Treatment of postoperative atrial fibrillation: The long road ahead

Abstract

Historically, POAF has been considered transient and relatively benign. Growing evidence suggests otherwise-particularly in the long term. Opportunities to improve the evidence base and treatment exist. The Invited Expert Opinion provides a perspective on this topic based on the following paper:

Incidence, etiology, and outcomes of pre- and post-operative atrial fibrillation in mitral valve procedures: a review

“…Currently, studies on prophylactic surgical or transcatheter ablation in MV surgery are few to none due to the uncertainty in benefits and risks of ablation in patients who present with sinus rhythm and the frequently transient nature of POAF [127,128] . Prophylactic surgical ablation has been reported for "high risk" (e.g., rheumatic heart disease patients undergoing MV repair) procedures [129] .…”

“…POAF in the field of MV disease has great potential to dramatically reduce the incidence of POAF, reduce mortality, and improve the quality of life for patients undergoing MV procedures due to the high incidence of POAF in these patients and opportunities for concomitant prophylactic ablative therapy. As of now, few studies exist to determine if prophylactic ablation in addition to MV surgery, is safe without increasing the risk of developing POAF and effective in reducing the incidence of POAF for patients who present with sinus rhythm but may be at risk for POAF [127,128] . The delayed progress in prophylactic ablation may be in part due to the hesitancy in pursuing concomitant surgical ablation in patients with atrial fibrillation undergoing MV surgery.…”

“…However, prophylactic ablation is promising, especially due to the high likelihood of developing POAF after MV surgery and may likely become standard therapy for these patients. For prophylactic ablation to be considered, it will be critical to identify risk factors in patients that predict specifically persistent POAF and compare its efficacy to prophylactic medical therapy in combination and alone [127,128] . Other important prophylactic therapy to consider are routine concomitant LAA closure for all patients undergoing MV surgery and transcatheter ablation prior to MV surgery for patients with pre-operative atrial fibrillation as a less invasive alternative procedure to concomitant surgical ablation.…”

Neurological Complications of Cardiac Procedures

“…[80][81][82] Historically, new-onset POAF was considered a shortterm complication that did not result in serious morbidity or mortality. 83 While POAF onset peaks on postoperative days 2 to 3 with a median duration of 22 hours, 53,57 and indeed often is (at least initially) transient with only 2.8% of POAF patients having persistent AF on discharge, 57 it is associated with significant long-term consequences.…”

Commentary: Minding the gaps

“…At the current time, our knowledge is limited regarding which risk factors and of what magnitude for POAF, as evidenced by scant guidelines regarding who most benefits from POAF prophylaxis, as well as ongoing debates regarding the safety and efficacy of preoperative b-blockade. 3 In fact, this very same author group examined risk prediction for atrial fibrillation at the same institutions during a similar time period, finding that the only score more predictive of POAF than age was the Cohorts for Heart and Aging Research in Genomic Epidemiology [CHARGE]-AF. 4 Notably, the receiver operating characteristic area for CHARGE-AF was only 0.68, landing it in the ''poor test'' category.…”