Postoperative atrial fibrillation is not an innocuous arrhytmia in LAVD patients

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Accepted Manuscript Postoperative atrial fibrillation is not an innocuous arrhytmia in LAVD patients Cipriano Abad, MD, PhD, FEBS(Hon, Gen Surg), EBCTS, Stefano Urso, MD, PhD, Bernardino Clavo, MD,

1 Accepted Manuscript Postoperative atrial fibrillation is not an innocuous arrhytmia in LAVD patients Cipriano Abad, MD, PhD, FEBS(Hon, Gen Surg), EBCTS, Stefano Urso, MD, PhD, Bernardino Clavo, MD, PhD PII: S (18)31225-X DOI: /j.jtcvs Reference: YMTC To appear in: The Journal of Thoracic and Cardiovascular Surgery Received Date: 10 April 2018 Revised Date: 18 April 2018 Accepted Date: 18 April 2018 Please cite this article as: Abad C, Urso S, Clavo B, Postoperative atrial fibrillation is not an innocuous arrhytmia in LAVD patients, The Journal of Thoracic and Cardiovascular Surgery (2018), doi: / j.jtcvs This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 Postoperative atrial fibrillation is not an innocuous arrhytmia in LAVD patients Cipriano Abad MD, PhD,FEBS(Hon,Gen Surg),EBCTS 1, Stefano Urso MD,PhD 1, Bernardino Clavo MD,PhD 2 1 Department of Cardiovascular Surgery,Hospital Universitario de Gran Canaria Dr Negrin,Las Palmas de Gran Canaria,Spain 2 Reseach Unit. Hospital Universitario de Gran Canaria Dr Negrin, Las Palmas de Gran Canaria.,Spain Corresponding author: Cipriano Abad MD,PhD,FEBS(Hon,Gen Surg),EBCTS Professor and Chairman of Surgery. Attending Cardiovascular Surgeon.Hospital Universitario de Gran Canaria Dr Negrin. Barranco de La Ballena sn.. Las Palmas de Gan Canaria Spain. cprnabad2@gmail.com Phone: The authors Cipriano Abad MD, Stefano Urso MD and Bernardino Clavo MD, have no conflicts of interest in this paper. In the case the article is accepted, the authors give the ownership to the JTCVS.

3 In this issue of the journal, Hawkins and co-workers (1) provide an interesting and valuable retrospective study. Information was collected from a regional database (the Virginia Cardiac Services Quality Initiative) derived from 7 hospitals which perform cardiac surgery. The investigators reviewed 1064 patients who had a continuous flow LVAD (HeartMate II, HeartMate III or HeartWare) implanted from 2009 to Among these 1064 patients, 375 (35%) had a history of preoperative atrial fibrillation (AF). Of the 689 patients without preoperative AF, 121 (17.6%) developed postoperative AF (POAF) and were compared to the 586 who did not develop POAF. The two groups had similar CPB times, aortic cross clamp times and hospital mortality. By univariate analysis the POAF group had many more morbidities (higher rate of RVAD implantation, increased risk of renal failure, higher resource utilization, longer ICU stay and longer hospital stay). In the group who developed POAF, the median hospital and ICU cost were significantly higher ($30,000 USD in hospital cost and over $4,000 USD in ICU related costs). This article points out three interesting and important issues in patients with an LVAD and POAF: 1) they had more postoperative complications, 2) they had a significantly increased hospital resource utilization and 3) right ventricular failure was a possible contributor to the POAF. Heart failure as emerged as a growing health problem in western countries. As the population ages, the number of patients with cardiac failure increases. LVAD therapy represents the best alternative for many patients with advanced symptomatic heart failure who do not respond to conventional medical treatment and those who are not candidates for percutaneous interventions, resynchronization therapy, cardiac surgery or heart transplantation. Furthermore, the limited availability of donors has increased the number of patients who receive a durable LVAD as destination therapy. LVAD therapy represent a significant modern contribution in the treatment of patients with advanced heart failure and can be life-saving in cases of cardiogenic shock. Mechanical support with LVAD improves not only patient survival but also their quality of life. AF is the most common supraventricular arrhythmia and is frequently found in patients with advanced heart failure. With the increasingly LVAD usage in these patients, a greater number have preoperative AF (2) also this therapy may contribute to POAF. The incidence and repercussions of AF in LVAD patients can be significant and strategies to diminish this arrhythmia should be undertaken. Surgeons may wish to consider concomitant interventions with LVAD insertion to reduce the risk of POAF including repair of tricuspid valve regurgitation, implantation of a RVAD in patients with right ventricular dysfunction, surgical exclusion of the left atrial appendage, or use of catheter or surgical ablation techniques. In addition, aggressive pharmacologic or electric cardioversion for POAF may reduce its complications. Today cardiac surgeons should also be involved in the financial implication and costs of their procedures. According to Kilic et al (3), postoperative complications are the primary drivers of cost variations. The costs of LVAD therapy might be reduced by decreasing postoperative morbidity and readmissions (4). Preventing postoperative complications is an important target for the heart team. Hawkins and colleagues should be congratulated for their contribution to our understanding of the potential causes of LVAD complications. Further research is required to determine the most effective methods to predict and treat POAF after LVAD implantation. REFERENCES 1. Hawkins RB, Mehaffi JH, Guo A, Charles EJ, Speir AM et al. Postoperative atrial

4 fibrillation is associated with increased morbidity and resoursce utilization after left ventricular assist device placement. J Thorac Cardiovasc Surgery Xia Y, Stern D, Friedman P, Golstein D. Preoperative atrial fibrillation may not increase thromboembolic events in left ventricular assist device recipients on midterm follow -up. J Heart-Lung Transp 2016;35: Kilic A, Sha AS, Conte JV, Mandak K, Baumgartner W, Cameron DE,et al. Understanding variability in hospital -specific cost of coronary artery bypass grafting represent an opportunity for standarizing care and improve resource use. J Thorac Cardiovasc Surg 2014;147: Shih T, Dimick JB. Reducing the cost of left ventricular assist devices.why it matters and can be done?. J Thorac Cardiovasc Surg

The Journal of Thoracic and Cardiovascular Surgery

The Journal of Thoracic and Cardiovascular Surgery Accepted Manuscript Nitric Oxide: Might make it Better? J. Hunter Mehaffey, MD, MSc, Robert B. Hawkins, MD, MSc PII: S0022-5223(18)32342-0 DOI: 10.1016/j.jtcvs.2018.08.070 Reference: YMTC 13398 To appear