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Khalpey Z, Aslam U, Wilson P, Deckwa J, Kumar U. Prophylactic Left Atrial Appendage Ligation During Coronary Artery Bypass Graft Surgery Allows Safe Avoidance of Anticoagulation Regardless of Postoperative Atrial Fibrillation. Cureus 2024; 16:e59876. [PMID: 38854212 PMCID: PMC11157991 DOI: 10.7759/cureus.59876] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 06/11/2024] Open
Abstract
Background New-onset postoperative atrial fibrillation (POAF) is the most common arrhythmia following cardiac surgery. POAF increases the risk of thromboembolism and stroke, as well as morbidity and mortality more generally. Despite evidence from the landmark PROTECT-AF and PREVAIL trials, left atrial appendage ligation (LAAL) is not routinely performed for thromboembolism prophylaxis in POAF, and anticoagulation remains the standard of care along with dual antiplatelet therapy. This study evaluated the efficacy of concomitant LAAL in eliminating the need for postoperative anticoagulation, regardless of POAF development, in patients undergoing coronary artery bypass grafting (CABG). Methods Between 2019 and 2021, 130 patients were selected to undergo concomitant LAAL while undergoing CABG surgery. Patients were then monitored for the incidence of new-onset POAF, and anticoagulation was strictly avoided for this indication. Demographic and outcome data were collected, with endpoints including transient ischemic attack (TIA) or stroke, death, and readmission within one year, as well as the length of hospital and intensive care unit (ICU) admissions. Results POAF occurred in 37 patients (28.5%), consistent with previous reports. However, none of the POAF patients experienced TIA or stroke during the one-year follow-up period, compared to 2 (2.15%) in the non-POAF group, a typical rate of postoperative stroke in such a patient population. No significant differences were observed between POAF and non-POAF cohorts in one-year stroke, all-cause mortality, readmission rates, or total hospital stay. Interestingly, the POAF cohort had a significantly longer mean ICU stay (4.24 vs 3.37 days, p = 0.0219), possibly due to the time required for arrhythmia control before discharge. The study population had a high mean CHA2DS2-VASc score (2.81), indicating an increased risk of thromboembolism, and a high mean HAS-BLED score, suggesting an elevated bleeding risk with anticoagulation. Conclusions LAAL appears to be an effective adjunct to CABG for thromboembolism prophylaxis in POAF. Formal anticoagulation was avoided in this study, with no significant differences in adverse events between POAF and non-POAF groups, suggesting that LAAL may be a suitable alternative to anticoagulation, especially in high-risk patients (e.g., those with elevated CHA2DS2-VASc or HAS-BLED scores). The safety and efficacy of this approach should be corroborated by larger randomized studies, such as the ongoing LeAAPS trial. LAAL during CABG may help reduce the risk of bleeding complications associated with anticoagulation while maintaining protection against thromboembolic events in patients who develop POAF.
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Affiliation(s)
- Zain Khalpey
- Department of Cardiothoracic Surgery, HonorHealth, Scottsdale, USA
| | - Usman Aslam
- Department of Cardiothoracic Surgery, HonorHealth, Scottsdale, USA
- Department of General Surgery, HonorHealth, Phoenix, USA
| | - Parker Wilson
- Department of Internal Medicine, Baylor University Medical Center, Dallas, USA
| | - Jessa Deckwa
- Department of Research, Nihon Kohden Digital Health Solutions, Irvine, USA
| | - Ujjawal Kumar
- Department of Cardiothoracic Surgery, HonorHealth, Scottsdale, USA
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
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Puscas A, Harpa MM, Brinzaniuc K, Al-Hussein H, Al-Hussein H, Banceu C, Opris C, Ghiragosian C, Flamind S, Balan R, Voidazan S, Suciu H. Evaluation of Perioperative Beta-Blockers and Factors Associated with Postoperative Atrial Fibrillation in Cardiac Surgery: A Single Center Experience. Rev Cardiovasc Med 2023; 24:370. [PMID: 39077087 PMCID: PMC11272838 DOI: 10.31083/j.rcm2412370] [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: 08/03/2023] [Revised: 09/04/2023] [Accepted: 09/14/2023] [Indexed: 07/31/2024] Open
Abstract
Background Postoperative atrial fibrillation (AF) has a complex etiology, and beta-blockers are commonly recommended for its pharmacological prevention. This study aims to assess the impact of beta-blocker therapy on postoperative AF occurrence in patients undergoing aortic valve replacement, mitral valve replacement, surgical revascularization of the myocardium, or a combination of these procedures. Methods The study encompassed 472 patients who received aortic valve replacement, mitral valve replacement, surgical revascularization, or their combination. We evaluated the efficacy of preoperative and one-month postoperative beta-blocker administration in preventing postoperative AF, and the associated risk factors involved in the development of postoperative AF. Results Of the total patient population, 36% experienced postoperative AF. Our study demonstrated a significant reduction in postoperative AF incidence among patients receiving beta-blocker treatment (all p-values < 0.05). Additionally, one-month post-surgery, beta-blocker treatment exerted a protective effect by maintaining the sinus rhythm (p = 0.0001). Regarding the risk factors involved in the development of postoperative AF, both age and left atrium (LA) sizeassessed pre-and postoperatively-were positively correlated with the occurrence of postoperative AF (p = 0.006). No relationship was found between leukocyte counts and AF incidence. Notably, C-reactive protein (CRP) levels were significantly elevated on the fifth postoperative day in patients with AF (p < 0.007). The duration of ischemia was significantly longer in patients with AF (p = 0.009). Conclusions This study establishes the efficacy of perioperative beta-blocker treatment in mitigating postoperative AF. One month post-surgery, most patients under beta-blocker therapy maintained sinus rhythm, suggesting a potential long-term protective effect of beta-blockers against late-onset AF.
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Affiliation(s)
- Alexandra Puscas
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
| | - Marius M. Harpa
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Klara Brinzaniuc
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Hussam Al-Hussein
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Hamida Al-Hussein
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Cosmin Banceu
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Carmen Opris
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Claudiu Ghiragosian
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Sanziana Flamind
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Robert Balan
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
- Klinik für Herzchirurgie, Klinikum Passau, 94032 Passau, Germany
| | - Septimiu Voidazan
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Horatiu Suciu
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
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Polintan ET, Monsalve R, Menghrajani RH, Sirilan KY, Nayak SS, Abdelmaseeh P, Patarroyo-Aponte G, Lo KB, Dani SS. Combination prophylactic amiodarone with beta-blockers versus beta-blockers in atrial fibrillation after cardiac surgery: A systematic-review and meta-analysis. Heart Lung 2023; 62:256-263. [PMID: 37619317 DOI: 10.1016/j.hrtlng.2023.08.006] [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: 04/27/2023] [Revised: 08/08/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Guideline recommendations regarding the preferred preventive measures for postoperative atrial fibrillation (POAF) are unclear, nor have we found any review articles addressing the combination of amiodarone and beta-blockers for the prevention of POAF. OBJECTIVES To investigate the efficacy and safety of combination beta-blockers and amiodarone in the prevention of POAF while also comparing the use of amiodarone and beta-blockers individually. METHODS We used Pubmed as the primary resource. POAF incidence was the primary outcome of this study. The secondary outcomes were hospital length of stay (LOS), ICU LOS, treatment-related drug discontinuation (TRDD), and mortality. The random-effects model assessed all pooled outcomes with 95% confidence intervals. Statistical significance was set at p≤0.05. RESULTS The amiodarone subgroup of POAF incidence saw a Risk Ratio (RR) of 0.81 [0.63, 1.06], p=0.12, while the combination subgroup resulted in a RR of 0.63 [0.49, 0.80], p <0.001. TRDD for the amiodarone subgroup resulted in a RR of 0.68 [0.25, 1.82], p=0.44, while the combination subgroup saw a RR of 0.84 [0.57, 1.23], p=0.36. For mortality, the amiodarone subgroup resulted in a RR of 0.97 [0.48, 1.98], p=0.93, while the combination subgroup resulted in a RR of 1.04 [0.27, 4.05], p=0.96. Both hospital and ICU LOS saw no significant difference between treatment arms for both the combination subgroup and amiodarone alone. Except for the incidence of postoperative atrial fibrillation (POAF) in the combination prophylaxis group, most of the measured outcomes did not meet the optimized information size (OIS) that was estimated. CONCLUSION Combination prophylaxis with amiodarone and beta-blockers significantly lowered risks of POAF incidence in comparison to beta-blockers alone while also having comparative mortality and TRDD outcomes.
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Affiliation(s)
| | - Reejeen Monsalve
- College of Medicine, Our Lady of Fatima University, Valenzuela City, Philippines
| | | | - Kym Yves Sirilan
- Department of Internal Medicine, Lincoln Medical Center, Bronx, NY, USA
| | - Sandeep Samethadka Nayak
- Division of Hospital Medicine, Department of Internal Medicine, Yale New Haven Bridgeport Hospital, Bridgeport, CT, USA
| | | | - Gabriel Patarroyo-Aponte
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kevin Bryan Lo
- Department of Medicine, Einstein Medical Center, Sidney Kimmel College of Medicine Thomas Jefferson University, Philadelphia, PA, USA
| | - Sourbha S Dani
- Department of Cardiology, Lahey Hospital & Medical Center, Burlington, MA, USA
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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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