Post-Operative Atrial Fibrillation: Current Treatments and Etiologies for a Persistent Surgical Complication

Abstract

Post-operative atrial fibrillation (POAF) is a persistent and serious surgical complication that occur in 20-55% of cardiac surgery cases. POAF may lead to adverse health outcomes such as stroke, thromboembolism, cardiac arrest, and mortality, and may develop long-term. Patients have a 2-fold increase in mortality risk and spend about 3.7 more days in the hospital and $16,000 more in medical costs during their visit. The mechanisms and risk factors of POAF are still poorly understood, yet a strong foundation of how a disease process occurs is needed to provide the most effective treatment. Current mechanisms that are postulated to contribute to POAF include an increase in sympathetic tone, oxidative stress, local and systemic inflammation, a trigger that induces atrial substrate changes, a driver to sustain POAF, and electrolyte disturbances such as hypomagnesemia. While needing more research, current risk factors include age, male sex, history of myocardial infarction or heart failure, hypertension, diabetes, obesity, and COPD. Treatments mostly include prophylaxis of repurposed drugs such as beta-blockers, statins, oral anticoagulants, antiarrhythmics, and Vitamin D and electrolyte supplementation. Autonomic denervation has also been a promising preventative measure for patients undergoing cardiac surgery. This critical review article provides an up-to-date and comprehensive summary of the pathophysiology of POAF, current clinical risk factors and management for POAF and discusses new pathways for further investigation.

The Role of Vitamin D Supplementation Before Coronary Artery Bypass Grafting in Preventing Postoperative Atrial Fibrillation in Patients With Vitamin D Deficiency or Insufficiency: A Systematic Review and Meta-Analysis

“…In addition, electrolyte disturbances in the postoperative period can also play a role in the pathogenesis of postoperative atrial fibrillation. Some of the risk factors for postoperative atrial fibrillation include advanced age, male gender, white race, and the presence of comorbidities such as chronic obstructive pulmonary disease, congestive heart failure, hypertension, prior history of atrial fibrillation, diabetes mellitus, hyperthyroidism, chronic kidney disease, obesity, and echocardiographic evidence of left atrial enlargement and left ventricular dysfunction [3,12].…”

“…While it has been suggested that vitamin D deficiency may be a risk factor for postoperative atrial fibrillation as it plays a role in reducing inflammation and acts as a negative regulator of RAAS and in improving overall cardiovascular health, some of the prior studies failed to demonstrate a significant correlation between low levels of vitamin D and the occurrence of new or postoperative atrial fibrillation conclusively [3,4]. Our review analyzed three randomized controlled studies in which people with vitamin D deficiency were given vitamin D supplementation in the preoperative period.…”

“…The exact mechanism of post-CABG AF is not fully understood, but it is thought to be related to factors such as inflammation, ischemia, and autonomic nervous system dysfunction [3]. One risk factor for POAF may be low vitamin D levels.…”

Association of Mitral Regurgitation with Postoperative Atrial Fibrillation in Critically Ill Noncardiac Surgery Patients: A Prospective Cohort Study

“…New-onset POAF can be a marker of increased illness severity. 43 , 44 However, early identification of high-risk patients can lead to initiating preventive measures (eg, utilizing drugs such as beta-blockers, statins, oral anticoagulants, antiarrhythmics, and electrolyte supplementation 45 ) before adverse cardiac events to reduce mortality and improve clinical outcomes. Prophylactic amiodarone used in high-risk individuals effectively reduced the incidence of POAF, improved outcomes, and reduced the associated health resource utilization and costs.…”

Intensivtherapie in der Herzchirurgie – alles anders?

“…Das postoperative Vorhofflimmern (POAF) ist eine häufige und unterschätzte Komplikation, die nach herzchirurgischen Eingriffen in 20-55 % der Fälle auftritt. POAF führt zu längerer Krankenhausverweildauer, erhöhter Morbidität und Letalität beispielsweise durch das Auftreten von Schlaganfällen, Thrombembolien, Herzstillstand und Übergang in chronisches Vorhofflimmern und verursacht somit deutlich erhöhte Kosten im Gesundheitswesen [20]. Im Folgenden werden Strategien zur Prophylaxe und Therapie des POAF vorgestellt.…”