1. Perioperative management of atrial fibrillation
Anaesthesia ,1998,53,pages

2. Prevalence 0.4% in adult less than 60 years old
12% in those over 75 years

3. Classification of AF
Drugs 2003;63(14)

4. etiology

5. Volatile anesthetic agent
Sensitizing the myocardium to catecholamine
Have an apparent antifibrillary effect in the ventricle following periods of ischemia and reperfusion similar to CCB like verapamil.
Depression of sinus node automaticity, increased supraventricular refractoriness and depressed AV nodal conduction

6. Clinical consequence Loss of “atrial kick”
Excessively rapid and irregular ventricular rate
Systemic thrombo-embolism and a significant risk of stroke
Patient discomfort due to palpitation

7. Loss of “atrial kick”
Absent (atrial fibrillation) , ineffective (atrial flutter) ,or altered timing of atrial contraction (low atrial or junctional rhythm) can reduce ventricular filling by 20-30%
LV dysfunction  more depend on atrial kick

8. Excessively rapid and irregular ventricular rate
Ventricular filling progressively becomes impaired at high heart rate (>120 beats/min in adult ).

9. Tachycardiomyopathy
Tachycardia-induced LV dysfunction due to high ventricular rate (>120 bpm) which is reversible with rate or rhythm control
LV dysfunction secondary to chronic tachycardia

10. Tachycardiomyopathy

11. Tachycardiomyopathy

12. What is the Optimal Ventricular Rate during Atrial Fibrillation?

13. What is the Optimal Ventricular Rate during Atrial Fibrillation?

14. Current recommandation for the targets of rate control
≦80-90 bpm at rests
≦ bpm during moderate exercise

15. Management strategies
Management of acute-onset AF
Maitenance of sinus rhythm
Control of ventricular rate
Prevention of thromboembolism

16. Management of acute-onset AF ~ cardiversion ~
DC cardioversion:
1.Indication : AF associated with hypotension, CHF, active ischemia or acute infarction. Patients with severe AS,MS,and hypertrophic cardiomyopathy
2.contraindication:
digoxin toxicity, a history of bradycardia or sick sinus syndrome,and inadequated correct precipitating factors.

17. Do Not DC cardioversion!!!
Duration of AF>48 hrs without >3 weeks anticoagulation or exclude the atrial thrombus by TEE
Do Not DC cardioversion!!!

18. Management of acute-onset AF ~ cardiversion ~
Pharmacological cardioversion:

19. Maintenance of sinus rhythm

20. Rate control
vs.
Rhythm control

22. Treatment option for rate control

23. Treatment option for rate control

24. Further investigation of AF
Full history and examination
12 lead ECG (including and ECG during periods of sinus rhythm if AF is paroxysmal in order to detect intra-atrial conduction defect)
Echocardiography(Dx of impaired LV function)
Serum chemistry screen including thyroid function test
Exercise ECG if arrythmia is exercise-induced.
Electrophysiological studies in p’t who are young or refractory to treatment.