk Musa
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, 47500 Subang Jaya, Selangor Malaysia
- Victorian Heart Institute, Monash University, Melbourne, Australia
| | | | | | | | | | | | - Julian A. Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, Australia
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Abdelmoneim SS, Heitner JF. Reply: Is New-Onset Postoperative AF a First Presentation of Paroxysmal AF?: The Answer Is Still Unclear. JACC Clin Electrophysiol 2021; 7:1436. [PMID: 34794666 DOI: 10.1016/j.jacep.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 10/19/2022]
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