Management of Postoperative Atrial Fibrillation Stephen D. Cassivi, MD MSc FRCSC FACS Professor of Surgery Vice Chair – Department of Surgery cassivi.stephen@mayo.edu

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

Take Home Messages

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;148:772-791. JACS 2013;219:831-841.

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.

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  1.7-3.4)  Resource utilization

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

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.

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

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

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

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

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

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

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

Postoperative Atrial Fibrillation – POAF Guidelines

JTCVS 2014;148:772-791.

Thromboembolic Stroke

CHA2DS2-VASc Chest 2010;137:263-72.

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

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

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

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

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

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

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

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

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

Anticoagulation Ann Thorac Surg 2011;92:421–7

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

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)

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

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

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

JACS 2013;219:831-841.

JACS 2013;219:831-841.

JACS 2013;219:831-841.

JACS 2013;219:831-841.

JACS 2013;219:831-841.

JACS 2013;219:831-841.

JACS 2013;219:831-841.

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;148:772-791. JACS 2013;219:831-841.

cassivi.stephen@mayo.edu