1. Management of Postoperative Atrial Fibrillation
Stephen D. Cassivi, MD MSc FRCSC FACS
Professor of Surgery
Vice Chair – Department of Surgery

2. Financial Relationship / Conflict of Interest Disclosure Statement
I have NO financial relationships or potential conflicts of interest to report

3. Take Home Messages

4. Take Home Messages Frequent Mostly Self-Limited Difficult to Prevent
Hemodynamic stability defines Treatment Goals
Unstable Patient  Restore HD stability
Stable Patient  Rate Control
Anticoagulation – based on individual patient risk
Key References: JTCVS 2014;148:
JACS 2013;219:

5. Postoperative Atrial Fibrillation - POAF
Most common sustained arrhythmia after pulmonary and esophageal surgery.
Occurring, depending on the nature of your particular practice, between 5 and 30% of cases.

6. Postoperative Atrial Fibrillation – POAF Impact
Major, potentially preventable adverse outcome
 ICU length of stay
 ICU readmission
 Hospital length of stay
 Morbidity – stroke, bleeding
 Mortality (RR  )
 Resource utilization

7. Postoperative Atrial Fibrillation – POAF Timecourse
POAF occurrence peaks on POD 2-4
90-98% of new onset POAF resolves within 4-6 weeks
Ann Thorac Surg 2011;92:421–7

8. Postoperative Atrial Fibrillation – POAF Mechanisms
Requires BOTH:
“Triggers”
Rapidly firing ectopic focus
Reentrant circuit of short cycle length
Multiple reentrant ‘wavelets’
“Vulnerable Substrate”
Sympathetic or parasympathetic stimulation
Atrial dilation or acute atrial stretch
Pericarditis
Fibrosis
Conduction abnormalities
Inflammation or oxidative stress
Rapidly firing ectopic focus (atrial or elsewhere)
Reentrant circuit of short cycle length (ORDERED reentry)
Multiple reentrant ‘wavelets’ (RANDOM reentry)
In the presence of vulnerable substrate, additional electrophysiologic abnormalities (drivers) will sustain AF.

9. Postoperative Atrial Fibrillation – POAF Incidence
Incidence varies
Incidence Intensity of surgical procedure

10. Postoperative Atrial Fibrillation – POAF Incidence
Incidence varies
Incidence Intensity of surgical procedure
Low Risk
of POAF
Bronchoscopy
VATS biopsy
Laparoscopic Nissen

11. Postoperative Atrial Fibrillation – POAF Incidence
Incidence varies
Incidence Intensity of surgical procedure
Low Risk
of POAF
Intermediate Risk
of POAF
Bronchoscopy
VATS biopsy
Laparoscopic Nissen
VATS Lobectomy
Open Lobectomy
Thymectomy

12. Postoperative Atrial Fibrillation – POAF Incidence
Incidence varies
Incidence Intensity of surgical procedure
Low Risk
of POAF
Intermediate Risk
of POAF
High Risk
of POAF
Bronchoscopy
VATS biopsy
Laparoscopic Nissen
VATS Lobectomy
Open Lobectomy
Thymectomy
Extrapleural
Pneumonectomy
Esophagectomy

13. Postoperative Atrial Fibrillation – POAF Incidence
New onset atrial fibrillation with rapid
ventricular response was documented in 44 patients
(7.3%), with 31 (70.5%) receiving antiarrhythmia treatment
within 45 minutes of onset.
Ann Thorac Surg 2008;86:927–33

14. Postoperative Atrial Fibrillation – POAF Incidence
New onset atrial fibrillation with rapid ventricular response
44/606 (7.3%)
New onset atrial fibrillation with rapid
ventricular response was documented in 44 patients
(7.3%), with 31 (70.5%) receiving antiarrhythmia treatment
within 45 minutes of onset.
Ann Thorac Surg 2008;86:927–33

15. Postoperative Atrial Fibrillation – POAF Incidence – Patient Factors
Modifiable Factors
Hypertension
Valvular Heart Disease
Obesity
Obstr. Sleep Apnea
Hyperthyroidism
Smoking
Nonmodifiable Factors
Age
Race
Male
History of arrhythmias

16. Postoperative Atrial Fibrillation – POAF Guidelines

18. JTCVS 2014;148:

20. Thromboembolic Stroke

21. CHA2DS2-VASc
Chest 2010;137:

23. Postoperative Atrial Fibrillation – POAF AATS Guidelines
Monitoring / Telemetry
No monitoring necessary – if:
Low Risk procedure
No prior history of arrhythmias/HF/CVA
CHA2DS2-VASc < 2
48-72 hours of Monitoring / Telemetry – if:
Intermed or High Risk procedure
CHA2DS2-VASc ≥ 2
Hx of pre-existing or periodic recurrent AF

24. Postoperative Atrial Fibrillation – POAF AATS Guidelines
Prevention
Avoidance of β-blockade withdrawal
Correction of abnormal serum Mg++ levels

25. Postoperative Atrial Fibrillation – POAF AATS Guidelines
Treatment
Depends on Hemodynamic Stability
UNSTABLE:
Restore Sinus Rhythm
STABLE:
Rate Control

26. Postoperative Atrial Fibrillation – POAF AATS Guidelines
Treatment
For ALL patients:
Reduce or stop catecholaminergic inotropic agents (if hemodynamics allow)
Optimize fluid balance
Correct electrolyte abnormalities
Treat/correct possible triggering factors
Bleeding, PE, Pneumothorax, Ischemia/MI, Infection/Sepsis

27. Postoperative Atrial Fibrillation – POAF AATS Guidelines
Treatment - UNSTABLE
Primary Goal = Restore Sinus Rhythm
Cardioversion
If Cardioversion unsuccessful or unstable POAF recurs:
Initiate IV Esmolol / Digoxin / Diltiazem / Amiodarone
Prepare to Cardiovert again

28. Postoperative Atrial Fibrillation – POAF AATS Guidelines
Treatment - STABLE
Primary Goal = Rate Control
Β-blocker (esmolol/metoprolol) or Ca++ channel blocker (diltiazem, verapamil) to achieve HR ≤ 110 bpm
For pts with HF, LV dysfnx, or unresponsive to above tx  Amiodarone
Caveat: WPW syndrome

29. Postoperative Atrial Fibrillation – POAF AATS Guidelines
Treatment
Cardiology consultation if:
Recurrent or refractory POAF
Persistent hemodynamic instability
CHAD-VASc score high
Require second-line anti-arrhythmic agent
Develop acute renal injury/failure

30. Postoperative Atrial Fibrillation – POAF AATS Guidelines
Follow-up
Cardiology follow-up if:
EF ≤ 45%
Dx of Systolic HF or Cardiomyopathy
Started NEW rhythm control agent
POAF last > 6 weeks

32. Postoperative Atrial Fibrillation – POAF AATS Guidelines
Anticoagulation Treatment
During first 48h from onset
Anticoagulation decision based on TE risk (CHADS-VASc)
Stable POAF >48 hours duration
Anticoagulation is recommended

33. Anticoagulation
Ann Thorac Surg 2011;92:421–7

34. Median Age – 71 years (Range 31 – 92)
Results
January 1994 – December 2009
759 Patients
Median Age – 71 years (Range 31 – 92)
527
232

35. 8 (1.1%) patients developed a stroke
Results Strokes
8 (1.1%) patients developed a stroke
Not anticoagulated - 3 (0.6%) pts.
Anticoagulated - 5 (2.2%) pts.
(p=0.057)

36. 49 (6.5%) patients developed a bleeding complication
Results Bleeding
49 (6.5%) patients developed a bleeding complication
Not anticoagulated - 27 (5.1%)* pts.
Anticoagulated - 22 (9.6%)* pts.
*statistically different p=0.009

37. Anticoagulation did not lower the risk of stroke or TIA
Conclusions
Anticoagulation did not lower the risk of stroke or TIA
Anticoagulation was associated with an increase in postoperative bleeding
Routine anticoagulation for POAF should be avoided

38. Postoperative Atrial Fibrillation – POAF Guidelines
Anticoagulation Treatment
Anticoagulation decision based on TE risk (CHADS-VASc)
Both within and beyond 48 hours

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47. Take Home Messages Frequent Mostly Self-Limited Difficult to Prevent
Hemodynamic stability defines Treatment Goals
Unstable Patient  Restore HD stability
Stable Patient  Rate Control
Anticoagulation – based on individual patient risk
Key References: JTCVS 2014;148:
JACS 2013;219: