Clinical factors associated with the development of postoperative atrial fibrillation in esophageal cancer patients receiving multimodality therapy before surgery

Abstract

Background: The incidence of esophageal cancer (EC) is increasing in the USA. Neoadjuvant therapy for locally advanced cancers followed by surgical resection is the standard of care. The most common postesophagectomy cardiac complication is atrial fibrillation (AF). New-onset postoperative AF can require a prolonged hospital stay and may confer an overall poorer prognosis. In this study, we seek to identify clinical factors associated with postoperative AF.Methods: Query of an IRB approved database of 1,039 esophagectomies at our institution revealed 677 patients with EC from 1999 to 2017 who underwent esophagectomy after neoadjuvant treatment. Age, treatment location (primary vs. other), gender, neoadjuvant radiation type [2D vs. 3D vs. intensity modulated radiation therapy (IMRT)], radiation dose, surgery type (transthoracic vs. transhiatal vs. three field), smoking history, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), operative time, blood transfusions, fluid management, and length of stay (LOS) were analyzed in relationship to the development of AF. Statistical analysis was performed with SPSS 24.Results: The mean age of the entire cohort was 64.3 (range, 28-86 years), with a Caucasian and male preponderance (White: 94.5%; male: 83.6%). Of the 677 patients, 14.9% (n=101) developed postoperative AF. Increasing age (P<0.001), increased radiation dose (P=0.034), operative time (P=0.001), and blood transfusions (P=0.027) were associated with AF. LOS was longer in patients with AF than those without AF (10.5 vs. 10.0 days, P=0.001). On multivariate analysis, increasing age (95% CI: 1.023-1.080, P<0.001) and radiation dose (95% CI: 1.000-1.001, P=0.034) remained significant. None of the other parameters assessed were associated with the development of AF.Conclusions: Increasing age and radiation dose were associated with the development of postoperative AF in this cohort. This study suggests that older patients or patients receiving higher radiation dose should be monitored more closely in the postoperative setting and potentially referred earlier preoperatively for cardiooncology assessment. Future study is required to determine if modification of current radiation techniques and cardiac dose constraints in this patient population may be warranted.

Development and validation of a nomogram to predict cardiac death after radiotherapy for esophageal cancer

“…We found in the literature that in patients with EC, radiation therapy given before or after surgery increases the risk of cardiac death. For example, two studies [ 31 , 32 ] have found that after preoperative radiotherapy, there was a 36% increase in late cardiac events and a 14.9% increase in atrial fibrillation, and the risks of late cardiovascular events and atrial fibrillation correlated with age and radiotherapy dose. Another study [ 33 ] showed that postoperative radiotherapy also increased cardiovascular events in patients with EC.…”

Risk factors for the development of postoperative atrial fibrillation after esophagectomy for esophageal cancer

“…Several studies have investigated the risk factors of POAF following esophagectomy. [ 6 , 7 , 11 , 12 ] However, the results were inconsistent because of the different size of study population and analysis methods. A meta-analysis was conducted to investigate the risk factors and subsequent events associated with the onset of POAF following esophagectomy.…”