A review and analysis of strategies for prediction, prevention and management of post-operative atrial fibrillation after non-cardiac thoracic surgery

Abstract

Atrial fibrillation (AF) is the most common sustained arrhythmia after non-cardiac thoracic surgery and is associated with a significant increase in perioperative morbidity, intensive care unit (ICU) admission, and mortality. Practical guidance is needed to assist clinicians in managing this critical issue and direct further research. Here we aim to provide a synoptic review and analysis of the literature to distil practical recommendations for prediction, prevention and management of post-operative atrial fibrillation (POAF) suitable for clinical application and further evaluation. To predict POAF, risk factors including age, gender, elevated pre-operative heart rate and extent of surgical resection have been reproducibly identified and integrated into scoring systems. To prevent POAF, prophylactic therapy with beta-blockers, amiodarone, or magnesium have demonstrated to be effective, but need further trials in high-risk populations. To manage unstable POAF that precipitates hypotension and hypoperfusion, although rare, requires immediate electrocardioversion to restore cardiac output and adequate oxygen delivery. For hemodynamically stable patients, rate control and prevention of adverse events are the objectives. We propose an individualized approach aimed at rate control using initial incremental low dose beta-blocker or calcium channel blocker (CCB) therapy with close monitoring of a patient's response, and continuation of the drug that they respond to, along with simultaneous identification and reduction of triggers of AF, in order for spontaneous return to sinus rhythm. For patients who persistently fail to respond to rate control therapy, rhythm control may be considered using an agent selected based on the patient's comorbidities and the medications' side effect profile. While controversial and requiring further study, anticoagulation therapy is recommended in patients with risk factors for thromboembolic events after 48 hours of persistent AF. We recommend continuous prospective monitoring of incidence and severity of POAF to track the impact of protocols to predict, prevent and manage POAF.

The role of the right atrium in development of postoperative atrial fibrillation: A speckle tracking echocardiography study

“…The role of both the LA and ventricle in the development of AF has been extensively demonstrated. [14][15][16] While LAVi was reported to have better predictive value than LVGLS in the estimation of POAF development in one study, another study reported that lower preoperative LVGLS could be associated with POAF. 17,18 Although the involvement of LA volume and functions is well known in the development of POAF, [19][20][21] Finally, AF with rapid ventricular response may also cause myocardial ischemia and tachycardiomyopaty.…”

“…In our study, LAVi, LVGL, and sPAP were closely associated with POAF development, which is consistent with the literature data. The role of both the LA and ventricle in the development of AF has been extensively demonstrated . While LAVi was reported to have better predictive value than LVGLS in the estimation of POAF development in one study, another study reported that lower preoperative LVGLS could be associated with POAF .…”

Reducing the Incidence of Amiodarone‐related Phlebitis Through Utilization of Evidence‐based Practice

“…IV amiodarone has multiple indications that can be used in a variety of settings, with its primary use to treat patients who are hemodynamically unstable with atrial or ventricular arrhythmias (Hilleman, & Spinler, 2012). In addition, it can be used to prevent atrial fibrillation post‐thoracic surgery (Smith et al, 2018; Zhao et al, 2017). Approximately 12%–46% of patients are at risk for atrial fibrillation after thoracic surgery, the most common complication (Smith et al, 2018; Zhao et al, 2017).…”

“…Approximately 12%–46% of patients are at risk for atrial fibrillation after thoracic surgery, the most common complication (Smith et al, 2018; Zhao et al, 2017). Patients may experience palpitations, dizziness, chest pain, shortness of breath, or hypotension when untreated, which can lead to increased morbidity, risk for ischemic stroke, longer length of stay, and the need for escalation of care (Rienstra et al, 2012; Smith et al, 2018; Zhao et al, 2017). Male patients with advanced age, an oncologic history, and comorbid conditions of the lungs are at increased risk compared to the general population (Smith et al, 2018).…”

“…Patients may experience palpitations, dizziness, chest pain, shortness of breath, or hypotension when untreated, which can lead to increased morbidity, risk for ischemic stroke, longer length of stay, and the need for escalation of care (Rienstra et al, 2012; Smith et al, 2018; Zhao et al, 2017). Male patients with advanced age, an oncologic history, and comorbid conditions of the lungs are at increased risk compared to the general population (Smith et al, 2018). In the preventative use setting, the duration of therapy is short term and therefore a central line is not usually indicated.…”