Management of Postoperative Atrial Fibrillation

Transcription

1 Management of Postoperative Atrial Fibrillation Stephen D. Cassivi, MD MSc FRCSC FACS Professor of Surgery Vice Chair Department of Surgery

2 Financial Relationship / Conflict of Interest Disclosure Statement I have NO financial relationships or potential conflicts of interest to report

3 Take Home Messages

4 Take Home Messages 1. Frequent 2. Mostly Self-Limited 3. Difficult to Prevent 4. Hemodynamic stability defines Treatment Goals Unstable Patient Restore HD stability Stable Patient Rate Control 5. Anticoagulation based on individual patient risk Key References: JTCVS 2014;148: JACS 2013;219:

5 Postoperative Atrial Fibrillation - POAF Most common sustained arrhythmia after pulmonary and esophageal surgery.

6 Postoperative Atrial Fibrillation POAF Impact Major, potentially preventable adverse outcome ICU length of stay ICU readmission Hospital length of stay Morbidity stroke, bleeding Mortality (RR ) Resource utilization

7 Postoperative Atrial Fibrillation POAF Timecourse POAF occurrence peaks on POD % of new onset POAF resolves within 4-6 weeks Ann Thorac Surg 2011;92:421 7

8 Postoperative Atrial Fibrillation POAF Mechanisms Requires BOTH: Triggers Rapidly firing ectopic focus Reentrant circuit of short cycle length Multiple reentrant wavelets Vulnerable Substrate Sympathetic or parasympathetic stimulation Atrial dilation or acute atrial stretch Pericarditis Fibrosis Conduction abnormalities Inflammation or oxidative stress

9 Postoperative Atrial Fibrillation POAF Incidence Incidence varies Incidence Intensity of surgical procedure

10 Postoperative Atrial Fibrillation POAF Incidence Incidence varies Incidence Intensity of surgical procedure Low Risk of POAF Bronchoscopy VATS biopsy Laparoscopic Nissen

11 Postoperative Atrial Fibrillation POAF Incidence Incidence varies Incidence Intensity of surgical procedure Low Risk of POAF Intermediate Risk of POAF Bronchoscopy VATS biopsy Laparoscopic Nissen VATS Lobectomy Open Lobectomy Thymectomy

12 Postoperative Atrial Fibrillation POAF Incidence Incidence varies Incidence Intensity of surgical procedure Low Risk of POAF Intermediate Risk of POAF High Risk of POAF Bronchoscopy VATS biopsy Laparoscopic Nissen VATS Lobectomy Open Lobectomy Thymectomy Extrapleural Pneumonectomy Esophagectomy

13 Postoperative Atrial Fibrillation POAF Incidence Ann Thorac Surg 2008;86:927 33

14 Postoperative Atrial Fibrillation POAF Incidence New onset atrial fibrillation with rapid ventricular response 44/606 (7.3%) Ann Thorac Surg 2008;86:927 33

15 Postoperative Atrial Fibrillation POAF Incidence Patient Factors Modifiable Factors Hypertension Valvular Heart Disease Obesity Obstr. Sleep Apnea Nonmodifiable Factors Age Race Male History of arrhythmias Hyperthyroidism Smoking

16 Postoperative Atrial Fibrillation POAF Guidelines

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18 JTCVS 2014;148:

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20 Thromboembolic Stroke

21 CHA 2 DS 2 -VASc Chest 2010;137:

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23 Postoperative Atrial Fibrillation POAF AATS Guidelines Monitoring / Telemetry No monitoring necessary if: Low Risk procedure No prior history of arrhythmias/hf/cva CHA 2 DS 2 -VASc < hours of Monitoring / Telemetry if: Intermed or High Risk procedure CHA 2 DS 2 -VASc 2 Hx of pre-existing or periodic recurrent AF

24 Postoperative Atrial Fibrillation POAF AATS Guidelines Prevention Avoidance of β-blockade withdrawal Correction of abnormal serum Mg ++ levels

25 Postoperative Atrial Fibrillation POAF AATS Guidelines Treatment Depends on Hemodynamic Stability UNSTABLE: Restore Sinus Rhythm STABLE: Rate Control

26 Postoperative Atrial Fibrillation POAF AATS Guidelines Treatment For ALL patients: Reduce or stop catecholaminergic inotropic agents (if hemodynamics allow) Optimize fluid balance Correct electrolyte abnormalities Treat/correct possible triggering factors Bleeding, PE, Pneumothorax, Ischemia/MI, Infection/Sepsis

27 Postoperative Atrial Fibrillation POAF AATS Guidelines Treatment - UNSTABLE Primary Goal = Restore Sinus Rhythm 1. Cardioversion 2. If Cardioversion unsuccessful or unstable POAF recurs: Initiate IV Esmolol / Digoxin / Diltiazem / Amiodarone Prepare to Cardiovert again

28 Postoperative Atrial Fibrillation POAF AATS Guidelines Treatment - STABLE Primary Goal = Rate Control 1. Β-blocker (esmolol/metoprolol) or Ca ++ channel blocker (diltiazem, verapamil) to achieve HR 110 bpm 2. For pts with HF, LV dysfnx, or unresponsive to above tx Amiodarone Caveat: WPW syndrome

29 Postoperative Atrial Fibrillation POAF AATS Guidelines Treatment Cardiology consultation if: Recurrent or refractory POAF Persistent hemodynamic instability CHAD-VASc score high Require second-line anti-arrhythmic agent Develop acute renal injury/failure

30 Postoperative Atrial Fibrillation POAF AATS Guidelines Follow-up Cardiology follow-up if: EF 45% Dx of Systolic HF or Cardiomyopathy Started NEW rhythm control agent POAF last > 6 weeks

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32 Postoperative Atrial Fibrillation POAF AATS Guidelines Anticoagulation Treatment During first 48h from onset Anticoagulation decision based on TE risk (CHADS-VASc) Stable POAF >48 hours duration Anticoagulation is recommended

33 Anticoagulation Ann Thorac Surg 2011;92:421 7

34 Results January 1994 December Patients Median Age 71 years (Range 31 92)

35 Results Strokes 8 (1.1%) patients developed a stroke Not anticoagulated - 3 (0.6%) pts. Anticoagulated - 5 (2.2%) pts. (p=0.057)

36 Results Bleeding 49 (6.5%) patients developed a bleeding complication Not anticoagulated - 27 (5.1%)* pts. Anticoagulated - 22 (9.6%)* pts. *statistically different p=0.009

37 Conclusions Anticoagulation did not lower the risk of stroke or TIA Anticoagulation was associated with an increase in postoperative bleeding Routine anticoagulation for POAF should be avoided

38 Postoperative Atrial Fibrillation POAF Guidelines Anticoagulation Treatment Anticoagulation decision based on TE risk (CHADS-VASc) Both within and beyond 48 hours

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47 Take Home Messages 1. Frequent 2. Mostly Self-Limited 3. Difficult to Prevent 4. Hemodynamic stability defines Treatment Goals Unstable Patient Restore HD stability Stable Patient Rate Control 5. Anticoagulation based on individual patient risk Key References: JTCVS 2014;148: JACS 2013;219:

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