Society of Cardiovascular Anesthesiologists/European Association of Cardiothoracic Anaesthetists Practice Advisory for the Management of Perioperative Atrial Fibrillation in Patients Undergoing Cardiac Surgery

Abstract

Postoperative atrial fibrillation (poAF) is the most common adverse event after cardiac surgery and is associated with increased morbidity, mortality, and hospital and intensive care unit length of stay. Despite progressive improvements in overall cardiac surgical operative mortality and postoperative morbidity, the incidence of poAF has remained unchanged at 30%–50%. A number of evidence-based recommendations regarding the perioperative management of atrial fibrillation (AF) have been released from leading cardiovascular societies in recent years; however, it is unknown how closely these guidelines are being followed by medical practitioners. In addition, many of these society recommendations are based on patient stratification into “normal” and “elevated” risk groups for AF, but criteria for that stratification have not been clearly defined. In an effort to improve the perioperative management of AF, the Society of Cardiovascular Anesthesiologists (SCA) Clinical Practice Improvement Committee developed a multidisciplinary Atrial Fibrillation Working Group that created a summary of current best practice based on a distillation of recent guidelines from professional societies involved in the care of cardiac surgical patients. An evidence-based set of survey questions was then generated to describe the current practice of perioperative AF management. Through collaboration with the European Association of Cardiothoracic Anaesthetists (EACTA), that survey was distributed to the combined memberships of both the SCA and EACTA, yielding 641 responses and resulting in the most comprehensive understanding to date of perioperative AF management in North America, Europe, and beyond. The survey data demonstrated the broad range of therapies utilized for the prevention and treatment of poAF, as well as a spectrum of adherence to published guidelines. With the goal of improving adherence, a graphical advisory tool was created with an easily accessible format that could be utilized for bedside management. Finally, given that no evidence-based threshold currently exists to differentiate patients at normal risk to develop poAF from those at elevated risk, the SCA/EACTA AF working group created a list of poAF risk factors using expert opinion and based on published risk score models for poAF. This approach allows stratification of patients into risk groups and facilitates adherence to the evidence-based recommendations summarized in the graphical advisory tool. It is our hope that these new additions to the clinical toolkit for the management of perioperative AF will improve the evidence-based care and outcomes of cardiac surgical patients worldwide.

New-Onset Atrial Fibrillation in Adult Patients After Cardiac Surgery

“…In this context, the Society of Cardiovascular Anesthesiologists (SCA) and the European Association of Cardiothoracic Anaesthesiologists (EACTA) Clinical Practice Improvement Group for AF after Cardiac Surgery recently published a comprehensive practice advisory, in which they also created a list of AFACS risk factors and prophylactic strategies using expert opinion, based on published risk score models for AFACS. These risk factors and prophylactic and therapeutic strategies have been summarized in a graphical advisory tool (Figure 1) [47••, 48••] and may enable improved adherence to evidence-based recommendations.…”

Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients

“…Additional information about the SCA's Continuous Practice Improvement initiative and the various focus working groups can be found in a recent manuscript and accompanying editorial by Muehlschlegel et al and Schwann et al, respectively. 42,43 The current report is the summary of recommendations for blood management in cardiac surgery, made by the SCA Continuous Practice Improvement Blood Conservation Working Group. This summary focuses on the perioperative management of adults undergoing cardiovascular surgery in which significant blood loss occurs or is expected.…”

Generating Hypotheses Is Great, but at Some Point We Just Need to Do the Trials and Get the Answers

“…5 The evidence base for many of these is sparse, and clinical practice is variable and inconsistent. 6,7 Many clinicians working in cardiac perioperative medicine will have been trained to insist on implementation of protocols stipulating the routine maintenance of high-normal serum potassium and magnesium concentrations for all patients after cardiac surgery, necessitating elaborate and non-negligible effort for measurement and supplementation. Indeed, it is known from the survey of clinical practices relating to the prevention and treatment of AFACS recently published in this journal that supplementation of potassium or magnesium is widespread, especially in European cardiac centers.…”

“…Indeed, it is known from the survey of clinical practices relating to the prevention and treatment of AFACS recently published in this journal that supplementation of potassium or magnesium is widespread, especially in European cardiac centers. 6,7 Interestingly, neither of these practices have any robust evidence base, and there are conflicting findings relating incident AFACS to postoperative electrolyte concentrations or supplementation therapy. On a worldwide basis, there seems to be equipoise between caregivers and units believing in routine supplementation and those who do not.…”