Daily atrial fibrillation issues: the view-point of a practicing surgeon

Abstract

Atrial Fibrillation (AF) is encountered daily by the cardiac surgeon. How to deal with a patient with pre existing AF who is on anticoagulation taking into account urgency, type of anticoagulation and procedure planned are some of the daily considerations encountered. When to start anticoagulation and other pharmacotherapy after the occurrence of post-op atrial fibrillation and the use of ablative therapies in view of bleeding and other complications are daily judgement calls made by surgeons. Whom to offer combined interventions are decisions the surgeon faces daily. While guidelines help in broad strokes, there is little help for individual situations which is due to structural problems and absence of universal definitions resulting in the lack of granular data needed for practical individualized daily decision making.

Keywords

Cardiac surgery / atrial fibrillation / anticoagulation / antiarrhythmic therapy / surgical ablation / guidelines

References

[1] Feinberg WM,Laupacis A,Hart RG.Prevalence, age distribution, and gender of patients with atrial fibrillation: analysis and implications.Arch Intern Med1995;155:469-73

[2] Shaw JR,Douketis J,Carrier M.Perioperative interruption of direct oral anticoagulants in patients with atrial fibrillation: a systematic review and meta-analysis.Res Pract Thromb Haemost2018;2:282-90 PMCID:PMC6055497

[3] Douketis JD,Spencer FA.Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.Chest2012;141:e326S-50S PMCID:PMC3278059

[4] Sousa-Uva M,Milojevic M.2017 EACTS Guidelines on perioperative medication in adult cardiac surgery.Eur J Cardiothorac Surg2018;53:5-33

[5] Ferrandis R,de Andrés J.The perioperative management of new direct oral anticoagulants: a question without answers.Thromb Haemost2013;110:515-22

[6] Spyropoulos AC.How I treat anticoagulated patients undergoing an elective procedure or surgery.Blood2012;120:2954-62

[7] Jahangir A,Friedman PA.Long-term progression and outcomes with aging in patients with lone atrial fibrillation: a 30-year follow-up study.Circulation2007;115:3050-6

[8] Kalavrouziotis D,Vyas T.Preoperative atrial fibrillation decreases event-free survival following cardiac surgery.Eur J Cardiothorac Surg2009;36:293-9

[9] Russell EA,Tran L.The burden and implications of preoperative atrial fibrillation in Australian heart valve surgery patients.Int J Cardiol2017;227:100-5

[10] Badhwar V,He X.The Society of Thoracic Surgeons Mitral Repair/Replacement Composite Score: a report of the society of thoracic surgeons quality measurement task force.Ann Thorac Surg2016;101:2265-71

[11] Saint LL,Cuculich PS.Incremental risk of the Cox-maze IV procedure for patients with atrial fibrillation undergoing mitral valve surgery.J Thorac Cardiovasc Surg2013;146:1072-7 PMCID:PMC3804550

[12] Gammie JS,Milford-Beland S.Atrial fibrillation correction surgery: lessons from the Society of Thoracic Surgeons National Cardiac Database.Ann Thorac Surg2008;85:909-14

[13] Ad N,Gammie JS,O'Brien SM.Surgical ablation of atrial fibrillation trends and outcomes in North America.J Thorac Cardiovasc Surg2012;144:1051-60

[14] Badhwar V,Damiano RJ Jr.The society of thoracic surgeons 2017 clinical practice guidelines for the surgical treatment of atrial fibrillation.Ann Thorac Surg2017;103:329-41

[15] Ad N,Shuman DJ,Miller CE.Amiodarone after surgical ablation for atrial fibrillation: Is it really necessary?.J Thorac Cardiovasc Surg2016;151:798-803

[16] Bakir NH,MacGregor RM.Concomitant surgical ablation for atrial fibrillation is associated with increased risk of acute kidney injury but improved late survival.J Thorac Cardiovasc Surg2021:S0022-5223(21)00118 PMCID:PMC8608247

[17] Lin ZQ,Li QZ,Lin F.Efficacy, safety, and long-term survival of concomitant valve replacement and bipolar radiofrequency ablation in patients aged 70 years and older: a comparative study with propensity score matching from a single-Centre.J Cardiothorac Surg2020;15:291 PMCID:PMC7531126

[18] Gillinov AM,Moskowitz AJ.CTSN. Rate control versus rhythm control for atrial fibrillation after cardiac surgery.N Engl J Med2016;374:1911-21 PMCID:PMC4908812

[19] Eikelboom R,Le ML,Arora RC.Postoperative atrial fibrillation after cardiac surgery: a systematic review and meta-analysis.Ann Thorac Surg2021;111:544-54

[20] LB; CCS Atrial Fibrillation Guidelines Committee. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: prevention and treatment of atrial fibrillation following cardiac surgery.Can J Cardiol2011;27:91-7

[21] Greenberg JW,Schuessler RB.Postoperative atrial fibrillation following cardiac surgery: a persistent complication.Eur J Cardiothorac Surg2017;52:665-72

[22] Phan K,Phan S,Thomas SP.New onset atrial fibrillation following coronary bypass surgery predicts long-term mortality: a systematic review and metanalysis.Eur J Cardiothorac Surg2015;48:817-824

[23] January CT,Calkins H.2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the american college of cardiology/american heart association task force on clinical practice guidelines and the heart rhythm society in collaboration with the society of thoracic surgeons.Circulation2019;140:e125-51