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.
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)
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).
- Hsiu-Rong L, Kin-Shing P, Kuen-Bao C. Atrial fibrillation: An anesthesiologist’s perspective. Acta Anest Taiwanica 2013 (34-36).
- Benjamin EJ, Wolf PA, D’Agostino RB, et al. Impact of atrial fibrillation on the risk of death: The Framingham Heart Study. Circulation 1998; 98:946 – 952.
- Stewart S, Hart CL, Hole DJ, McMurray JJ. A population-based study of the long- term risks associated with atrial fibrillation: 20-year follow-up of the Renfrew/ Paisley study. Am J Med 2002; 113 :359 – 364.
- Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B and Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS The Task Force for the management of atrial fibrillation of the European Society of Cardiology. European Heart Journal 2016. 37. 2893–2962.
- Krijthe BP, Kunst A, Benjamin EJ, et al. Projections on the number of individuals with atrial fibrillation in the European Union, from 2000 to 2060.Eur Heart J 2013;342746 – 2751.
- Zoni-Berisso M, Lercari F, Carazza T, Domenicucci S. Epidemiology of atrial fibrillation: European perspective. Clin Epidemiol 2014; 6:213 – 220.
- Steinberg BA, Zhao Y, He X, et al. Management of postoperative atrial fibrillation and subsequent outcomes in contemporary patients undergoing cardiac surgery: insights from the Society of Thoracic Surgeons CAPS-Care Atrial Fibrillation Registry. Clin Cardiol 2014; 37:7 – 13.
- Mansoor E. De novo atrial fibrillation post cardiac surgery: The Durban experience. Cardiovasc J Afr 2014; 25:282 – 287.
- Dunning J, Treasure T, Versteegh M, et al. Guidelines on the prevention and management of de novo atrial fibrillation after cardiac and thoracic surgery. Eur J Cardiothorac Surg 2006;30(6):852 – 72.
- Anderson E, Dyke C, Levy JH. Anticoagulation strategies for the management of postoperative atrial fibrillation. Clin Lab Med 2014; 34:537–561.
- Heldal M, Atar D. Pharmacological conversion of recent-onset atrial fibrillation: a systematic review. Scand Cardiovasc J Suppl 2013; 47:2–10.
- Gillinov AM, Bagiella E, Moskowitz AJ, et al. Rate Control versus Rhythm Control for Atrial Fibrillation after Cardiac Surgery. N Engl J Med 2016; 374:1911–1921.
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