Management and Prevention of Atrial fibrillation after Cardiovascular surgery

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Management and Prevention of Atrial fibrillation
after Cardiovascular surgery

• ?? 4A ICU intern???
• 2004/5/17

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Introduction

• AF is the most common after cardiac surgery
• Prevalence
• 40 after CABG 60 after valvular surgery
• Usually occurred 1-5 days after OP, Peak day 2
• Usually a self-limited course
• increasing rate of post-operative stroke
• Risk factor
• David B. Bharucha, Peter R. Kowey. Management and
  prevention of atrial fibrillation after
  cardiovascular surgery. The American journal of
  cardiology 20008520D-24D

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Etiology

• Table 2
• preexisting age-related degenerative cardiac
  changes in atrial myocardium (collagen)
• abnormalities electrophysiologic parameters
• Prolonged P-wave duration was observed to be
  sensivtive(83), but not specific(43), predictor.

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Prophylaxis

• Patients at greatest risk
• Pretreatment with beta-blockers decreased
  incidence of AF, most effective
• 40 to 20 in pt undergoing CABG
• 60 to 30 in pt undergoing valvular surgery
• Sotalol (beta-blocker and class lll agent)
• Aminodarone 600mg 7 days preoperatively
• Digoxin and verapamil no effects
• Fuster and Ryden et al. ACC/AHA/ESC practice
  guidelines. JACC October 20011266i-lxx

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Prophylaxis

• Table 3 and pacing

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Treatment

• Rate control is preferred unless hemodynamic
  unstable
• Rate control Beta-blocker, CCB, IV aminodarone
• Digoxin is less effective (post-op high
  adrenergic state)
• Electrical cardioversion, if homodynamic unstable
• Not pursued because of high recurrence rate
  self-limited course
• Post-conversion pharmacologic therapy
• Chemical cardioversion, especially if
• ibutilide (newer class lll), aminodarone,
  sotalol
• Anticoagulation (courmadin), when AF gt48 h.
• Fuster and Ryden et al. ACC/AHA/ESC practice
  guidelines. JACC October 20011266i-lxx

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Treatment

• Table 3 and pacing

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ACC/AHA/ESC practice guidelines

• Recommendations for Prevention and Management of
  Postoperative AF
• Class I
• 1. Treat patients undergoing cardiac surgery with
  an oral beta-blocker to prevent postoperative AF,
  unless contraindicated. (Level of Evidence A)
• 2. In patients who develop postoperative AF,
  achieve rate control by administration of AV
  nodal blocking agents. (Level of Evidence B)
• Class IIa
• 1. Administer sotalol or amiodarone
  prophylactically to patients at increased risk of
  developing postoperative AF. (Level of Evidence
  B)

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• Class IIa
• 2. Restore sinus rhythm in patients who develop
  postoperative AF by pharmacological cardioversion
  with ibutilide or direct-current cardioversion,
  as recommended for nonsurgical patients. (Level
  of Evidence B)
• 3. In patients with recurrent or refractory
  postoperative AF, attempt maintenance of sinus
  rhythm by administration of antiarrhythmic
  medications, as recommended for patients with CAD
  who develop AF. (Level of Evidence B)
• 4. Administer antithrombotic medication in
  patients who develop postoperative AF, as
  recommended for nonsurgical patients. (Level of
  Evidence B)

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AF after cardiac surgery
stable
unstable
Rate control
conversion
Beta-blocker CCB aminodarone
chemical cardioversion
Electrical cardioversion
maintenance
Persisted gt48h
spontaneous conversion
recurrence
No recurrence
Anticoagulation TX Keep rate control
follow up
DC after gt1-2mo
back to the start
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• Thanks for your attention!!