The peri‐operative management of atrial fibrillation

Abstract

SummaryAtrial fibrillation is a common arrhythmia frequently seen in surgical patients. The onset of new atrial fibrillation during the peri-operative period is less common. There are many possible precipitating factors, although volatile agents themselves may have an antifibrillatory action. The management of atrial fibrillation includes removal of any precipitating factors and treatment of the arrhythmia itself. Immediate management of acute-onset atrial fibrillation is usually direct current cardioversion. Alternatively, anti-arrhythmic drugs can be used to achieve cardioversion. In patients with rapid, chronic atrial fibrillation or those refractory to cardioversion, priority is given to control of the ventricular rate. Thrombo-embolism is a significant risk if atrial fibrillation is paroxysmal or persists for more than 48 h.

Effectiveness of direct-current cardioversion for treatment of supraventricular tachyarrhythmias, in particular atrial fibrillation, in surgical intensive care patients*

“…Despite an initial success rate, arbitrarily defined as restoration of SR for at least 5 mins, of 35%, only 16% and 13.5% of patients remained in SR at 24 and 48 hrs, respectively. These results are in striking contrast to current recommendations suggesting that DCC is an efficient first-line therapy for treatment of SVT in the surgical ICU (6,7).…”

“…In the postoperative period, direct-current cardioversion (DCC) has been suggested as a first-line therapy for SVT of acute onset, especially in patients with deteriorating hemodynamics (6 -8). In contrast to drug therapy, DCC should be rapid acting and devoid of major complications that have been associated with different drug therapies (6). Unfortunately, prospective investigations on the success rate of DCC in surgical patients and, in particular, in the ICU are still lacking.…”

Ibutilide for rapid conversion of atrial fibrillation or flutter in a mixed critically ill patient population

“…Interestingly, this finding is in line with recent observational data, where, in contrast to the literature [23,24], electric cardioversion was only effective in 35% of surgical ICU-patients in restoring sinus rhythm [8]. It also confirms data on ibutilide in stable ICU-patients after cardiac surgery, where ibutilide converted atrial fibrillation in 44% and 45% of patients, respectively [15,16].…”

Review article: The role of hypotension in perioperative stroke

“…7,44,45 In turn, intraoperative hypotension is a risk factor for the development of atrial fibrillation. 46,47 Assuming hypotension increases the risk of postoperative atrial fibrillation, one could also speculate that it also increases the risk of a postoperative stroke, without being the direct cause.…”