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Postoperative atrial fibrillation: mechanism, prevention, and future perspective

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Abstract

Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery, despite improvements in anesthesia, surgical techniques, and medical therapies. Although beta-blockers have been proven to be effective, the incidence of POAF is around 20 % even with these agents. The mechanism of POAF is not fully elucidated and no optimal strategy has been established for POAF. There are two important elements of “structural” and “electrical” remodelling of the atrium in the mechanism of POAF. A patient’s age and preoperative left atrial fibrosis can predict POAF associated with structural remodelling. Although inflammation and oxidative stress during cardiac surgery may be the underlying mechanisms for electrical remodelling causing POAF, there are no reliable clinical parameters for their detection. Nonetheless, postoperative P-wave dispersion and electromechanical delay, which reflects excitation–contraction coupling abnormalities, could be new parameters for POAF. In conclusion, despite the importance of prevention of POAF, there are only a few parameters for predicting POAF. It is therefore necessary to consider both disease-mediated structural remodeling before surgery and electrical remodeling caused by cardiac surgery.

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References

  1. Hravnak M, Hoffman LA, Saul MI, Zullo TG, Whitman GR, Griffith BP. Predictors and impact of atrial fibrillation after isolated coronary artery bypass grafting. Crit Care Med. 2002;30:330–7.

    Article  PubMed  Google Scholar 

  2. Mathew JP, Fontes ML, Tudor IC, Ramsay J, Duke P, Mazer CD, et al. Investigators of the Ischemia Research and Education Foundation; Multicenter Study of Perioperative Ischemia Research Group. A multicenter risk index for atrial fibrillation after cardiac surgery. JAMA. 2004;291:1720–9.

    Article  PubMed  CAS  Google Scholar 

  3. Zaman AG, Archbold RA, Helft G, Paul EA, Curzen NP, Mills PG. Atrial fibrillation after coronary artery bypass surgery: a model for preoperative risk stratification. Circulation. 2000;101:1403–8.

    Article  PubMed  CAS  Google Scholar 

  4. Bramer S, van Straten AH, Soliman Hamad MA, Berreklouw E, Martens EJ, Maessen JG. The impact of new-onset postoperative atrial fibrillation on mortality after coronary artery bypass grafting. Ann Thorac Surg. 2010;90:443–9.

    Article  PubMed  Google Scholar 

  5. Bradley D, Creswell LL, Hogue CW Jr, Epstein AE, Prystowsky EN, Daoud EG. American College of Chest Physicians. Pharmacologic prophylaxis: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery. Chest. 2005;128:39S–47S.

    Article  PubMed  CAS  Google Scholar 

  6. Lúcio Ede A, Flores A, Blacher C, Leães PE, Lucchese FA, Ribeiro JP. Effectiveness of metoprolol in preventing atrial fibrillation and flutter in the postoperative period of coronary artery bypass graft surgery. Arq Bras Cardiol. 2004;82:42–6.

    PubMed  Google Scholar 

  7. Ali IM, Sanalla AA, Clark V. Beta-blocker effects on postoperative atrial fibrillation. Eur J Cardiothorac Surg. 1997;11:1154–7.

    Article  PubMed  CAS  Google Scholar 

  8. Lamb RK, Prabhakar G, Thorpe JA, Smith S, Norton R, Dyde JA. The use of atenolol in the prevention of supraventricular arrhythmias following coronary artery surgery. Eur Heart J. 1988;9:32–6.

    PubMed  CAS  Google Scholar 

  9. Daudon P, Corcos T, Gandjbakhch I, Levasseur JP, Cabrol A, Cabrol C. Prevention of atrial fibrillation or flutter by acebutolol after coronary bypass grafting. Am J Cardiol. 1986;58:933–6.

    Article  PubMed  CAS  Google Scholar 

  10. Silverman NA, Wright R, Levitsky S. Efficacy of low-dose propranolol in preventing postoperative supraventricular tachyarrhythmias: a prospective, randomized study. Ann Surg. 1982;196:194–7.

    Article  PubMed  CAS  Google Scholar 

  11. Stephenson LW, MacVaugh H III, Tomasello DN, Josephson ME. Propranolol for prevention of postoperative cardiac arrhythmias: a randomized study. Ann Thorac Surg. 1980;29:113–6.

    Article  PubMed  CAS  Google Scholar 

  12. Crystal E, Connolly SJ, Sleik K, Ginger TJ, Yusuf S. Interventions on prevention of postoperative atrial fibrillation in patients undergoing heart surgery: a meta-analysis. Circulation. 2002;106:75–80.

    Article  PubMed  Google Scholar 

  13. Price J, Tee R, Lam BK, Hendry P, Green MS, Rubens FD. Current use of prophylactic strategies for postoperative atrial fibrillation: a survey of Canadian cardiac surgeons. Ann Thorac Surg. 2009;88:106–10.

    Article  PubMed  Google Scholar 

  14. Dunning J, Treasure T, Versteegh M, Nashef SA. EACTS Audit and Guidelines Committee: guidelines on the prevention and management of de novo atrial fibrillation after cardiac and thoracic surgery. Eur J Cardiothorac Surg. 2006;30:852–72.

    Article  PubMed  Google Scholar 

  15. Mathew JP, Parks R, Savino JS, Friedman AS, Koch C, Mangano DT, et al. MultiCenter Study of Perioperative Ischemia Research Group. Atrial fibrillation following coronary artery bypass graft surgery: predictors, outcomes, and resource utilization. JAMA. 1996;276:300–6.

    Article  PubMed  CAS  Google Scholar 

  16. Korantzopoulos P, Kolettis TM, Galaris D, Goudevenos JA. The role of oxidative stress in the pathogenesis and perpetuation of atrial fibrillation. Int J Cardiol. 2007;115:135–43.

    Article  PubMed  Google Scholar 

  17. Aldhoon B, Melenovský V, Peichl P, Kautzner J. New insights into mechanisms of atrial fibrillation. Physiol Res. 2010;59:1–12.

    PubMed  CAS  Google Scholar 

  18. Rodrigo R, Cereceda M, Castillo R, Asenjo R, Zamorano J, Araya J, et al. Prevention of atrial fibrillation following cardiac surgery: basis for a novel therapeutic strategy based on non-hypoxic myocardial preconditioning. Pharmacol Ther. 2008;118:104–27.

    Article  PubMed  CAS  Google Scholar 

  19. Vaziri SM, Larson MG, Benjamin EJ, Levy D. Echocardiographic predictors of nonrheumatic atrial fibrillation. The Framingham Heart Study. Circulation. 1994;89:724–30.

    Article  PubMed  CAS  Google Scholar 

  20. Chen YJ, Chen SA, Tai CT, Wen ZC, Feng AN, Ding YA, et al. Role of atrial electrophysiology and autonomic nervous system in patients with supraventricular tachycardia and paroxysmal atrial fibrillation. J Am Coll Cardiol. 1998;32:732–8.

    Article  PubMed  CAS  Google Scholar 

  21. Skubas NJ, Barzilai B, Hogue CW Jr. Atrial fibrillation after coronary artery bypass graft surgery is unrelated to cardiac abnormalities detected by transesophageal echocardiography. Anesth Analg. 2001;93:14–9.

    Article  PubMed  CAS  Google Scholar 

  22. Shore-Lesserson L, Moskowitz D, Hametz C, Andrews D, Yamada T, Vela-Cantos F, et al. Use of intraoperative transesophageal echocardiography to predict atrial fibrillation after coronary artery bypass grafting. Anesthesiology. 2001;95:652–8.

    Article  PubMed  CAS  Google Scholar 

  23. Hogue CW Jr, Creswell LL, Gutterman DD, Fleisher LA. American College of Chest Physicians: epidemiology, mechanisms, and risks: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery. Chest. 2005;128:9–16.

    Article  Google Scholar 

  24. Goette A, Juenemann G, Peters B, Klein HU, Roessner A, Huth C, et al. Determinants and consequences of atrial fibrosis in patients undergoing open heart surgery. Cardiovasc Res. 2002;54:390–6.

    Article  PubMed  CAS  Google Scholar 

  25. Wang GD, Shen LH, Wang L, Li HW, Zhang YC, Chen H. Relationship between integrated backscatter and atrial fibrosis in patients with and without atrial fibrillation who are undergoing coronary bypass surgery. Clin Cardiol. 2009;32:56–61.

    Article  Google Scholar 

  26. Olshansky B. Interrelationships between the autonomic nervous system and atrial fibrillation. Prog Cardiovasc Dis. 2005;48:57–78.

    Article  PubMed  CAS  Google Scholar 

  27. Dimmer C, Tavernier R, Gjorgov N, Van Nooten G, Clement DL, Jordaens L. Variations of autonomic tone preceding onset of atrial fibrillation after coronary artery bypass grafting. Am J Cardiol. 1998;82:22–5.

    Article  PubMed  CAS  Google Scholar 

  28. Chen PS, Tan AY. Autonomic nerve activity and atrial fibrillation. Heart Rhythm. 2007;4:61–4.

    Article  CAS  Google Scholar 

  29. Wazni OM, Martin DO, Marrouche NF, Latif AA, Ziada K, Shaaraoui M, et al. Plasma B-type natriuretic peptide levels predict postoperative atrial fibrillation in patients undergoing cardiac surgery. Circulation. 2004;110:124–7.

    Article  PubMed  CAS  Google Scholar 

  30. Tavakol M, Hassan KZ, Abdula RK, Briggs W, Oribabor CE, Tortolani AJ, et al. Utility of brain natriuretic peptide as a predictor of atrial fibrillation after cardiac operations. Ann Thorac Surg. 2009;88:802–7.

    Article  PubMed  Google Scholar 

  31. Schmidt-Ott UM, Ascheim DD. Thyroid hormone and heart failure. Curr Heart Fail Rep. 2006;3:114–9.

    Article  PubMed  CAS  Google Scholar 

  32. Park YJ, Yoon JW, Kim KI, Lee YJ, Kim KW, Choi SH, et al. Subclinical hypothyroidism might increase the risk of transient atrial fibrillation after coronary artery bypass grafting. Ann Thorac Surg. 2009;87:1846–52.

    Article  PubMed  Google Scholar 

  33. Faggiano P, D’Aloia A, Zanelli E, Gualeni A, Musatti P, Giordano A. Contribution of left atrial pressure and dimension to signal-averaged P-wave duration in patients with chronic congestive heart failure. Am J Cardiol. 1997;79:219–22.

    Article  PubMed  CAS  Google Scholar 

  34. Song J, Kalus JS, Caron MF, Kluger J, White CM. Effect of diuresis on P-wave duration and dispersion. Pharmacotherapy. 2002;22:564–8.

    Article  PubMed  Google Scholar 

  35. Steinberg JS, Zelenkofske S, Wong SC, Gelernt M, Sciacca R, Menchavez E. Value of the P-wave signal-averaged ECG for predicting atrial fibrillation after cardiac surgery. Circulation. 1993;88:2618–22.

    Article  PubMed  CAS  Google Scholar 

  36. Zaman AG, Alamgir F, Richens T, Williams R, Rothman MT, Mills PG. The role of signal averaged P wave duration and serum magnesium as a combined predictor of atrial fibrillation after elective coronary artery bypass surgery. Heart. 1997;77:527–31.

    PubMed  CAS  Google Scholar 

  37. Chandy J, Nakai T, Lee RJ, Bellows WH, Dzankic S, Leung JM. Increases in P-wave dispersion predict postoperative atrial fibrillation after coronary artery bypass graft surgery. Anesth Analg. 2004;98:303–10.

    Article  PubMed  Google Scholar 

  38. Anselmi A, Possati G, Gaudino M. Postoperative inflammatory reaction and atrial fibrillation: simple correlation or causation? Ann Thorac Surg. 2009;88:326–33.

    Article  PubMed  Google Scholar 

  39. Ishii Y, Schuessler RB, Gaynor SL, Yamada K, Fu AS, Boineau JP, et al. Inflammation of atrium after cardiac surgery is associated with inhomogeneity of atrial conduction and atrial fibrillation. Circulation. 2005;111:2881–8.

    Article  PubMed  CAS  Google Scholar 

  40. Gaudino M, Andreotti F, Zamparelli R, Di Castelnuovo A, Nasso G, Burzotta F, et al. The −174G/C interleukin-6 polymorphism influences postoperative interleukin-6 levels and postoperative atrial fibrillation. Is atrial fibrillation an inflammatory complication? Circulation. 2003;108:195–9.

    Article  Google Scholar 

  41. Yared JP, Starr NJ, Torres FK, Bashour CA, Bourdakos G, Piedmonte M, et al. Effects of single dose, postinduction dexamethasone on recovery after cardiac surgery. Ann Thorac Surg. 2000;69:1420–4.

    Article  PubMed  CAS  Google Scholar 

  42. Yared JP, Bakri MH, Erzurum SC, Moravec CS, Laskowski DM, Van Wagoner DR, et al. Effect of dexamethasone on atrial fibrillation after cardiac surgery: prospective, randomized, double-blind, placebo-controlled trial. J Cardiothorac Vasc Anesth. 2007;21:68–75.

    Article  PubMed  CAS  Google Scholar 

  43. Ruffin RT Jr, Kluger J, Baker WL, Wills SM, White CM, Coleman CI. Association between perioperative NSAID use and post-cardiothoracic surgery atrial fibrillation, blood transfusions, and cardiovascular outcomes: a nested cohort study from the AF Suppression Trials (AFIST) I, II and III. Curr Med Res Opin. 2008;24:1131–6.

    Article  PubMed  Google Scholar 

  44. Ramlawi B, Otu H, Mieno S, Boodhwani M, Sodha NR, Clements RT, et al. Oxidative stress and atrial fibrillation after cardiac surgery: a case–control study. Ann Thorac Surg. 2007;84:1166–72.

    Article  PubMed  Google Scholar 

  45. Eslami M, Badkoubeh RS, Mousavi M, Radmehr H, Salehi M, Tavakoli N, et al. Oral ascorbic acid in combination with beta-blockers is more effective than beta-blockers alone in the prevention of atrial fibrillation after coronary artery bypass grafting. Tex Heart Inst J. 2007;34:268–74.

    PubMed  Google Scholar 

  46. Baker WL, Anglade MW, Baker EL, White CM, Kluger J, Coleman CI. Use of N-acetylcysteine to reduce post-cardiothoracic surgery complications: a meta-analysis. Eur J Cardiothorac Surg. 2009;35:521–7.

    Article  PubMed  Google Scholar 

  47. Chen WT, Krishnan GM, Sood N, Kluger J, Coleman CI. Effect of statins on atrial fibrillation after cardiac surgery: a duration- and dose-response meta-analysis. J Thorac Cardiovasc Surg. 2010;140:364–72.

    Article  PubMed  CAS  Google Scholar 

  48. Goldhaber JI, Qayyum MS. Oxygen free radicals and excitation-contraction coupling. Antioxid Redox Signal. 2000;2:55–64.

    Article  PubMed  CAS  Google Scholar 

  49. Shingu Y, Kubota S, Wakasa S, Ebuoka N, Mori D, Ooka T, et al. Left-ventricular electromechanical delay is prolonged in patients with postoperative atrial fibrillation. Eur J Cardiothorac Surg. 2011;39:684–8.

    Article  PubMed  Google Scholar 

  50. Roshanali F, Mandegar MH, Yousefnia MA, Rayatzadeh H, Alaeddini F, Amouzadeh F. Prediction of atrial fibrillation via atrial electromechanical interval after coronary artery bypass grafting. Circulation. 2007;116:2012–7.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Cardiovascular Surgery, Hokkaido University Graduate School of Medicine, Kita 14, Nishi 5, Kitaku, Sapporo, 060-8648, Japan

    Yasushige Shingu, Suguru Kubota, Satoru Wakasa, Tomonori Ooka, Tsuyoshi Tachibana & Yoshiro Matsui

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  1. Yasushige Shingu
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  2. Suguru Kubota
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Correspondence to Yoshiro Matsui.

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Shingu, Y., Kubota, S., Wakasa, S. et al. Postoperative atrial fibrillation: mechanism, prevention, and future perspective. Surg Today 42, 819–824 (2012). https://doi.org/10.1007/s00595-012-0199-4

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