Background

Atrial fibrillation (AF) is not only the most common arrhythmia in the global population but also the most frequent one encountered in the operating room (1) AF is independently associated with increased risk of all-cause mortality and morbidity (2, 3). In 2010, the estimated numbers of men and women with AF worldwide were 20.9 million and 12.6 million, respectively. Estimates suggest an AF prevalence of approximately 3% in adults aged 20 years or older with greater prevalence in older persons and in patients with conditions such as hypertension, heart failure, etc (4,5,6). AF is common after cardiac surgery but also after other major surgery and is associated with increased length of hospital stay and higher rates of complications and mortality (7, 8). The treatment of post-operative AF is mainly based on studies of patients undergoing cardiac surgery, with much less evidence in the non-cardiac surgery setting (4).

Materials and methods

In this article I would like to summarize available evidence on a perioperative management of atrial fibrillation, with the aim of assisting health professionals in selecting the best management strategies. I reviewed data published in the last decades on the subject of perioperative management of atrial fibrillation.

Results

Based on the presentation, duration, and spontaneous termination of AF episodes, five types of AF are traditionally distinguished: first diagnosed, paroxysmal, persistent, long-standing persistent and permanent AF (4). Post-operative atrial fibrillation is a common complication after cardiac and thoracic surgery but also not uncommon after other major surgery (4,9). Treatment may include rhythm control or rate control. Rate control: Beta-blockers reduce post-operative AF and supraventricular tachycardias (4, 9) and are routinely recommended. Amiodaron may be used in patients where beta blocker therapy is not possible (9). OAC at discharge has been associated with a reduced long-term mortality, without evidence from controlled trials (10). In haemodynamically unstable patient’s rhythm control therapy in post-operative atrial fibrillation, cardioversion and consideration of antiarrhythmic drugs is recommended (11). A recent medium-sized trial randomizing patients with post-operative AF to either rhythm control therapy with amiodarone or to rate control did not find a difference in hospital admissions during a 60-day follow-up (12)

Conclusion

Perioperative oral beta-blocker therapy is recommended for the prevention of post-operative AF after cardiac surgery (IB). Restoration of sinus rhythm by electrical cardioversion or antiarrhythmic drugs is recommended in postoperative AF with haemodynamic instability (IC). Long-term anticoagulation should be considered in patients with AF after cardiac surgery at risk for stroke risk (IIaB). Antiarrhythmic drugs should be considered for symptomatic postoperative AF after cardiac surgery in an attempt to restore sinus rhythm (IIaC). Perioperative amiodarone should be considered as prophylactic therapy to prevent AF after cardiac surgery (IIaA) Asymptomatic postoperative AF should initially be managed with rate control and anticoagulation (IIaB) Intravenous vernakalant may be considered for cardioversion of postoperative AF in patients without severe heart failure, hypotension, or severe structural heart disease (especially aortic stenosis) (IibB) (4).

Literature

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