Comparison of Two Central Venous Pressure Control Strategies to Prevent Atrial Fibrillation After Coronary Artery Bypass Grafting

Abstract

BackgroundAtrial fibrillation (AF) takes place in 10-40% of patients undergoing coronary artery bypass grafting (CABG), and increases cardiovascular mortality. Enlargement of atrial chambers is associated with increased AF incidence, so patients with higher central venous pressure (CVP) are expected to have larger atrial distension, which increases AF incidence.ObjectiveTo compare post-CABG AF incidence, following two CVP control strategies.MethodsInterventional, randomized, controlled clinical study. The sample comprised 140 patients undergoing CABG between 2011 and 2015. They were randomized into two groups, G15 and G20, with CVP maintained ≤ 15 cmH2O and ≤ 20 cmH2O, respectively.Results70 patients were included in each group. The AF incidence in G15 was 8.57%, and in G20, 22.86%, with absolute risk reduction of 14.28%, and number needed to treat (NNT) of 7 (p = 0.03). Mortality (G15 = 5.71%; G20 = 11.42%; p = 0.07), hospital length of stay (G15 = 7.14 days; G20 = 8.21 days; p = 0.36), number of grafts (median: G15 = 3, G2 = 2; p = 0.22) and cardiopulmonary bypass use (G15 = 67.10%; G20 = 55.70%; p = 0.22) were statistically similar. Age (p = 0.04) and hospital length of stay (p = 0.001) were significantly higher in patients who developed AF in both groups.ConclusionKeeping CVP low in the first 72 post-CABG hours reduces the relative risk of AF, and may be useful to prevent AF after CABG.

Predictors Affecting Postoperative Atrial Fibrillation in Patients After Coronary Artery Bypass Graft

“…The only established risk factor for POAF is age. Age-induced myocardial structural changes due to degenerative processes facilitate fibrosis and dilatation, thereby causing abnormal conduction and automaticity, which comprise an ineffective electrical pathway system (Costa et al, 2017;Mostafa, El-Haddad, Shenoy, & Tuliani, 2012). Patients with a BMI of greater than 25 were predominantly in the non-POAF group, and there was no significant difference in BMI between the two groups.…”

“…AF mostly occurs as a result of reentry in multiple areas and premature atrial beats during the vulnerable phase. It is one of the most common and prevalent types of arrhythmia worldwide, and its prevalence increases with advancing age (Bhatt & Fischer, 2015;Costa et al, 2017;January et al, 2014).…”

Hemodynamic effects of Vernakalant in cardio-surgical ICU-patients treated for recent-onset postoperative atrial fibrillation

“…No notable change in CVP before and after the administration of Vernakalant could be noted. With increased CVP being an indirect marker for increased global ventricular preload 33,34 , and our study collective remaining at constant CVP-levels, at least a situation of non-inferiority in terms of patients' volume status after being treated with Vernakalant can be suggested.…”

Thrombosis associated with ventriculoatrial shunts

“…Moreover, high central venous pressures caused by additional volume to the right atrium from the VAS can lead to greater atrial distention and therefore a higher incidence of arrhythmia [34], like atrial fibrillation. The onset of arrhythmia in turn can increase central venous pressure, potentially preventing CSF flow down into the right atrium and cause shunt malfunction and even reflowing of blood [34,35]. At this juncture, blood will become stagnant, and the risk of intraluminal clot formation is increased [36].…”

“…In VAS patients, the atrial catheter could be abnormally positioned and acted as foci of arrhythmia by irritating the chamber wall [ 16 ]. Moreover, high central venous pressures caused by additional volume to the right atrium from the VAS can lead to greater atrial distention and therefore a higher incidence of arrhythmia [ 34 ], like atrial fibrillation. The onset of arrhythmia in turn can increase central venous pressure, potentially preventing CSF flow down into the right atrium and cause shunt malfunction and even reflowing of blood [ 34 , 35 ].…”