A Comparison of Outcome in Patients With Preoperative Atrial Fibrillation and Patients in Sinus Rhythm

doi:10.1016/j.athoracsur.2011.04.119

The Annals of Thoracic Surgery

Volume 92, Issue 4, October 2011, Pages 1391-1395

Presented at the Poster Session of the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2011.

https://doi.org/10.1016/j.athoracsur.2011.04.119 Get rights and content

Background

Approximately 10% to 15% of patients undergoing cardiac operations suffer from atrial fibrillation (AF) at the time of surgery. The current risk stratification methods do not include preoperative arrhythmias. The aim of this study was to assess the effect of preoperative AF on the immediate postoperative outcome of patients undergoing cardiac surgery as well as in the midterm and long-term outcomes.

Methods

We reviewed patient data for our institution for a 10-year period; a total of 14,320 patients undergoing any cardiac operation were included; 12,395 (86.5%) had sinus rhythm preoperatively and 1,925 (13.5%) were in persistent AF. After propensity matching and adjusting for the preoperative and operative characteristics, 1,800 patients remained in each group and were compared.

Results

Before and after adjusting for the preoperative and operative characteristics, inotropic support, ventilation time, renal failure, stroke, and surgical wound infection rates were all significantly higher for the patients with AF (p < 0.001). Intensive care unit stay and hospital stay as well as in-hospital mortality were also significantly higher among the patients with AF compared with the sinus rhythm group (p < 0.001). At 30 days, 5-year and 10-year mortality rates in the AF group were significantly higher compared with those in sinus rhythm group (p < 0.001).

Conclusions

Atrial fibrillation preoperatively is associated with a higher incidence of postoperative complications. This arrhythmia is an important variable that appears to have been excluded from the current risk stratification systems. Our experience suggests that AF should be considered in the development/update of risk-stratifying methodologies to improve the predictive accuracy.

Section snippets

Material and Methods

This study was registered and approved by the Audit and Ethics Department of our institution. Only prospectively collected patients' clinical data and their hospital numbers were reviewed retrospectively, therefore the requirement for obtaining consent from the individuals was waived. We reviewed the data on patients who underwent any cardiac operation in our institution for a 10-year period between1999 and 2010. Exclusion criteria were (1) patients who had other preoperative arrhythmias rather

Results

Results are demonstrated in Table 2. Before adjusting for the preoperative and operative characteristics, the group with AF was significantly older, 70.5 versus 63.3 years. History of myocardial infarction, respiratory disease, cerebrovascular incidence, renal impairment, and number of cases with ejection fraction less than 30% were significantly higher in the AF group (p < 0.001). The average logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 8.3 and 3.1 in the AF

Comment

Preexisting AF negatively affects outcome after cardiac surgery. Our results suggest that even after adjusting for the preoperative characteristics and cardiac procedure, patients in preoperative AF have a higher and longer requirement for the inotropic and ventilatory support. Except for myocardial infarction, complications such as renal failure and permanent stroke have also been shown to be higher with preexisting AF. These patients also demonstrated longer hospital and intensive care unit

References (22)

P.A. Wolf et al.
Secular trends in the prevalence of atrial fibrillationThe Framingham Heart Study
Am Heart J
(1996)
D.L. Ngaage et al.
Does preoperative atrial fibrillation influence early and late outcomes of coronary artery bypass grafting?
J Thorac Cardiovasc Surg
(2007)
J.S. Gammie et al.
Atrial fibrillation correction surgery: lessons from The Society of Thoracic Surgeons National Cardiac Database
Ann Thorac Surg
(2008)
M.A. Quader et al.
Does preoperative atrial fibrillation reduce survival after coronary artery bypass grafting?
Ann Thorac Surg
(2004)
N. Ad et al.
Does preoperative atrial fibrillation increase the risk for mortality and morbidity after coronary artery bypass grafting?
J Thorac Cardiovasc Surg
(2009)
K. Bando et al.
Impact of preoperative and postoperative atrial fibrillation on outcome after mitral valvuloplasty for nonischemic mitral regurgitation
J Thorac Cardiovasc Surg
(2005)
E.H. Blackstone
Comparing apples and oranges
J Thorac Cardiovasc Surg
(2002)
C.A. Rogers et al.
Coronary surgery in patients with preexisting chronic atrial fibrillation: early and midterm clinical outcome
Ann Thorac Surg
(2006)
J.F. Obadia et al.
Outcome of atrial fibrillation after mitral valve repair
J Thorac Cardiovasc Surg
(1997)
Y.L. Chua et al.
Outcome of mitral valve repair in patients with preoperative atrial fibrillation: should the maze procedure be combined with mitral valvuloplasty?
J Thorac Cardiovasc Surg
(1994)

R. Schulenberg et al.

Chronic atrial fibrillation is associated with reduced survival after aortic and double valve replacement

Ann Thorac Surg

(2010)

Cited by (25)

Pre-operative atrial fibrillation and early right ventricular failure after left ventricular assist device implantation: a systematic review and meta-analysis
2021, American Heart Journal
Right ventricular failure (RVF) remains a major cause of morbidity and mortality after left ventricular assist device (LVAD). Atrial fibrillation (AF) is known for its deleterious effects on cardiac function and hemodynamics. The association of pre-operative AF with the risk of early post-LVAD RVF has not been well described.
A comprehensive literature search was performed through April, 9 2021. Cohort studies comparing the risk of post-operative RVF and/or need for right ventricular assist device (RVAD) after LVAD in patients with or without AF were included. Pooled odds ratio (OR) with 95% confidence intervals (CI) and I² statistic were calculated using the random-effects model.
Six studies were included in the analysis. Post-operative RVF was reported in 5 studies (1,841 patients) and RVAD use was reported in 4 studies (1,355 patients). There is a non-significant trend toward a higher risk of post-operative RVF in the AF group (pooled OR=1.25, 95%CI=0.99-1.58). No significant association between AF and RVAD use is noted (pooled OR=1.17, 95%CI=0.82-1.66).
Pre-operative AF is not significantly associated with higher risks of post-operative RVF and RVAD use after LVAD implantation, although the trend toward higher post-operative RVF is observed in patients with pre-operative AF. Additional research using a larger study population is warranted to better understand the association of pre-operative AF and the development of post-LVAD RVF.
Meta-Analysis of the Effect of Preoperative Atrial Fibrillation on Outcomes After Left Ventricular Assist Device Implantation
2019, American Journal of Cardiology
Citation Excerpt :
Further research is required to fully understand the effect of altered anticoagulation on the risk of TE and bleeding in patients with AF. Furthermore, we did not find increased risk of any type of stroke even though, preoperative AF has been documented to increase the incidence of stroke in adults who underwent cardiac surgery.21,22 To our knowledge, this is the first meta-analysis to combine the results of the effects of preoperative AF in patients with LVAD implants.
The effect of preoperative atrial fibrillation (AF) on clinical outcomes after left ventricular assist device (LVAD) implantation remains uncertain. We sought to conduct a meta-analysis to assess the safety and efficacy of LVAD implantation in AF patients. Medline and Scopus were searched for studies that assessed the effect of preoperative AF on clinical outcomes in patients who underwent LVAD implantation. Outcomes of interest included all-cause mortality, thromboembolic events, and bleeding. Estimates were combined using random effects model to calculate risk ratios (RRs) with 95% confidence intervals. In this meta-analysis of 7 studies including 5,658 patients, preoperative AF was not associated with increased risk of all-cause mortality at 30 days (RR = 0.84 [0.51, 1.37]; p = 0.49; I² = 0%), 6 months (RR = 1.17 [0.96, 1.14]; p = 0.11; I² = 21%), 1 year (RR = 1.16 [0.84, 1.60]; p = 0.37; I² = 53%) and 2 years (RR = 1.14 [0.96, 1.36]; p = 0.12; I² = 23%). Preoperative AF did not increase the risk of thromboembolism (RR = 0.86 [0.38, 1.92]; p = 0.71; I² = 26%), pump thrombosis (RR = 1.22 [0.88, 1.68]; p = 0.23; I² = 49%), stroke (RR = 1.02 [0.87, 1.19]; p = 0.79; I² = 11%), or major bleeding (RR = 0.86 [0.38, 1.92]; p = 0.71; I² = 26%) after LVAD implantation. However, AF was associated with significantly increased risk of gastro-intestinal bleeding in patients receiving LVADs (RR = 1.27 [1.05, 1.55]; p = 0.014; I² = 0%). In conclusion, this meta-analysis reports a significantly increased risk of gastrointestinal (GI) bleeding in LVADs recipients having concomitant AF. However, AF had no significant effect on all-cause mortality, stroke, or thromboembolic events in these patients. Further well-conducted studies are needed to validate these results.
A left ventricular end-diastolic dimension less than 6.0 cm is associated with mortality after implantation of an axial-flow pump
2019, Journal of Thoracic and Cardiovascular Surgery
The effects of having a lower left ventricular end-diastolic dimension before HeartMate II (Thoratec Corp, Pleasanton, Calif) left ventricular assist device implantation remain unclear. We analyzed our single-center data on HeartMate II implantation to determine whether having a lower left ventricular end-diastolic dimension preoperatively was associated with inferior outcomes.
From November 2003 to March 2016, 393 patients with chronic heart failure underwent primary HeartMate II implantation. We compared the preoperative left ventricular end-diastolic dimension and associated survival outcomes of these patients to determine the left ventricular end-diastolic dimension cutoff for worse overall survival. Then, we compared the preoperative demographics, stroke rate, and mortality of patients with a left ventricular end-diastolic dimension above the cutoff for worse survival with those of patients with a left ventricular end-diastolic dimension below the cutoff.
A Cox multivariate regression model showed that low left ventricular end-diastolic dimension was an independent predictor of mortality (hazard ratio, 1.49; P = .02). The Contal and O'Quigley method showed that overall survival postimplantation was decreased in patients with a left ventricular end-diastolic dimension less than 6.0 cm (n = 91). Kaplan–Meier analysis confirmed that the left ventricular end-diastolic dimension less than 6.0 cm group had lower overall survival than the left ventricular end-diastolic dimension 6.0 cm or greater group (P = .04). Furthermore, a competing-risk analysis showed that postoperative stroke was more common in the left ventricular end-diastolic dimension less than 6.0 cm group than in the left ventricular end-diastolic dimension 6.0 cm or greater group (P < .01).
Overall survival was decreased and postoperative stroke was increased in HeartMate II recipients with a preoperative left ventricular end-diastolic dimension less than 6.0 cm. Future research should determine the left ventricular end-diastolic dimension cutoff values for safely implanting other support devices, and device designs should be improved to better accommodate the needs of patients with a limited left ventricle size.
Vitamin C for the critically ill: Is the evidence strong enough?
2019, Nutrition
Vitamin C exhibits interesting properties in the context of critical illness, with benefits described in neurologic, cardiovascular, renal, and hematologic systems, both in in vitro and in animal models. Through direct effects on bacterial replication, immunomodulation, and antioxidant reserve of the organism, vitamin C directly affects the pathophysiological process of sepsis, trauma, burn, and systemic inflammation. Even if several observational trials have linked vitamin C deficiency to worse outcomes, the evidence is not such as to provide us with a distinction between causality effects or simple epiphenomenon, and the current focus is on interventional trials.
Pharmacokinetic data suggest that a minimal supplementation of 3 g/d intravenously is required to restore normal serum values in critically ill patients with known deficiency. According to these data, only five trials, including a retrospective analysis, studied pharmacologic dose: three as an antioxidant cocktail and two as monotherapy. The largest trial, conducted in 2002, reported reduced incidence of multiorgan failure and duration of mechanical ventilation. Recently a retrospective analysis reported impressive results after administration of vitamin C, thiamine, and hydrocortisone. The two most recent trials reported improved clinical outcomes, including improved mortality, but contained significant methodological limitations. A recent systematic review did not find clinical benefits with the most-studied low-dose oral supplementation, potentially because of suboptimal or insufficient repletion.
Current guidelines do not support the administration of high-dose vitamin C in critically ill patients. Future larger trials are required to support any therapy, but the low cost and safety profile can justify supplementation in the meantime. Metabolomics study will further help understand biological effect.
Preoperative atrial fibrillation portends poor outcomes after coronary bypass graft surgery: A systematic review and meta-analysis
2018, Journal of Thoracic and Cardiovascular Surgery
Preoperative atrial fibrillation may not increase thromboembolic events in left ventricular assist device recipients on midterm follow-up
2016, Journal of Heart and Lung Transplantation
Atrial fibrillation (AF) is a well-established risk factor for thromboembolic (TE) complications. AF is frequently found in patients with advanced heart failure, including patients undergoing left ventricular assist device (LVAD) implantation. However, reports on whether preoperative AF increases the risk of TE events after LVAD implantation are scarce and limited to single-center or 2-center studies. We sought to evaluate the association of preoperative AF with TE events and patient survival using the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS).
A retrospective analysis of INTERMACS data of primary continuous-flow LVADs implanted between May 2012 and December 2013 was performed. Adult patients were dichotomized as having AF or no AF (NAF). TE events were defined as cerebrovascular accident, transient ischemic attack, hemolysis, arterial non–central nervous system embolism, or explant because of pump thrombosis. Kaplan-Meier analysis and multivariate Cox regression were performed for freedom from TE and patient survival.
Of 3,909 patients identified during the study period, 838 (21.4%) had preoperative AF. Patients with AF were older, were likely to be male, and had more comorbidities (p < 0.01). In the AF group, 236 TE events occurred in 175 (20.9%) patients. In the NAF group, 900 TE events occurred in 691 (22.5%) patients. The TE event rate was not significantly different between the 2 groups (0.36 events/patient-year in AF group vs 0.37 events/patient-year in NAF group, p = 0.60). On univariate analysis, AF was not significantly associated with freedom from TE but was associated with decreased patient survival (log-rank test p = 0.03). On multivariate analysis, AF was not significantly associated with either TE (adjusted hazard ratio 0.95; 95% confidence interval, 0.80–1.13) or patient survival (adjusted hazard ratio 1.09; 95% confidence interval, 0.91–1.31).
Analysis of INTERMACS suggests that preoperative AF may not increase the risk of postoperative TE complications or patient mortality on midterm follow-up. Longer follow-up to confirm these findings is warranted.

View all citing articles on Scopus

View full text

Original articleAdult cardiacA Comparison of Outcome in Patients With Preoperative Atrial Fibrillation and Patients in Sinus Rhythm

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Am Heart J

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Original article
Adult cardiac
A Comparison of Outcome in Patients With Preoperative Atrial Fibrillation and Patients in Sinus Rhythm