Atrial fibrillation after pulmonary lobectomy for lung cancer affects long-term survival in a prospective single-center study

Crosslink between atrial fibrillation and cancer: a therapeutic conundrum

Atrial fibrillation (AF) is more common in patients with malignancies than in general population. The pathophysiological processes include the pro-inflammatory condition and the exaggerated inflammatory reaction to chemotherapy, radiotherapy, and surgery interventions. Thus, it is pivotal to decrease morbidity and mortality in this group by providing appropriate care and prevention. In this subset, the risk of thromboembolic and bleeding events is high and the common risk score such as CHA2DS2-VASc and HAS-BLED employed in non-oncologic patients have limited evidence in cancer patients. A paucity of evidence in the setting in individuals having both malignancies and atrial fibrillation entangle the clinician when it comes to therapeutic management. Tailored management is recommended of anticoagulation treatment could be difficult, and there is. In this review, we try to explain the mechanism of AF in cancer patients as well as its management in this setting.

Risk Factors and Prognosis of Perioperative Atrial Fibrillation in Elderly Patients Undergoing VATS Lung Surgery: A Retrospective Cohort Study

Background

Atrial fibrillation (AF) has become the most common postoperative arrhythmia of thoracic surgery. This study aimed to investigate the risk factors and complications of perioperative atrial fibrillation (PoAF) in elderly patients who underwent video-assisted thoracoscopic surgery (VATS).

Methods

Data were collected from patients who underwent VATS between January 2013 and December 2022 at Peking Union Medical College Hospital (PUMCH). Univariable analyses and multivariable logistic regression analyses were used to determine the factors correlated with PoAF. Receiver operating characteristic (ROC) curve was used to evaluate the discrimination of the indicators to predict PoAF.

Results

The study enrolled 2920 patients, with a PoAF incidence of 5.2% (95% CI 4.4%-6.0%). In the logistic regression analyses, male sex (OR=1.496, 95% CI 1.056-2.129, P=0.024), left atrial anteroposterior dimension (LAD) ≥40 mm (OR=2.154, 95% CI 1.235-3.578, P=0.004), hypertension (HTN) without regular treatment (OR=2.044, 95% CI 0.961-3.921, P=0.044), a history of hyperthyroidism (OR=4.443, 95% CI 0.947-15.306, P=0.030), surgery of the left upper lobe (compared to other lung lobes) (OR=1.625, 95% CI 1.139-2.297, P=0.007), postoperative high blood glucose (BG) (OR=2.482, 95% CI 0.912-5.688, P=0.048), and the time of chest tube removal (per day postoperatively) (OR=1.116, 95% CI 1.038-1.195, P=0.002) were found to be significantly associated with PoAF. The area under the ROC curve was 0.707 (95% CI 0.519-0.799). 86.9% patients were successfully converted to sinus rhythm. Compared with the non-PoAF group, the PoAF group had significantly greater risks of prolonged air leakage, postoperative acute coronary syndrome, longer ICU stays, and longer hospital stays.

Conclusion

Male sex, LAD≥40 mm, HTN without regular treatment, a history of hyperthyroidism, surgery of the left upper lobe, postoperative BG, and the time of chest tube removal were associated with PoAF. These findings may help clinicians identify high-risk patients and take preventive measures to minimize the incidence and adverse prognosis of PoAF.

New-Onset Atrial Fibrillation Is a Red Flag to Microvascular Free Tissue Transfer Failure in Head and Neck Cancer Patients

BACKGROUND

 Postoperative new-onset atrial fibrillation (AF) has been shown to be associated with increased surgical morbidity and mortality following cancer ablation surgery. However, evidence of new-onset AF's impact on surgical outcomes in head and neck cancer patients undergoing tumor ablation and microvascular free tissue transfer remains scarce. This study aims to evaluate the association between AF and surgical outcomes in these patients.

METHODS

 We enrolled head and neck cancer patients who underwent tumor ablation reconstructed with microvascular free tissue transfer from the National Health Insurance Research Database (NHIRD). Patients were grouped into the following: (1) without AF, (2) new-onset AF, and (3) preexisting AF. The groups were matched by propensity score based on age, gender, cancer stage, and comorbidities. The primary outcome was postoperative complications, whereas all-cause mortality was the secondary outcome.

RESULTS

 In total, 26,817 patients were included in this study. After matching, we identified 2,176 (79.24%) patients without AF, 285 (10.37%) with preexisting AF, and 285 (10.37%) with new-onset AF. Our results demonstrated that the free flap failure rate was twofold escalated in patients with new-onset AF (9.8%) compared to those without AF (5.4%) or preexisting AF (5.3%; p = 0.01). However, we did not identify significant differences among other postoperative complications across groups. Additionally, we found that the risk of all-cause mortality was significantly elevated in patients with preexisting AF (p < 0.001) compared to those without AF or new-onset AF.

CONCLUSION

 Our study demonstrated that new-onset AF is associated with an increased risk of flap failure and could serve as a predictor. On the other hand, all-cause mortality in patients with preexisting AF was significantly elevated. Close postoperative monitoring in patients with new-onset and preexisting AF is crucial to identify any potential adverse effects.

Serum lipopolysaccharide associated with new-onset atrial fibrillation in patients with non-small-cell lung cancer a retrospective observational study

Lipopolysaccharide (LPS) is related to atrial fibrillation (AF). But so far, the relationship between LPS and new-onset AF (NOAF) in patients with lung cancer is unrevealed. This study was to investigate the association between LPS and NOAF in patients after lung cancer surgery. This was a single-center retrospective clinical observational study. Patients diagnosed with non-small-cell lung cancer (NSCLC) were enrolled. All patients receiving lung cancer surgery and at least 24 h electrocardiogram (ECG) examination was recorded during the hospitalization. The incidence of NOAF in this study was 34/406 (8.4%). The univariate analysis showed that NOAF was associated with age, intraoperative blood transfusion (IBT), chronic obstructive pulmonary disorder (COPD), and LPS. After adjusting risk factors, it was found that age, IBT and LPS (OR, 1.031; 95% CI: 1.001-1.042; P = 0.002) were still risk factors for NOAF. The area under curve (AUC) value was 0.709 for the LPS. When the LPS was added to the conventional model, the Net reclassification index (NRI) and integrated discrimination index (IDI) were improved significantly. Elevated LPS is associated with an increased risk of NOAF in patients after lung cancer surgery. LPS contributed to the discrimination of the NOAF risk model and improved it markedly.

Drug-induced atrial fibrillation. A narrative review of a forgotten adverse effect

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with an increased morbidity and mortality. There is clinical evidence that an increasing number of cardiovascular and non-cardiovascular drugs, mainly anticancer drugs, can induce AF either in patients with or without pre-existing cardiac disorders, but drug-induced AF (DIAF) has not received the attention that it might deserve. In many cases DIAF is asymptomatic and paroxysmal and patients recover sinus rhythm spontaneously, but sometimes, DIAF persists, and it is necessary to perform a cardioversion. Furthermore, DIAF is not mentioned in clinical guidelines on the treatment of AF. The risk of DIAF increases in elderly and in patients treated with polypharmacy and with risk factors and comorbidities that commonly coexist with AF. This is the case of cancer patients. Under these circumstances ascribing causality of DIAF to a given drug often represents a clinical challenge. We review the incidence, the pathophysiological mechanisms, risk factors, clinical relevance, and treatment of DIAF. Because of the limited information presently available, further research is needed to obtain a deeper insight into DIAF. Meanwhile, it is important that clinicians are aware of the problem that DIAF represents, recognize which drugs may cause DIAF, and consider the possibility that a drug may be responsible for a new-onset AF episode.

Incident Atrial Fibrillation and Survival Outcomes in Esophageal Cancer following Radiotherapy

PURPOSE

Radiation therapy (RT) associates with long-term cardiotoxicity. In preclinical models, RT exposure induces early cardiotoxic arrhythmias including atrial fibrillation (AF). Yet, whether this occurs in patients is unknown.

METHODS AND MATERIALS

Leveraging a large cohort of consecutive patients with esophageal cancer treated with thoracic RT from 2007 to 2019, we assessed incidence and outcomes of incident AF. Secondary outcomes included major adverse cardiovascular events (MACE), defined as AF, heart failure, ventricular arrhythmias, and sudden death, by cardiac RT dose. We also assessed the relationship between AF development and progression-free and overall survival. Observed incident AF rates were compared with Framingham predicted rates, and absolute excess risks were estimated. Multivariate regression was used to define the relationship between clinical and RT measures, and outcomes. Differences in outcomes, by AF status, were also evaluated via 30-day landmark analysis. Furthermore, we assessed the effect of cardiac substructure RT dose (eg, left atrium, LA) on the risk of post RT-related outcomes.

RESULTS

Overall, from 238 RT treated patients with esophageal cancer, 21.4% developed incident AF, and 33% developed MACE with the majority (84%) of events occurring ≤2 years of RT initiation (median time to AF, 4.1 months). Cumulative incidence of AF and MACE at 1 year was 19.5%, and 25.7%, respectively; translating into an observed incident AF rate of 824 per 10,000 person-years, compared with the Framingham predicted rate of 92 (relative risk, 8.96; P < .001, absolute excess risk 732). Increasing LA dose strongly associated with incident AF (P = .001); and those with AF saw worse disease progression (hazard ratio, 1.54; P = .03). In multivariate models, outside of traditional cancer-related factors, increasing RT dose to the LA remained associated with worse overall survival.

CONCLUSIONS

Among patients with esophageal cancer, radiation therapy increases AF risk, and associates with worse long-term outcomes.

Cardiac Arrhythmias in Patients Treated for Lung Cancer: A Review

Cardio-oncology currently faces one of the greatest challenges in the field of health care. The main goal of this discipline is to ensure that patients treated for cancer do not suffer or die from cardiovascular disease. The number of studies on the mechanisms of heart injury during cancer treatment is constantly increasing. However, there is insufficient data on heart rhythm disorders that may result from this treatment. This issue seems to be particularly important in patients with lung cancer, in whom anticancer therapy, especially radiotherapy, may contribute to the onset of cardiac arrhythmias. The observed relationship between cardiac dosimetry and radiotherapy-induced cardiotoxicity in lung cancer treatment may explain the increased mortality from cardiovascular causes in patients after chest irradiation. Further research is essential to elucidate the role of cardiac arrhythmias in this context. Conversely, recent reports have highlighted the application of stereotactic arrhythmia radioablation (STAR) in the treatment of ventricular tachycardia. This review of available studies on the epidemiology, pathogenesis, diagnosis, and treatment of arrhythmias in patients treated for lung cancer aims to draw attention to the need for regular cardiological monitoring in this group of patients. Improving cardiac care for patients with lung cancer has the potential to enhance their overall therapeutic outcomes.

Prevention of new-onset atrial fibrillation in elderly patients undergoing anatomic pulmonary resection by infusion of magnesium sulfate: protocol for a randomized controlled trial

Atrial fibrillation (AF) is the most commonly sustained arrhythmia after pulmonary resection, which has been shown to predict higher hospital morbidity and mortality. The lack of strong evidence-based medical evidence makes doctors have very few options for medications to prevent new-onset AF following thoracic surgery. Magnesium can prevent perioperative AF in patients undergoing cardiac surgery. However, this has not yet been fully studied in patients undergoing non-cardiac thoracic surgery, which is the aim of this study. This is a single-center, prospective, double-blind, randomized controlled trial. In total, 838 eligible patients were randomly assigned to one of two study groups, namely, the control group or the magnesium group. The patients in the magnesium group preoperatively received 80 mg magnesium sulfate/kg ideal weight in 100 ml normal saline 30 min. The control group received the same volumes of normal saline simultaneously. The primary outcome is the incidence of new-onset AF intra-operative and on the first, second, and third postoperative days. The secondary outcomes are bradycardia, hypertension, hypotension, and flushing. The occurrence of stroke or any other type of arrhythmia is also recorded. Postoperative respiratory suppression and gastrointestinal discomfort, intensive care unit stays and total duration of hospital stays, in-hospital mortality, and 3-month all-cause mortality are also recorded as important outcomes. This study aims to prospectively evaluate the prophylactic effects of magnesium sulfate against AF compared with a placebo control group during and following anatomic pulmonary resection. The results may provide reliable evidence for the prophylactic value of magnesium against AF in patients with lung cancer. The trial was approved by the Clinical Research Ethics Committee of Shanghai Pulmonary Hospital and has been registered at Chinese Clinical Trial Registry: www.chictr.org.cn, identifier: ChiCTR2300068046.

Lung Lobectomy Is an Embolic Risk Factor for Cerebral Infarction, Even in the Long-term Postoperative Phase

The vein stump created after lung lobectomy has been reported to cause thrombus and subsequently cerebral infarction. However, its assessment after a long-term postoperative course remains unreported. The pulmonary vein stump is a structure near the left atrial appendage; therefore, such patients may be at a constant risk of thrombus formation. We herein report two cases of cerebral infarction associated with lung lobectomy. Transesophageal echocardiography revealed mobile thrombi in the pulmonary vein stump. Both patients had cancer recurrence, and hypercoagulability may have contributed to thrombus formation. This vein stump should be investigated as an embolic source, even after a long postoperative duration.

Relationship between postoperative atrial fibrillation and its recurrence after lung resection

PURPOSE

Atrial fibrillation (AF) frequently occurs after pulmonary resection and is commonly referred to as postoperative atrial fibrillation (POAF). This study explored whether or not POAF is related to the recurrence of AF in the chronic phase.

METHODS

A total of 1311 consecutive patients without a history of AF who underwent lung resection based on a diagnosis of lung tumor were retrospectively analyzed.

RESULTS

POAF occurred in 46 patients (3.5%), and a logistic regression analysis revealed that the age (p < 0.05), history of hyperthyroidism (p < 0.05), and major lung resection (p < 0.05) were independent predictors of POAF. AF events in the chronic phase were observed in 15 (32.6%) and 45 (3.6%) patients with and without POAF, respectively. A Cox regression analysis revealed that POAF was the only independent predictor of AF development in the chronic phase (p < 0.01). The Kaplan-Meier curve and log-rank test revealed that the cumulative incidence of AF in the chronic phase was significantly higher in patients with POAF than in those without POAF (p < 0.01).

CONCLUSION

POAF was an independent predictor for AF in the chronic phase after lung resection. Further investigations including cases of catheter ablation and optimal medical therapy for patients with POAF after lung resection are needed.

Perioperative systemic magnesium sulfate minimizes the incidence of atrial fibrillation after thoracotomy for lung resection: a prospective observational study

Background

Postoperative atrial fibrillation (POAF) is the most common complication following general thoracic surgery. POAF significantly increases the risk of adverse cardiovascular events, such as thromboembolism, heart failure, and mortality. Additionally, it also leads to prolonged hospital stays and higher costs. The objective of this observational study was to examine the impact of perioperative administration of magnesium sulphate (MgSO4) on the incidence of POAF.

Methods

A prospective observational study was conducted, enrolling one hundred patients undergoing thoracotomy for lung resection. We compared the incidence of atrial fibrillation (AF) before and after implementing a change in our standard anesthetic management, which involved the addition of MgSO4. MgSO4 was administered during anesthesia induction at a dose of 40 mg/kg over ten minutes, followed by a 24-hour infusion at a rate of 10 mg/kg/h. The primary outcome was the incidence of POAF within the first seven days after surgery.

Results

Within the initial three days following surgery, there was no significant difference in the cumulative incidence of POAF between the MgSO4 group and the control group. However, on postoperative day 7, patients treated with MgSO4 exhibited a reduced incidence of POAF compared to the control group (4% vs. 26%; P=0.01). In the subgroup of patients not receiving pre-existing β-blockers, the addition of MgSO4 significantly decreased the occurrence of POAF (14% vs. 80%; P<0.001).

Conclusions

Prophylactic administration of MgSO4 is a potentially beneficial approach for reducing the incidence of POAF after non-cardiac surgery, particularly in patients not receiving long-term β-blocker treatment.

Left Atrial Appendage Closure Outcomes in Patients With Cancer at a Single Tertiary Center

Atrial fibrillation is the most common arrhythmia in patients with underlying malignancy. Patients with cancer have a higher risk of bleeding, and at the same time, carry an elevated risk of thromboembolism related to the hypercoagulable state, type of cancer, and anticancer treatment, rendering safe anticoagulation challenging in this population. Left atrial appendage closure is an alternative treatment option in patients with atrial fibrillation and high bleeding risk; however, the data on patients with cancer are limited. Our study aimed to compare the long-term outcomes in patients with cancer receiving left atrial appendage closure using the WATCHMAN device. This is a prospective, single-center study comparing outcomes in 389 patients who underwent percutaneous left atrial appendage closure using the WATCHMAN device over 5 years in a single, large academic hospital in the United States. The postprocedural outcomes of mortality, stroke, and major bleeding were evaluated in patients with and without cancer. Our study included 57 patients with cancer and 332 without cancer. The baseline characteristics were similar between the 2 groups. Metastatic disease was present in 16.4% of patients, and 25% were receiving active treatment at the time of the procedure. The median follow-up time was 354 (interquartile range 85 to 790) days. There was no difference in mortality (hazard ratio [HR] 1.3, 95% confidence interval [CI] 0.72 to 2.35, p = 0.38), major bleeding episodes (HR 1.2, 95% CI 0.45 to 3.33, p = 0.68), and stroke (HR 0.64, 95% CI 0.19 to 2.21, p = 0.49) at 3 years after the procedure in patients with and without cancer. There was no difference in the composite outcome (postprocedural mortality, stroke, and major bleeding) between the 2 groups (HR 1.25, CI 0.75 to 2.07, p = 0.38). Percutaneous left atrial appendage closure in patients with cancer appears to be safe and has a similar long-term risk compared with patients without cancer.

Vagal electrostimulation in postoperative thoracic surgery reduces the systemic inflammatory response and cardiopulmonary complications: an experimental study in pigs

Background

Conventional thoracotomy (CT) often leads to systemic inflammatory response syndrome (SIRS), which induces several clinical complications. CT remains widely used in low-income institutions. Although minimally invasive surgical procedures, such as robotic surgery (RS), have been used to prevent many of the complications inherit from the surgical procedure. Here, we investigated the protective effect of vagus nerve stimulation (VNS) in a pre-clinical model during CT or RS and postoperative period (POP) relative to clinical complications and inflammatory control. The objective was to compare hemodynamic features and cytokine levels in the blood, lung, and bronchoalveolar lavage (BAL) fluids of animals subjected to CT or RS with or without VNS.

Methods

Twenty-four minipigs were subjected to 12 animals CT and 12 animals RS, with or without VNS, and accompanied 24 h later by pulmonary lobectomy. Blood samples for evaluating the hemodynamic parameters were collected before the surgical preparation, immediately after the beginning of VNS, and every 4 h until 24 h after the lobectomy. BAL fluid and lung tissue were collected at the end of the experiment. Cytokine levels were evaluated in the blood, BAL fluid, and lung tissues.

Results

VNS maintained a more stable heart rate during POP and decreased the incidence of overall cardiac complications while preventing increase in IL-6 levels 12 h after lobectomy, compared to sham animals. No differences were found in cytokine expression in the BAL fluid and lung tissue in any of the studied groups.

Conclusions

Taken together, our data suggested that VNS should be considered a non-pharmacological tool in the prevention of the exacerbated inflammatory response responsible for severe clinical complications, especially in more aggressive surgical procedures.

Clinical Benefits of Lobe-Specific Lymph Node Dissection in Surgery for NSCLC: A Systematic Review and Meta-Analysis

Introduction

The impact of lobe-specific lymph node dissection (LS-LND) in surgery for NSCLC remains controversial compared with that of systematic lymph node dissection (S-LND). This study aimed to compare clinical outcomes between the two strategies, including postoperative complications, and to explain the advantages of LS-LND.

Methods

We searched for studies comparing LS-LND and S-LND up to April 14, 2022, using PubMed, EMBASE, and Web of Science. The primary outcomes were overall survival and recurrence-free survival. Secondary outcomes included postoperative complications, such as arrhythmia, chylothorax, and pneumonia. We evaluated the risk of bias and assessed the evidence quality using GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

Results

A total of 13 studies, including one randomized controlled trial and 12 retrospective studies with 11,522 patients who underwent curative resections for lung cancer, were included. The results indicated that LS-LND had favorable overall survival (hazard ratio [HR] = 0.80, 95% confidence interval [CI]: 0.73-0.87) but no difference in recurrence-free survival (HR = 0.96, 95% CI: 0.84-1.09) on comparison with S-LND. In terms of postoperative complications, patients undergoing LS-LND had a lower rate of chylothorax (risk ratio [RR] = 0.54, 95% CI: 0.35-0.85) and arrhythmia (RR = 0.74, 95% CI: 0.57-0.97) than patients undergoing S-LND, but the risk of postoperative pneumonia was not different. The overall quality of evidence was low to moderate owing to the risk of bias related to heterogeneous study populations.

Conclusions

Patients undergoing LS-LND had a comparable and favorable long-term prognosis and a lower rate of postoperative complications. Nevertheless, further standardized studies are necessary to improve the quality of evidence.

Predictors and impact of postoperative atrial fibrillation following thoracic surgery: a state-of-the-art review

This review of 19 studies (39,783 patients) of atrial fibrillation after thoracic surgery addresses the pathophysiology, incidence, and consequences of atrial fibrillation in this population, as well as its prevention and management. Interestingly, atrial fibrillation was most often identified in patients not previously known to have the disease. Rhythm control with amiodarone was the most commonly used treatment and nearly all patients were discharged in sinus rhythm. Major predictors were age; male sex; history of atrial fibrillation; congestive heart failure; left atrial enlargement; elevated brain natriuretic peptide level; and the invasiveness of procedures. Overall, patients with atrial fibrillation stayed 3 days longer in hospital. We also discuss the importance of standardising research on this subject and provide recommendations that might mitigate the impact postoperative atrial fibrillation on hospital resources.

Acute Kidney Injury After General Thoracic Surgery: A Systematic Review and Meta-Analysis

INTRODUCTION

The clinical importance of postoperative acute kidney injury (AKI) in patients undergoing general thoracic surgery is unclear. We aimed to systematically review the incidence, risk factors, and prognostic implications of AKI as a complication after general thoracic surgery.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library from January 2004 to September 2021. Observational or interventional studies that enrolled ≥50 patients undergoing general thoracic surgery and reported postoperative AKI defined using contemporary consensus criteria were included for meta-analysis.

RESULTS

Thirty-seven articles reporting 35 unique cohorts were eligible. In 29 studies that enrolled 58,140 consecutive patients, the pooled incidence of postoperative AKI was 8.0% (95% confidence interval [CI]: 6.2-10.0). The incidence was 3.8 (2.0-6.2) % after sublobar resection, 6.7 (4.1-9.9) % after lobectomy, 12.1 (8.1-16.6) % after bilobectomy/pneumonectomy, and 10.5 (5.6-16.7) % after esophagectomy. Considerable heterogeneity in reported incidences of AKI was observed across studies. Short-term mortality was higher (unadjusted risk ratio: 5.07, 95% CI: 2.99-8.60) and length of hospital stay was longer (weighted mean difference: 3.53, 95% CI: 2.56-4.49, d) in patients with postoperative AKI (11 studies, 28,480 patients). Several risk factors for AKI after thoracic surgery were identified.

CONCLUSIONS

AKI occurs frequently after general thoracic surgery and is associated with increased short-term mortality and length of hospital stay. For patients undergoing general thoracic surgery, AKI may be an important postoperative complication that needs early risk evaluation and mitigation.

Cardiovascular Toxicity and Risk Mitigation with Lung Cancer Treatment

PURPOSE OF REVIEW

Patients with lung cancer often have concomitant cardiovascular comorbidities and receive potentially cardiotoxic therapies. As oncologic outcomes improve, the relative impact of cardiovascular disease on lung cancer survivors is expected to increase. This review summarizes cardiovascular toxicities observed after treatment for lung cancer, as well as recommended risk mitigation strategies.

RECENT FINDINGS

A variety of cardiovascular events may be observed after surgery, radiation therapy (RT), and systemic therapy. The risk of cardiovascular events after radiation therapy (RT) is higher than previously appreciated (23-32%), and RT dose to the heart is a modifiable risk factor. Targeted agents and immune checkpoint inhibitors have been associated with cardiovascular toxicities distinct from those of cytotoxic agents; these are rare but can be severe and require prompt intervention. Optimization of cardiovascular risk factors is important at all phases of cancer therapy and survivorship. Recommended practices for baseline risk assessment, preventive measures, and appropriate monitoring are discussed herein.

Kinase Inhibitors and Atrial Fibrillation

Recent advances have significantly expanded the options of available therapeutics for cancer treatment, including novel targeted cancer therapies. Within this broad category of targeted therapies is the class of kinase inhibitors (KIs), which target kinases that have undergone aberrant activation in cancerous cells. Although KIs have shown a benefit in treating various forms of malignancy, they have also been shown to cause a wide array of cardiovascular toxicities, with cardiac arrhythmias, in particular atrial fibrillation (AF), being 1 of the predominant side effects. The occurrence of AF in patients undergoing cancer treatment can complicate the treatment approach and poses unique clinical challenges. The association of KIs and AF has led to new research aimed at trying to elucidate the underlying mechanisms. Furthermore, there are unique considerations to treating KI-induced AF because of the anticoagulant properties of some KIs as well as drug-drug interactions with KIs and some cardiovascular medications. Here, we review the current literature pertaining to KI-induced AF.

Perioperative cardiovascular pathophysiology in patients undergoing lung resection surgery: a narrative review

Although thoracic surgery is understood to confer a high risk of postoperative respiratory complications, the substantial haemodynamic challenges posed are less well appreciated. This review highlights the influence of cardiovascular comorbidity on outcome, reviews the complex pathophysiological changes inherent in one-lung ventilation and lung resection, and examines their influence on cardiovascular complications and postoperative functional limitation. There is now good evidence for the presence of right ventricular dysfunction postoperatively, a finding that persists to at least 3 months. This dysfunction results from increased right ventricular afterload occurring both intraoperatively and persisting postoperatively. Although many patients adapt well, those with reduced right ventricular contractile reserve and reduced pulmonary vascular flow reserve might struggle. Postoperative right ventricular dysfunction has been implicated in the aetiology of postoperative atrial fibrillation and perioperative myocardial injury, both common cardiovascular complications which are increasingly being appreciated to have impact long into the postoperative period. In response to the physiological demands of critical illness or exercise, contractile reserve, flow reserve, or both can be overwhelmed resulting in acute decompensation or impaired long-term functional capacity. Aiding adaptation to the unique perioperative physiology seen in patients undergoing thoracic surgery could provide a novel therapeutic avenue to prevent cardiovascular complications and improve long-term functional capacity after surgery.

Atrial fibrillation and cancer: prevalence and relative risk from a nationwide study

Background

Atrial fibrillation (AF) is an increasingly recognized codiagnosis in patients with cancer.

Objectives

This study aimed to provide a robust and contemporary estimate on the coprevalence and relative risk of AF in patients with cancer.

Methods

We conducted a nationwide analysis, utilizing diagnosis codes from the Austrian Association of Social Security Providers dataset. Estimates of the coprevalence of cancer and AF and the relative risk of AF in patients with cancer compared with individuals without cancer were obtained as point prevalences with binomial exact confidence intervals and summarized across age groups and cancer types with random-effects models.

Results

Overall, 8,306,244 persons were included in the present analysis, of whom 158,675 (prevalence estimate, 1.91%; 95% CI, 1.90-1.92) had a cancer diagnosis code and 112,827 (1.36%; 95% CI, 1.35-1.36) an AF diagnosis code, respectively. The prevalence estimate for AF in patients with cancer was 9.77% (95% CI, 9.63-9.92) and 1.19% (95% CI, 1.19-1.20) in the noncancer population. Conversely, 13.74% (95% CI, 13.54-13.94) of patients with AF had a concurrent cancer diagnosis. The corresponding age-stratified random-effects relative risk ratio for AF in patients with cancer compared with no cancer diagnosis was 10.45 (95% CI, 7.47-14.62). The strongest associations between cancer and AF were observed in younger persons and patients with hematologic malignancies.

Conclusion

Cancer and AF have a substantial coprevalence in the population. This finding corroborates the concept that cancer and AF have common risk factors and pathophysiology.

Comprehensive analysis of roles of atrial-fibrillation-related genes in lung adenocarcinoma using bioinformatic methods

Atrial fibrillation (AF) is the most common tachyarrhythmia in the world. Lung cancer is the leading cause of cancer deaths in 93 countries. Previous studies demonstrated that the prevalence of AF was higher in patients with lung cancer. However, research on the associations between AF and lung cancer is still rare. In the present study, we first identified AF-related genes using weighted gene correlation network analysis. We then analyzed the expression profiles, prognosis, immune infiltration, and methylation characteristics of these genes in LUAD patients using bioinformatics analysis. We found several AF-related genes, including CBX3, BUB1, DSC2, P4HA1, and CYP4Z1, which differently expressed between tumor and normal tissues. Survival analysis demonstrated that CYP4Z1 was positively correlated with overall survival in LUAD patients, while CBX3, BUB1, DSC2, and P4HA1 were negatively correlated. Moreover, we found that the methylation level of DSC2 in normal lung tissues was significantly higher than that in tumor tissues, and six methylation sites in the DNA sequences of DSC2 were identified negatively correlated with its expression levels. Immune infiltration analysis suggested that levels of immune cell infiltration were related to gene expression levels in varying degrees. We identified AF-related genes and found these genes were correlated with prognosis, immune infiltration, and methylation levels in lung cancer patients. We also constructed a risk signature based on these genes in LUAD patients. We hoped that the current study could provide a novel insight into roles of AF-related genes in lung cancer patients.

Outcomes of malignancy in adults with congenital heart disease: a single center experience

Background

Malignancy is known to be a major cause of death in adult congenital heart disease (ACHD). However, data regarding cardiovascular and cancer-related outcomes in ACHD are lacking.

Methods

We conducted a retrospective single-center cohort study comprising patients with ACHD and malignancy. The primary outcome was all-cause mortality. Key secondary outcomes included major adverse cardiovascular and cerebrovascular events (MACCE), cardiotoxicity events and consequent cancer therapy modifications.

Results

Sixty-eight patients with ACHD and a history of cancer were included in the study. 82% of patients had moderate or great ACHD anatomic complexity. Over a median follow-up of 5 years after cancer diagnosis, 16 (24%) patients died, with 69% of deaths being due to cancer. Univariate predictors of mortality were baseline arrhythmia (OR 3.82, 95% CI 1.15-12.67, p = 0.028), baseline diuretic therapy (OR 3.54, 95% CI 1.04-12.04, p = 0.044) and advanced cancer stage at diagnosis (OR 2.37, 95% CI 1.32-4.25, p = 0.004). MACCE occurred in 40 (59%) patients and was independently predicted by baseline diuretic requirement (OR 9.91, 95% CI 1.12-87.85, p = 0.039). A 14% incidence of cardiotoxicity was seen; 3 patients needed modification and 1 patient needed temporary interruption of cancer therapy for 2 weeks.

Conclusions

Considerable mortality occurred in this cohort of patients with ACHD and cancer; most deaths were cancer-related. A high rate of MACCE was observed, yet rates of obligatory modification of cancer therapy due to cardiotoxicity were low.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40959-022-00144-z.

Are cardiovascular comorbidities always associated with a worse prognosis in patients with lung cancer?

Many factors contribute to mortality in lung cancer, including the presence of concomitant cardiovascular disease. In the treatment of early stage of lung cancer, the presence of comorbidities and occurence of cardiotoxicity may be prognostic. The effect of cardiotoxicity of radiotherapy and chemoradiotherapy on overall survival has been documented. Acute arterial and venous thromboembolic events seem to correlate with the degree of the histological malignancy, its clinical advancement, and even with optimal cardiac treatment, they may influence the survival time. In the case of high-grade and advanced lung cancer stage especially in an unresectable stadium, the prognosis depends primarily on the factors related to the histopathological and molecular diagnosis. Electrocardiographic and echocardiographic abnormalities may be prognostic factors, as they seem to correlate with the patient's performance status as well as tumor localization and size.

Less Known but Clinically Relevant Comorbidities of Atrial Fibrillation: A Narrative Review

BACKGROUND

The important risk factors for atrial fibrillation (AF) in the general population are not always equally important in specific and relatively prevalent diseases.

OBJECTIVE

The main goal of this narrative review is to focus attention on the presence and the relationship of AF with several important diseases, such as cancer or sepsis, in order to: 1) stimulate further research in the field, and 2) draw attention to this relationship and search for AF in clinical practice.

METHODS

We searched PubMed, SCOPUS, Elsevier, Wiley, Springer, Oxford Journals, Cambridge, SAGE, and Google Scholar for less-known comorbidities of AF. The search was limited to publications in English. No time limits were applied.

RESULTS

AF is widely represented in cardiovascular and other important diseases, even in those in which AF is rarely mentioned. In some specific clinical subsets of AF patients (e.g., patients with sepsis or cancer), the general risk factors for AF may not be so important. Patients with new-onset AF have a several-fold increase in relative risk of cancer, deep vein thrombosis, and pulmonary thromboembolism (PTE) during the follow-up.

CONCLUSION

AF presence, prognosis, and optimal therapeutic approach are insufficiently recognised in several prevalent diseases, including life-threatening ones. There is a need for a better search for AF in PTE, pulmonary oedema, aortic dissection, sepsis, cancer and several gastrointestinal diseases. Improved AF detection would influence treatment and improve outcomes.

Evaluation of gastroesophageal reflux disease and hiatal hernia as risk factors for lobectomy complications

Objective

Up to 40% of lobectomies are complicated by adverse events. Gastroesophageal reflux disease (GERD) and hiatal hernia have been associated with morbidity across a range of clinical scenarios, yet their relation to recovery from pulmonary resection is understudied. We evaluated GERD and hiatal hernia as predictors of complications after lobectomy for lung cancer.

Methods

Lobectomy patients at Yale-New Haven Hospital between January 2014 and April 2021 were evaluated for predictors of 30-day postoperative complications, pneumonia, atrial arrhythmia, readmission, and mortality. Multivariable regression models included sociodemographic characteristics, body mass index, surgical approach, cardiopulmonary comorbidities, hiatal hernia, GERD, and preoperative acid-suppressive therapy as predictors.

Results

Overall, 824 patients underwent lobectomy, including 50.5% with a hiatal hernia and 38.7% with GERD. The median age was 68 [interquartile range, 61-74] years, and the majority were female (58.4%). At least 1 postoperative complication developed in 39.6% of patients, including atrial arrhythmia (11.7%) and pneumonia (4.1%). Male sex (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.11-2.06, P = .01), age ≥70 years (OR, 1.55; 95% CI, 1.13-2.11, P = .01), hiatal hernia (OR, 1.40; 95% CI, 1.03-1.90, P = .03), and intraoperative packed red blood cells (OR, 4.80; 95% CI, 1.51-15.20, P = .01) were significant risk factors for developing at least 1 postoperative complication. Hiatal hernia was also a significant predictor of atrial arrhythmia (OR, 1.64; 95% CI, 1.02-2.62, P = .04) but was not associated with other adverse events.

Conclusions

Our findings indicate that hiatal hernia may be a novel risk factor for complications, especially atrial arrhythmia, following lobectomy that should be considered in the preoperative evaluation of lung cancer patients.

Screening, Diagnosis and Management of Atrial Fibrillation in Cancer Patients: Current Evidence and Future Perspectives

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the general population, carrying a high morbimortality burden, and this also holds true in cancer patients. The association between AF and cancer goes even further, with some studies suggesting that AF can be a marker of occult cancer. There is, however, a remarkable paucity of data concerning specific challenges of AF management in cancer patients. AF prompt recognition and management in this special population can lessen the arrhythmia-related morbidity and have an important prognostic benefit. This review will focus on current AF diagnosis and management challenges in cancer patients, with special emphasis on AF screening strategies and devices, and anticoagulation therapy with non-vitamin K antagonist oral anti-coagulants (NOACs) for thromboembolic prevention in these patients. Some insights concerning future perspectives for AF prevention, diagnosis, and treatment in this special population will also be addressed.

Better prediction of stroke in atrial fibrillation with incorporation of cancer in CHA2DS2VASC score: CCHA2DS2VASC score

Introduction

Atrial fibrillation (AF) is associated with an increased risk of stroke. Despite evidence linking cancer and thrombosis, cancer is not part of the CHA₂DS₂VASc score.

Hypothesis

Cancer is an independent risk factor for thromboembolic stroke in patients with AF.

Method

The SEER database was utilized to identify patients with lung, colon, breast, and prostate cancers with AF and no prior diagnosis of stroke and. compared to controls within the dataset. The primary endpoint was rates of stroke per 100 person-years. Cox regression modeling and a nested model comparing CHA₂DS₂VASc score (Model 1) with a complete model including cancer diagnosis (Model 2) were performed. Models were compared using Akaike Information Criterion (AIC) and Net Reclassification Index (NRI). A propensity-matched cohort with equivalent CHA₂DS₂VASc scores determining stroke-free survival was also performed.

Results

A total of 101,185 patients were included in the analysis, with 48,242 in the Cancer and 52,943 in the Non-cancer Group. Stroke rate per 100 person-years was significantly higher in the Cancer Group. The CHA₂DS₂VASc model (Model 1) was compared against a model including cancer (Model 2) showing improved predictability as assessed by both NRI and AIC. Cox regression analysis calculated a hazard ratio of 1.085 for Cancer, which was comparable to age >75, female sex, and diabetes. Propensity matched Kaplan-Meier curve demonstrated a decreased probability of stroke-free survival in the Cancer Group.

Conclusion

Cancers increase the risk of stroke in patients with AF. Consideration should be given to the addition of cancer to the clinical scoring system.

Prediction, prevention and management of new onset peri-operative atrial fibrillation and flutter in patients undergoing non-cardiac thoracic surgery: a narrative review

Peri-operative atrial fibrillation and flutter (POAF) is recognized as a common complication of non-cardiac thoracic surgery. It is associated with hemodynamic instability, prolonged hospital stay, a risk of stroke and increased risk of mortality. The potential pathogenesis for POAF after non-cardiac thoracic surgery is multifactorial and not fully understood yet. Evaluation of risk factors and prediction of POAF can be beneficial for prevention and management of POAF in patients undergoing non-cardiac thoracic surgery. In this article, we reviewed related studies in order to provide a practically and clinically applicable strategy for anesthesiologists to effectively predict, prevent and manage new onset POAF in patients undergoing non-cardiac thoracic surgery.

Baseline Electrocardiographic and Echocardiographic Assessment May Help Predict Survival in Lung Cancer Patients-A Prospective Cardio-Oncology Study

Cardiovascular disease and cancer coexist and lead to exertional dyspnea. The aim of the study was to determine the prognostic significance of cardiac comorbidities, ECG and baseline echocardiography in lung cancer patients with varying degrees of reduced performance status. This prospective study included 104 patients with histopathologically confirmed lung cancer, pre-qualified for systemic treatment due to metastatic or locally advanced malignancy but not eligible for thoracic surgery. The patients underwent a comprehensive cardio-oncological evaluation. Overall survival negative predictors included low ECOG 2 (Eastern Cooperative Oncology Group) performance status, stage IV (bone or liver/adrenal metastases in particular), pleural effusion, the use of analgesics and among cardiac factors, two ECG parameters: atrial fibrillation (HR = 2.39) and heart rate >90/min (HR = 1.67). Among echocardiographic parameters, RVSP > 39 mmHg was a negative predictor (HR = 2.01), while RVSP < 21 mmHg and RV free wall strain < −30% were positive predictors (HR = 0.36 and HR = 0.56, respectively), whereas RV GLS < −25.5% had a borderline significance (HR = 0.59; p = 0.05). Logistical regression analysis showed ECOG = 2 significantly correlated with the following echocardiographic parameters: increasing RVSP, RV GLS, RV free wall strain and decreasing ACT, FAC (p < 0.05). Selected echocardiographic parameters may be helpful in predicting poor performance in lung cancer patients and, supplemented with ECG evaluation, broaden the possibilities of prognostic evaluation.

Higher Mortality Associated With New-Onset Atrial Fibrillation in Cancer Patients: A Systematic Review and Meta-Analysis

Aim

This research was conducted to evaluate the mortality outcome of cancer patients with new-onset atrial fibrillation. We also aimed to assess if there was any confounding relation between the mortality of these patients and surgical intervention.

Materials and Methods

A systemic search was conducted from electronic databases (PubMed/Medline, Cochrane Library, and Google Scholar) from inception to 7 February 2022. All statistical analyses were conducted in Review Manager 5.4.1. Studies meeting inclusion criteria were selected. Only those studies that involved cancer patients without pre-existing atrial fibrillation were selected, and mortality rate was compared between the patients who developed atrial fibrillation and those who did not. A random-effect model was used when heterogeneity was seen to pool the studies, and the result was reported in the odds ratio (OR) and the corresponding 95% confidence interval (CI).

Results

Eighteen studies were selected for meta-analysis. Statistical analysis showed that the cancer patients who subsequently developed atrial fibrillation had a significantly higher mortality rate as compared to those who did not (OR = 1.90 [1.65, 2.19]; p &lt; 0.00001; I2 = 100%). We also separately analyzed the mortality risk in the surgery group and the non-surgery group. Statistical analysis showed that there was significantly higher mortality rate associated with new-onset atrial fibrillation in cancer patients in the surgery group (OR= 3.68 [2.29, 5.94]; p &lt; 0.00001; I2 = 61%) as well as in the non-surgery group (OR = 1.64 [1.39, 1.93]; p &lt; 0.00001; I2 = 100%).

Conclusion

Cancer patients, who subsequently developed atrial fibrillation, had a higher mortality rate as compared to those cancer patients who did not develop atrial fibrillation. A higher mortality rate was seen in both surgical and non-surgical subgroups. This implies that extra care and specific measures must be taken in the management of cancer patients with new-onset atrial fibrillation.

Association Between Perioperative Adverse Cardiac Events and Mortality During One-Year Follow-Up After Noncardiac Surgery

Background

Cardiac complications are associated with perioperative mortality, but perioperative adverse cardiac events (PACEs) that are associated with long‐term mortality have not been clearly defined. We identified PACE as a composite of myocardial infarction, coronary revascularization, congestive heart failure, arrhythmic attack, acute pulmonary embolism, cardiac arrest, or stroke during the 30‐day postoperative period and we compared mortality according to PACE occurrence.

Methods and Results

From January 2011 to June 2019, a total of 203 787 consecutive adult patients underwent noncardiac surgery at our institution. After excluding those with 30‐day mortality, mortality during a 1‐year follow‐up was compared. Machine learning with the extreme gradient boosting algorithm was also used to evaluate whether PACE was associated with 1‐year mortality. After excluding 1203 patients with 30‐day mortality, 202 584 patients were divided into 7994 (3.9%) patients with PACE and 194 590 (96.1%) without PACE. After an adjustment, the mortality was higher in the PACE group (2.1% versus 7.7%; hazard ratio [HR], 1.90; 95% CI, 1.74–2.09; P<0.001). Results were similar for 7839 pairs of propensity‐score‐matched patients (4.9% versus 7.9%; HR, 1.64; 95% CI, 1.44–1.87; P<0.001). PACE was significantly associated with mortality in the extreme gradient boostingmodel.

Conclusions

PACE as a composite outcome was associated with 1‐year mortality. Further studies are needed for PACE to be accepted as an end point in clinical studies of noncardiac surgery.

Prevalence, trends, and outcomes of atrial fibrillation in hospitalized patients with metastatic cancer: findings from a national sample

BACKGROUND

Epidemiological evidence regarding the link between cancer and atrial fibrillation (AF) are limited and outcomes of metastatic cancer comorbid with AF need to be elucidated.

OBJECTIVE

This study aims to evaluate the prevalence, temporal trends, and outcomes of AF in hospitalized metastatic cancer patients.

METHODS

The National Inpatient Sample (NIS) database was used to identify adult patients with metastatic tumors from 2003 to 2014. We analyzed the trends in AF prevalence, in-hospital mortality, total cost, length of stay (LOS), and comorbidities pertaining to metastatic cancer. Multivariable-adjusted models were used to evaluate the association of AF with clinical factors, in-hospital mortality, total cost, and LOS.

RESULTS

Among 2,478,598 patients with metastatic cancer, 8.74% (216,737) were diagnosed with AF. The proportion of comorbid AF increased from 8.28% in 2003 to 10.06% in 2014 (p < 0.0001). Older age, white race, male, Medicare, higher income, larger hospital bed size, and urban teaching hospital were associated with higher AF occurrence. Among primary tumor sites, lung cancer experienced the highest odds of AF compared to other cancers. Patients with metastasis to lymph node and respiratory organ had higher odds of AF. In metastatic cancer, AF was associated with higher in-hospital mortality (odds ratio: 1.48; 95% confidence interval: 1.43-1.54), 18% longer LOS, and 19% higher cost.

CONCLUSIONS

AF prevalence in metastatic cancer continues to increase from 2003 to 2014. AF is linked to poorer prognosis and higher healthcare resource utilization. As the population ages, optimal preventive and treatment management strategies are needed for metastatic cancer comorbid with AF.

The Growing Impact of Cardiovascular Oncology: Epidemiology and Pathophysiology

Progress in the treatment of cancer has significantly improved survival of oncologic patients in recent decades. However, anticancer therapies, particularly some new, more potent and targeted agents, are potentially cardiotoxic. As a consequence, cardiovascular complications, including heart failure, arterial hypertension, coronary artery disease, venous thromboembolism, peripheral vascular disease, arrhythmias, pericardial disease, and pulmonary hypertension, as related to cancer itself or to anticancer treatments, are increasingly observed and may adversely affect prognosis in oncologic patients. Cardiovascular oncology is an emerging field in cardiology and internal medicine, which is rapidly growing, dealing with the prevention, the early detection, and the management of cardiovascular disease, in all stages of anticancer therapy and during the survivorship period, now crucial for reducing cardiovascular morbidity and mortality in cancer patients. In this narrative review, the existing literature regarding the epidemiology of cardiovascular oncology, the mechanisms of cardiovascular complications in cancer, and the pathophysiology of cardiotoxicity related to chemotherapeutic agents, targeted therapies, immunotherapies, and radiotherapy will be analyzed and summarized.

External validity of a model to predict postoperative atrial fibrillation after thoracic surgery

OBJECTIVES

A prediction model developed by Passman et al. stratifies patients' risk of postoperative atrial fibrillation (POAF) after major non-cardiac thoracic surgery using 3 simple factors (sex, age and preoperative resting heart rate). The model has neither undergone external validation nor proven to be relevant in current thoracic surgery practice.

METHODS

A retrospective single-centre analysis of all patients who underwent major non-cardiac thoracic surgery (2008-2017) with prospective documentation of incidence and severity of POAF was used for external validation of Passman's derivation sample (published in 2005 with 856 patients). The model calibration was assessed by evaluating the incidence of POAF and patients' risk scores (0-6).

RESULTS

A total of 2054 patients were included. Among them, POAF occurred in 164 (7.9%), compared to 147 (17.2%) in Passman's study. Differences in our sample compared to Passman's sample included mean heart rate (75.7 vs 73.7 bpm, P < 0.001), proportion of patients with hypertension (46.1 vs 29.4%, P < 0.001), proportion of extensive lung resections, particularly pneumonectomy (6.1 vs 21%, P < 0.001) and proportion of minimally invasive surgeries (56.6% vs 0%). The model demonstrated a positive correlation between risk scores and POAF incidence (risk score 1.2% vs 6.16%).

CONCLUSIONS

The POAF model demonstrated good calibration in our population, despite a lower overall incidence of POAF compared to the derivation study. POAF rates were higher among patients with a higher risk score and undergoing procedures with greater intrathoracic dissection. This tool may be useful in identifying patients who are at risk of POAF when undergoing major thoracic surgery and may, therefore, benefit from targeted prophylactic therapy.

Outcome of Organ Dysfunction in the Perioperative Period

While intraoperative mortality has diminished greatly over the last several decades, the risk of death within 30 days of surgery remains stubbornly high and is ultimately related to perioperative organ failure. Perioperative strokes, while rare (<2% in noncardiac surgery), are associated with a more than 10-fold increase in mortality. Rapid identification and treatment are key to maximizing long-term outcomes. Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are separate but related perioperative neurological disorders, both of which are associated with poor long-term outcomes. To date, there are few known interventions that can ameliorate the risk of perioperative central nervous system dysfunction. Major adverse cardiac events (MACE) are a major contributor to adverse clinical outcomes following surgical procedures. Recently, advances in diagnostic strategies (eg, high-sensitivity cardiac troponin [hs-cTn] assays) have improved our understanding of MACE. Recently, the dabigatran in patients with myocardial injury after noncardiac surgery (MINS; Management of myocardial injury After NoncArdiac surGEry) trial demonstrated that a direct thrombin inhibitor could improve outcomes following MINS. While the risk of acute respiratory distress syndrome (ARDS) after surgery is approximately 0.2%, other less severe complications (eg, pneumonia, reintubation) are closer to 2%. While intensive care unit (ICU) concepts related to ARDS have migrated into the operating room, whether or not adverse pulmonary outcomes impact long-term outcomes in surgical patients remains a matter of debate. The standardization of acute kidney injury (AKI) definition has improved the ability of clinicians to measure and study the incidence of this important source of perioperative morbidity. AKI is associated with increased mortality as well as nonrenal morbidity (eg, myocardial infarction) after major surgery. Gastrointestinal complications after surgery range from ileus (common in abdominal procedures and associated with an increased length of stay) to less common complications such as mesenteric ischemia and gastrointestinal bleeding, both of which are associated with very high mortality. Outside of cardiothoracic surgery, the incidence of perioperative hepatic injury is not well described but, in this population, is associated with worsened long-term outcomes. Hyperglycemia is a common perioperative complication and occurs in patients undergoing both cardiac and noncardiac surgery. Both hyper- and hypoglycemia are associated with worsened long-term outcomes in cardiac and noncardiac surgery. Better diagnosis and increased understanding of perioperative organ injury has led to an increased appreciation for the specific role that particular organ systems play in poor long-term outcomes and has set the stage for targeted therapeutic interventions.

Association Between Perioperative Atrial Fibrillation and Long-term Risks of Stroke and Death in Noncardiac Surgery: Systematic Review and Meta-analysis

BACKGROUND

Atrial fibrillation (AF) is frequently reported as a complication of noncardiac surgery. It is unknown whether new-onset perioperative AF is associated with an increased risk of stroke and death beyond the perioperative period. We performed a systematic review and meta-analysis to assess the long-term risks of stroke and mortality associated with new-onset perioperative AF after noncardiac surgery.

METHODS

MEDLINE and EMBASE were searched from inception to March 2020 for studies reporting on the association between perioperative AF and the risk of stroke and death occurring beyond 30 days after noncardiac surgery. Reference screening, study selection, data extraction, and quality assessment were performed in duplicate. Data were pooled using inverse variance-weighted random-effects models and presented as risk ratios (RRs).

RESULTS

From 7344 citations, we included 31 studies (3,529,493 patients). The weighted mean incidence of perioperative AF was 0.7%. During a mean follow-up of 28.1 ± 9.4 months, perioperative AF was associated with an increased risk of stroke (1.5 vs 0.9 strokes per 100 patient-years; RR: 2.9, 95% confidence interval [CI]: 2.1-3.9, I2 = 78%). Perioperative AF was also associated with a significantly higher risk of all-cause mortality (21.0 vs 7.6 deaths per 100 patient-years; RR: 1.8, 95% CI: 1.5-2.2, I2 = 94%). The pooled adjusted hazard ratios for stroke and all-cause mortality were 1.9 (95% CI: 1.6-2.2, I2 = 31%) and 1.5 (95% CI: 1.3-1.7, I2 = 20%), respectively.

CONCLUSIONS

Patients who had perioperative AF after noncardiac surgery had a higher long-term risk of stroke and mortality compared with patients who did not. Whether this risk is modifiable with oral anticoagulation therapy should be investigated.

Cancer and atrial fibrillation: Epidemiology, mechanisms, and anticoagulation treatment

Cancer patients are at an increased risk of developing atrial fibrillation (AF) and thrombosis. However, the management of anticoagulation in patients with both diseases may be challenging, and data on these patients are lacking. We summarize the current evidence on the incidence and prevalence of cancer in AF and vice versa and provide some practical considerations on the management of oral anticoagulation in specific clinical situations. Low-molecular weight heparins are not approved for thromboprophylaxis in AF, and management of warfarin can be difficult. The use of direct oral anticoagulants may be particularly attractive for their rapid onset/offset action and lower bleeding risk.

Risk factors and outcomes of intraoperative atrial fibrillation in patients undergoing thoracoscopic anatomic lung surgery

Background

Atrial fibrillation (AF) is common after thoracoscopic anatomic lung surgery and can be associated with increased adverse outcomes. However, the incidence, risk factors, and related outcomes of intraoperative AF in thoracoscopic anatomical lung surgery are unknown.

Methods

We retrospectively analyzed the files of 14,986 patients who had presented to the Shanghai Chest Hospital for thoracoscopic anatomic lung operations between January 2016 and December 2018. Univariate and multivariate analyses were conducted to identify risk factors for intraoperative AF, and a 1:1 propensity score-matched (PSM) analysis was performed to compare postoperative outcomes.

Results

The incidence of intraoperative AF was 1.2% (177/14,986). Multivariate analysis identified age older than or equal to 60 years [odds ratio (OR) =1.872, P<0.001], male sex (OR =2.979, P<0.001), diabetes mellitus (OR =2.287, P=0.014), lesion diameter of 1.4 cm or larger (OR =1.855, P=0.002), clinical nodal involvement (OR =1.920, P=0.005), lobectomy resection (OR =2.958, P=0.001), and right resection (OR =1.475, P=0.021) as independent risk factors for intraoperative AF. After 1:1 PSM, we evaluated outcomes in 350 (175 pairs) patients with or without intraoperative AF. Patients who had intraoperative AF were associated with prolonged median ICU stay {28 [26-54] vs. 24 [22-44] hours, P=0.001} and length of stay (LOS) {6 [4-7] vs. 5 [4-6] days, P=0.009}. However, the differences in cardiovascular, pulmonary, and other complications were not significant. In the subgroup analysis, patients who recovered sinus rhythm during operation (n=16) had a shorter median LOS {4 [4-6] vs. 6 [4-7] days, P=0.031}, and a similar incidence of complications compared with patients who recovered sinus rhythm after surgery (n=159).

Conclusions

We identified 7 independent risk factors for intraoperative AF, which were associated with prolonged ICU and hospital stays. The findings may help clinicians identify high-risk patients and take preventive measures to minimize the incidence and adverse outcomes of intraoperative AF.

Atrial Cardiomyopathy and Atrial Fibrillation in Cancer

The number of patients with oncologic and cardiologic comorbidities is increasing. A growing number of evidence shows an inextricable link between cancer, atrial fibrillation, and atrial cardiomyopathy. Cancer itself and resultant inflammation, anticancer treatment, and other comorbidities lead to atrial remodeling and fibrosis, which increases the tendency to develop atrial cardiomyopathy and atrial fibrillation. The scarcity of current literature and ambiguous results make its relationship difficult to fully understand. In this review, we will summarize existing evidence of the relationships and interactions among cancer, atrial cardiomyopathy, and atrial fibrillation and discuss the underlying mechanisms, and provide better information for the management of these patients.

Risk factors and survival analysis of arrhythmia following lung cancer surgery: a retrospective study

Background

Surgical treatment of lung cancer is one of the important treatments for early-stage non-small cell lung cancer (NSCLC). However, arrhythmia, especially atrial fibrillation (AF) and supraventricular arrhythmia, are quite common among patients after surgical treatment of lung cancer. The impact of postoperative arrhythmia (PA) on survival is rarely reported. Our aim was to evaluate the risk factors of PA and its impact on overall survival (OS) after lung cancer surgery.

Methods

A total of 344 patients diagnosed with NSCLC who underwent lung cancer surgery were enrolled in this study. These patients were divided into two groups based on the occurrence of PA. Univariate and multivariate logistic regression analyses were conducted to identify the risk factors of PA. The Kaplan-Meier method was applied to show the OS differences between the two groups.

Results

The incidence of PA was 16% (55/344). Among these 55 patients, 20 had AF, 30 had sinus tachycardia, and 5 had premature beats. A total of 332 patients underwent lung cancer radical resection. Operation type (P<0.001), preoperative abnormal ECG (P=0.032), transfusion (P=0.016), postoperative serum potassium concentration (P=0.001) and clinical stage (P<0.05) were risk factors for PA. PA (HR 2.083, 95% CI, 1.334–3.253; P=0.001), age (HR 1.543, 95% CI, 1.063–2.239; P=0.025) and mediastinal lymph node metastasis (HR 2.655, 95% CI, 1.809–3.897; P<0.001) were independent prognostic risk factors for OS by multivariate cox analysis.

Conclusions

We identified PA as an independent prognostic risk factor to predict poor OS in patients who underwent lung cancer surgery and had risk factors for PA. We therefore provides guidance for PA in improving the prognosis of lung cancer patients.

Cancer Radiation Therapy May Be Associated With Atrial Fibrillation

Background: The association of atrial fibrillation (AF) with cancer and cancer types is inconclusive. Similarly, data regarding the association of AF with different cancer therapies are controversial.

Objectives: To study the association of AF with cancer subtypes and cancer therapies.

Methods: We studied all patients aged 18–89 years who presented to the Feist Weiller Cancer Center, with or without a diagnosis of cancer, between January 2011 and February 2016. Electronic health records were systematically queried for baseline demographics and ICD-9 and ICD-10 codes for specific co-morbidities. Patients with a diagnosis of AF were tabulated based on cross-validation with the ECG database and/or by recorded history. We assessed the prevalence and risk of AF based on cancer diagnosis, specific cancer type, and cancer therapy.

Results: A total of 14,600 patients were analyzed. Compared to non-cancer patients (n = 6,801), cancer patients (n = 7,799) had a significantly higher prevalence of AF (4.3 vs. 3.1%; p < 0.001). However, following correction for covariates in a multivariable logistic regression model, malignancy was not found to be an independent risk factor for AF (p = 0.32). While patients with solid tumors had a numerically higher prevalence of AF than those with hematological malignancies (4.3 vs. 4.1%), tumor type was not independently associated with AF (p = 0.13). AF prevalence was higher in patients receiving chemotherapy (4.1%), radiation therapy (5.1%), or both (6.9%) when compared to patients not receiving any therapy (3.6%, p = 0.01). On multivariable logistic regression, radiation therapy remained an independent risk factor for AF for the entire study population (p = 0.03) as well as for the cancer population (p < 0.01).

Conclusions: Radiation therapy for cancer is an independent risk factor for AF. The known association between cancer and AF may be mediated, at least in part, by the effects of radiation therapy.

Variation in management of post-operative atrial fibrillation (POAF) after thoracic surgery

OBJECTIVES

New-onset post-operative atrial fibrillation (POAF) is a frequent adverse event following major thoracic surgery and is associated with increased risk of perioperative morbidity, length of stay and stroke. It is managed initially with rate and rhythm control therapy; however, optimal duration and the need for anticoagulation are poorly understood. This study aims to assess practice variation regarding POAF management and duration.

METHODS

This retrospective, single-center cohort study included patients who underwent major thoracic surgery and developed POAF between 2008 and 2017, managed with rate and rhythm control therapy alone. Demographic, clinical, and surgical variables/outcomes, POAF management, and incidence of POAF recurrence in the 30-day post-operative period were collected. Chi-square and T-tests determined significance.

RESULTS

Of 2054 patients undergoing thoracic surgery, 155 (75%) patients developed POAF. Different rate and rhythm control agents were used, most commonly metoprolol. 107 (69%) continued rate and rhythm control therapy upon hospital discharge for a mean of 56 days. Among the 48 patients with discontinuation of rate and rhythm control therapy on discharge, none demonstrated recurrence of POAF; in contrast to 3 of 107 patients who continued on therapy. Among patients with CHA₂DS₂-VASc score ≥ 2, 15% were prescribed anticoagulation on discharge.

CONCLUSIONS

Use of rate and rhythm control therapy and anticoagulation for POAF is significantly varied in practice. Many patients are not continued on rate and rhythm control after hospital discharge, which does not appear to impact risk of POAF recurrence. Further research to inform guidelines for POAF management, including therapy duration and indications for anticoagulation is warranted.

Surgical factors associated with new-onset postoperative atrial fibrillation after lung resection: the EPAFT multicentre study

PURPOSE OF THE STUDY

Postoperative atrial fibrillation (POAF) is a recognised complication in approximately 10% of major lung resections. In order to best target preoperative treatment, this study aimed at determining the association of incidence of POAF in patients undergoing lung resection to surgical and anatomical factors, such as surgical approach, extent of resection and laterality.

STUDY DESIGN

Evaluation of Post-operative Atrial Fibrillation in Thoracic surgery (EPAFT): a multicentre, population-based, retrospective, cross-sectional, observational study including 1367 patients undergoing lung resections between April 2016 and March 2017. The primary outcome was the presence of POAF following resection. POAF was defined as at least one episode of symptomatic or asymptomatic AF confirmed by ECG within 7 days from the thoracic procedure or prior to discharge from the hospital.

RESULTS

POAF was observed in 7.4% of patients: 3.1% in minor resection (video-assisted thoracoscopic surgery (VATS): 2.5%; thoracotomy: 3.8%), 9.0% in simple lobectomy (VATS: 7.3%, thoracotomy: 9.9%), 6.0% in complex resection (thoracotomy: 6.3%) and 11.4% in pneumonectomy. POAF was higher in left (4.0%) vs right (2.4%) minor resections, and in left (9.9%) vs right (8.3%) lobectomy, but higher in right (7.5%) complex resections, and the highest in right pneumonectomy (17.6%). No significant variations were observed as per sex, laterality or resected lobes. A positive univariable and multivariable association was observed for increasing age and increasing extent of resection, but not thoracotomy. Median (Q1-Q3) hospital stay was 9 (7-14) days in POAF and 5 (4-7) days in non-AF patients (p<0.001), with an increased cerebrovascular accident burden (p<0.001) and long-term mortality (p<0.001).

CONCLUSIONS

Among patients undergoing lung resection, POAF was significantly associated with age, increasing invasiveness of approach and increasing extent of resection. In addition, POAF carried a significant long-term mortality rate and burden of cerebrovascular accident. Appropriate prophylaxis should be targeted at these groups.

Impact of timing of atrial fibrillation, CHA2DS2-VASc score and cancer therapeutics on mortality in oncology patients

OBJECTIVES

To investigate timing and age distribution of atrial fibrillation (AF) in selected oncology patients, and the impact of AF timing, CHA2DS2-VASc score and cancer therapeutics on mortality.

METHODS

This is a retrospective cohort study of oncology patients referred to the cardio-oncology service from 2011 to 2018 for echocardiographic cardiosurveillance and/or pre-existing cardiovascular risk factor/disease management. Rates of first AF diagnosis was assessed using a parametric multiphase hazard model (predictive modelling) and non-parametrically by Kaplan-Meier with transformations tested using a bootstrap methodology.

RESULTS

Among 6754 patients identified, 174 patients had their first AF diagnosis before cancer while 609 patients had their first diagnosis of AF after cancer. Most first AF diagnosis occurred at/early after cancer diagnosis. Increasing AF prevalence at time of cancer diagnosis was seen across older age groups ranges. Diagnosis of cancer at an older age and exposure to cardiotoxic treatment (anthracyclines, HER2-neu inhibitors, tyrosine kinase inhibitors including ibrutinib and radiation) were associated with an increased risk of AF.Modelling of the hazard function of AF identified a high left-skewed peak within 3 years after cancer diagnosis ('early phase'), followed by a gradual late slight rise 3 years after cancer diagnosis ('late phase'). AF diagnosis was only associated with death in the early phase (p<0.001), while CHA2DS2-VASc score was only associated with death in the late phase (p<0.001).

CONCLUSIONS

This study reports a nuanced/complex relationship between AF and cancer. First diagnosis of AF in patients with cancer was more common at/early after cancer diagnosis, especially in older patients and those exposed to cardiotoxic treatment. Pre-existing AF or a diagnosis of AF within 3 years after cancer diagnosis carried a negative prognosis. CHA2DS2-VASc score did not relate to mortality in those that developed AF within 3 years of cancer diagnosis.

Postoperative atrial fibrillation as a risk factor for cardiovascular complications in non-cardiac surgery

Reducing mortality due to cardiovascular complications (CVC) after non-cardiac surgery is one of the priority tasks of modern healthcare. According to the literature data, it is the CVC that are leading cause of perioperative mortality in non-cardiac surgery. Atrial fibrillation (AF) is a common complication after surgery. It is believed that in most cases the AF is potentiated by a combination of factors. It is intraoperative triggers, such as deliberate hypotension, anemia, injury, and pain, that can directly contribute to development of arrhythmia. However, heart rate monitoring after non-cardiac surgery is performed in only a small number of patients, so in most cases, arrhythmias remain unreported. The Revised Cardiac Risk Index (RCRI) and theAmericanCollegeof Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator are the current tools for assessing perioperative cardiovascular risk. Postoperative AF is not included in any CVC risk stratification system. The presented review systematizes the data that postoperative AF is closely associated with perioperative complications and in some cases it may be the only marker of these complications.  It has been shown that AF detection is of great clinical importance in both high-risk patients and, especially, in patients with a low risk of potential complications in non-cardiac surgery.

Atrial Fibrillation and Stroke Risk in Patients With Cancer: A Primer for Oncologists

Cancer and atrial fibrillation (AF) are common conditions, but for patients affected with both, there is a lack of data about management of anticoagulation and cerebrovascular outcomes. In the first section of this review, we summarize the most relevant studies on stroke risk and management of AF in patients with active cancer, attempting to answer questions of whether to anticoagulate, whom to anticoagulate, and what agents to use. In the second section of the review, we suggest a decision algorithm on the basis of the available evidence and provide practical recommendations for each of the anticoagulant options. In the third section, we discuss the limitations of the available evidence. On the basis of low-quality evidence, we find that patients with cancer and AF have a risk of stroke similar to that of the general population but a substantially higher risk of bleeding regardless of the anticoagulant agent used; this makes anticoagulation-related decisions complex and evidence from the general population not immediately applicable. In general, we suggest stopping anticoagulation in patients with high risk of bleeding and in those with a moderate bleeding risk without a high thromboembolic risk and recommend anticoagulation as in the general population for patients at a low risk for bleeding. However, regardless of initial therapy, we recommend reassessing whether anticoagulation should be given at each point in the clinical course of the disease. High-quality evidence to guide anticoagulation for AF in patients with cancer is needed.

Can local infiltration of lidocaine reduce the postoperative atrial fibrillation rate in patients undergoing lobectomy for lung cancer?

Background: Postoperative atrial fibrillation (POAF) occurs frequently after lung cancer surgery. Unfortunately, owing to the multifactorial etiology of POAF, no single drug or intervention can prevent POAF in all cases. The effects of local interventions after lung cancer surgery are unknown. This study investigated the effects of local infiltration of an anesthetic (lidocaine) on the post-lobectomy POAF rate.Methods: This non-randomized study included 81 patients who underwent lobectomy for lung cancer. Patients were divided into a lidocaine-infiltration group comprising patients who received lidocaine infiltration around the pulmonary veins and a no-intervention group. Patients were monitored for the development of POAF during hospitalization. Pre- and postoperative demographic and clinical data were analyzed.Results: AF occurred in 3 (7.5%) of 40 patients in the lidocaine-infiltration group and in 10 (24.39%) of 41 patients in the standard surgical resection group. Overall, it was observed that intraoperative lidocaine infiltration resulted in a lower POAF rate (p < .05).Conclusion: Local infiltration of lidocaine around the pulmonary veins in patients undergoing lobectomy for lung cancer was associated with a lower incidence of POAF, which is attributable to the local anesthetic and autonomic effects of lidocaine.