THE IMPACT OF ATRIAL FIBRILLATION IN CARDIAC SURGERY Wim J De Vries. DEPARTMENT CARDIOTHORACIC SURGERY UNIVERSITY OF THE FREE STATE UNIVERSITAS HOSPITAL

? Benign Rhythm ? Malignant Rhythm THE IMPACT OF ATRIAL FIBRILLATION IN CARDIAC SURGERY

New-onset. postoperative atrial fibrillation occurs in 30% of patients undergoing CABG, with the peak incidence on the second to third postoperative day It is associated with a 2- to 3-fold increase in postoperative risk for stroke. Patients at risk for postoperative atrial fibrillation have been identified and include those with COPD, proximal right CAD, prolonged cross-clamp time, atrial ischemia, advanced age, and withdrawal of beta-blockers. Identifying at-risk patients and directing treatment to these patients appears to be effective in reducing the incidence of nost-C ABG atrial fibrillation. And thus the morbid complication of postoperative strokes associated with this arrhythmia.Minimally invasive and.Qff pump beating- heart procedures may also reduce the incidence of postoperative atrial fibrillation Eagle and Guyton et al ACC/AHA Practice Guidelines INTRODUCTION

AIM AND METHODS AIM -Incidence of post operative Atrial fibrillation -Identify patients at risk for Atrial fibrillation -Morbidity and mortality of Atrial fibrillation

Methods 5 Year period, records of patients were prospectively entered in a Departemental database. AIM -Incidence of post operative Atrial fibrillation -Identify patients a risk for Atrial fibrillation -Morbidity and mortality of Atrial fibrillation AIM AND METHODS..

Total 1022 patients - OPCAB(301) - CABG(721 ) STUDY POPULATION

Total 1022 patients – OPCAB(29,4%) –CABG(70%) Males (72%) STUDY POPULATION

Total 1022 patients - OPCAB(301) - CABG(721) Males 798 – 72% Age (33-84) Mean 60,5 years STUDY POPULATION

Incidence of Atial Fibrillation N = Total ,7 %

RESULTS Male Sex Female Age > 65 Smoking Obesity Hypertension COPD Diabetes Rhythm Risk N %RROR ,2% 29,8% 54,9% 26,5% 56,9% 44,2% 11,9% 5,8% 52,9% 34,0% 13,9% 5,2% 29% 15% 2,3 2,07 1,2 1,25 1,5 2,6 1,9 5,5 3,3 1,6 1,20 2,1 2,8 2,9 P <0,0001 0,004 0,01 <0,001 0,005 0, A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus

RESULTS.. Renal imp Perif Vasc Pulm Hypert Previous MI Angina Unstable Stable Rhythm Risk N %RROR ,2% 3,5% 6,6% 2,4% 2,6% 1,4% 46,3% 42,7% 88% 69,4% 60,2% 49,7% 28,4% 19,7% 2,07 2,3 1,7 1,08 1,2 1,4 2,1 5,5 1,8 1,08 3,4 1,5 1,6 P 0,04 0,01 NS <0,0001 0, A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus

RESULTS.. Renal impairm Perif Vascular Pulm Hypert Previous MI Angina Unstable Stable Risk factor A- Fib Sinus RROR 2,07 2,3 1,7 1,08 1,2 1,4 2,1 5,5 1,8 1,08 3,4 1,5 1,6 P 0,04 0,01 NS <0,0001 0,01 3,5% 2,4% 1,4% 42,7% 69,4% 49,7% 19,7% 7,2% 6,6% 2,6% 46,3% 88% 1,2% 1,4% N=151N=871 (11) (10) (4) (70) (134) (91) (43) (31) (21) (13) (372) (605) (433) (172) % NN

RESULTS… CCS >= III ASA >= III NYHA >= III Emergent IABP Eject Frac Rhythm Risk N %RROR Med 54,3% 36,7% 71,5% 40,4% 43% 24% 15,2% 9,7% 20,5% 13,2% 59% 58% 1,4 1,7 1,6 1,5 2,04 3,7 2,3 1,7 1,6 P A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus <0,0001 0,02 NS

RESULTS…. Vessels Diseased LAD Right Sx Left Main # Dst Anas > 3 Off-Pump On Pump Perf Time Rhythm Risk N %RROR (M) 104(M) 84% 60% 59,6% 47,4% 20% 24,4% 13,9% 8,3% 68,2% 42,9% 7,3% 17,8% 1,3 1,2 0,83 1,8 1,5 0,4 2,5 1,5 0,52 2,06 2,8 0,36 P 0,0001 0,01 NS 0,006 <0,0001 NS A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus

RESULTS…. Hospital Stay A-Fib + Hospital Stay Sinus Hospital Stay N %RROR 8(Median) 6(Median) P <0,

RESULTS….. Hospital Stay A-Fib Hospital Stay Sinus Stroke A-Fib + Stroke Sinus Stroke N %RROR 8(Median) 6(Median) 6,6% 3,05% P <0,0001 <0, /151 21/871 2,12,2

RESULTS…… Hospital Stay A-Fib Hospital Stay Sinus Stroke A- Fib + Stroke Sinus Mortality A- fib + Mortality Sinus Mortality N %RROR 8(M) 6(M) 6,6% 2,5% 11% 2.4% P <0,0001 <0,03 <0, /151 22/871 17/151 21/871 2,1 4,6 2,2 5,1

RISK PATIENTS Males Age > 65 Years Peripheral Vasc Dis Angina NYHA > III ASA > III CCS > III Emergent IABP On-Pump Surgery OR 5,5 3,3 5,5 3,4 2,3 3,7 2,04 1,7 1,6 0,36 P <0,0001 0,01 <0,0001 0,02 <0,0001

RISK PATIENTS.. Hypertension Smoking COPD Diabetes Renal Impairment Obesity LAD Lesion Right Lesion Left Main Disease # Distal Anastomosis >= 3 OR 2,17 1,6 2,9 2,5 2,1 1,2 2,5 1,5 2,06 2,8 P <0,001 <0,004 0,0001 0,03 0,04 0, 01 0,0001 0,01 0,006 <0,0001

Conclusion : Atrial Fibrillation Incidence 14,7% Mortality 11% Median hospital stay 8 days Incidence of stroke 6,6 %

Conclusion: Atrial Fibrillation.. Atrial Fibrillation is probably a marker of underlying disease Post operatively (Tip of the Iceberg). (Ears of hippopotamus) Atrial fibrillation Age Diabetes Hypertension On Pump Atrial Ischemia Atrial fibrillation Age Diabetes Hypertension On Pump Atrial Ischemia

MANAGEMENT Identify the risk patients Atrial fibrillation Age Diabetes Hypertension On Pump Atrial Ischemia

Identify the risk patients Non withdrawal of B Blockers MANAGEMENT.

Identify the risk patients Non withdrawal of B Blockers Prophylactic use of Amidiarone and or B Blockers MANAGEMENT..

Identify the risk patients Non withdrawal of B Blockers Prophylactic uses of Amidiorone and B Blockers Post operative overdrive pacing of the atrium MANAGEMENT…

Identify the risk patients Non withdrawal of B Blockers Prophylactic uses of Amidiarone and B Blockers Post operative pacing of the atrium Aggressive Treatment of Atrium Fibrillation Post operative to prevent stroke MANAGEMENT….

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