- Email: [email protected]
A more aggressive approach for the prevention of postoperative atrial fibrillation is warranted
Accepted Manuscript A More Aggressive Approach for the Prevention of Post Operative Atrial Fibrillation is Warranted Scott Goldman, MD PII:
S0022-5223(17)31852-4
DOI:
10.1016/j.jtcvs.2017.08.089
Reference:
YMTC 11908
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 23 August 2017 Accepted Date: 26 August 2017
Please cite this article as: Goldman S, A More Aggressive Approach for the Prevention of Post Operative Atrial Fibrillation is Warranted, The Journal of Thoracic and Cardiovascular Surgery (2017), doi: 10.1016/j.jtcvs.2017.08.089. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
A More Aggressive Approach for the Prevention of Post Operative Atrial
RI PT
Fibrillation is Warranted
Scott Goldman MD, Director Structural Heart Program Lankenau Heart Institute
M AN U
SC
Wynnewood, PA
Author Correspondence:
Scott Goldman, MD
Lankenau Medical Center
TE D
100 Lancaster Avenue Suite #280
Wynnewood, PA 19096
EP
Phone: 610-896-9255
AC C
Email: [email protected]
Disclosure Statement: Scott Goldman, MD is a consultant to St. Jude Medical, Edwards Lifesciences and Abbott
ACCEPTED MANUSCRIPT
A More Aggressive Approach for the Prevention of Post Operative Atrial Fibrillation is Warranted
Lankenau Heart Institute Wynnewood, PA
RI PT
Scott Goldman MD, Director Structural Heart Program
SC
Akintoye (1) and colleges report on data from the OPERA trial (2), a randomized controlled trial evaluating the use of fish oil to prevent postoperative atrial fibrillation
M AN U
(POAF). The trial failed to demonstrate any benefit in the fish-oil group. The trial was prospective with clear definitions of both POAF and POAF requiring treatment (rt). Utilizing these data they looked specifically at surgical factors related to the incidence of POAF. They also reported how these factors and the occurrence of POAF related to
TE D
MACE rates, 30-day, one-year mortality and resource utilization. They found that the overall rate of POAF was 31% and the rate of POAFrt was 24%. The MACE rate and mortality were low at 2.3% and 1.6%. The one-year mortality
EP
was also low at 3.1%.
Not surprisingly they report that the highest rate of POAF occurred with the most
AC C
complex surgery. When they looked specifically at CABG, off-pump surgery was protective against POAF in younger patients and males. The occurrence of POAF had a negative impact on one-year mortality, and
POAFrt had negative impact on 30-day and one-year mortality. The occurrence of POAF also increased resource utilization both in ICU hours and postoperative length of stay.
ACCEPTED MANUSCRIPT
From these data it is clear that POAF remains an unsolved clinical problem with high cost in both resource utilization and worse clinical outcomes. To date, the only clinical guidelines for prevention of POAF are pre- and post-operative beta-blocker therapy in
RI PT
patients undergoing CABG (3). Despite adherence to this guideline, the incidence of POAF remains high and there are no specific guidelines for more complex cases.
These data suggest that a more aggressive approach for the prevention of POAF is
SC
warranted. Clearly, patients at high risk for POAF should be considered for more aggressive prophylaxis.
M AN U
How can we identify these patients and how should they be treated? These data reveal that the most complex cases are at the highest risk, and that patient factors such as COPD and increased left-atrial size increase this risk. Newer technology such as highresolution ECG has been shown to be of predictive value in POAF (4).
TE D
Prophylaxis may include perioperative amiodarone in combination with betablockade.(5) A recent randomized control trial revealed that bi-atrial pacing is an effective strategy for the prevention of POAF(6). Another interesting trial utilizing a
EP
spray hydrogel containing amiodarone decreased the rate of POAF from 30% in the control group to 8% in the study group without producing measurable blood levels of the
AC C
drug (7).
I believe that it is time to move some of these findings into clinical practice. We
should take a quality-initiative approach using multimodal therapies and clinical strategies to lower the impact of POAF, as well as work on establishing guidelines for all cardiac surgery cases for prevention of POAF. We should carefully and fully determine the risk of POAF in cardiac surgery patients, in addition to the risk of morbidity and
ACCEPTED MANUSCRIPT
mortality. Preoperative echo evaluation for left-atrial size should be included in the work up these patients. In the future, high-resolution ECG analysis may be used predict this risk for patients.
RI PT
We may also attempt to minimize the effect of complex surgery by adopting a
hybrid tactic in patients with both valvular and coronary disease when appropriate. Offpump CABG may be used judiciously in younger males. Use of perioperative
SC
amiodarone in combination with beta-blockade should be considered in high-risk patients. Bi-atrial pacing may also be considered in these patients.
M AN U
We should encourage the development of new therapies such as hydrogel spray with amiodarone. Only with a comprehensive approach including thorough preoperative evaluation to determine the risk of POAF, multimodality prophylaxis in higher risk patients, and carefully planned surgical strategies, will we have an impact on the
AC C
EP
TE D
persistent high rate of POAF and its high cost in both lives and resource utilization.
ACCEPTED MANUSCRIPT
1)Emmanuel Akintoye1, MD, MPH; Frank Sellke, MD; Roberto Marchioli, MD; Luigi Tavazzi, MD; Dariush Mozaffarian, MD, DrPH Factors Associated with Postoperative Atrial Fibrillation and Other Adverse 1 Events after Cardiac Surgery
RI PT
2)OPERA Trial Clinicaltrials.gov Unique identifier: NCT00970489al 3) ACC Clinical guidelines
SC
4) Jurij M. Kalisnik, MD, PhD1, Viktor Avbelj, PhD2, Jon Vratanar3, Tilen Tumpaj, MD4, Janez Zibert, PhD5. Reliable Prediction of Postoperative Atrial Fibrillation from Highresolution ECG-based Assessment of Cardiac Autonomic Derangement and altered Heart Rhythm Dynamics Poster ISMICS 2016
M AN U
5) Johann Auer, Thomas Weber, Robert Berent, Rudolf Puschmann, Peter Hartl, ChoiKeung Ng, Christian Schwarz, Ernst Lehner, Ulrike Strasser, Elisabeth Lassnig, Gudrun Lamm, Bernd Eber A comparison between oral antiarrhythmic drugs in the prevention of atrial fibrillation after cardiac surgery: the pilot study of prevention of postoperative atrial fibrillation (SPPAF), a randomized, placebo-controlled trial; American Heart Journal Volume 147, Issue 4, April 2004, Pages 636-6436)
TE D
6)Bidar E; Maesen B; Nieman F; Verheule S; Schotten U; Maessen JG. Heart Rhythm 2014 Jul;11(7):1156-62 A prospective randomized controlled trial on the incidence and predictors of late-phase postoperative atrial fibrillation up to 30 days and the preventive value of biatrial pacing.
AC C
EP
7)Wang W; Mei YQ; Yuan XH; Feng XD. Clinical efficacy of epicardial application of drug-releasing hydrogels to prevent postoperative atrial fibrillation. J Thorac Cardiovasc Surg 2016 Jan;151(1):80-5
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0022-5223(17)31852-4
DOI:
10.1016/j.jtcvs.2017.08.089
Reference:
YMTC 11908
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 23 August 2017 Accepted Date: 26 August 2017
Please cite this article as: Goldman S, A More Aggressive Approach for the Prevention of Post Operative Atrial Fibrillation is Warranted, The Journal of Thoracic and Cardiovascular Surgery (2017), doi: 10.1016/j.jtcvs.2017.08.089. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
A More Aggressive Approach for the Prevention of Post Operative Atrial
RI PT
Fibrillation is Warranted
Scott Goldman MD, Director Structural Heart Program Lankenau Heart Institute
M AN U
SC
Wynnewood, PA
Author Correspondence:
Scott Goldman, MD
Lankenau Medical Center
TE D
100 Lancaster Avenue Suite #280
Wynnewood, PA 19096
EP
Phone: 610-896-9255
AC C
Email: [email protected]
Disclosure Statement: Scott Goldman, MD is a consultant to St. Jude Medical, Edwards Lifesciences and Abbott
ACCEPTED MANUSCRIPT
A More Aggressive Approach for the Prevention of Post Operative Atrial Fibrillation is Warranted
Lankenau Heart Institute Wynnewood, PA
RI PT
Scott Goldman MD, Director Structural Heart Program
SC
Akintoye (1) and colleges report on data from the OPERA trial (2), a randomized controlled trial evaluating the use of fish oil to prevent postoperative atrial fibrillation
M AN U
(POAF). The trial failed to demonstrate any benefit in the fish-oil group. The trial was prospective with clear definitions of both POAF and POAF requiring treatment (rt). Utilizing these data they looked specifically at surgical factors related to the incidence of POAF. They also reported how these factors and the occurrence of POAF related to
TE D
MACE rates, 30-day, one-year mortality and resource utilization. They found that the overall rate of POAF was 31% and the rate of POAFrt was 24%. The MACE rate and mortality were low at 2.3% and 1.6%. The one-year mortality
EP
was also low at 3.1%.
Not surprisingly they report that the highest rate of POAF occurred with the most
AC C
complex surgery. When they looked specifically at CABG, off-pump surgery was protective against POAF in younger patients and males. The occurrence of POAF had a negative impact on one-year mortality, and
POAFrt had negative impact on 30-day and one-year mortality. The occurrence of POAF also increased resource utilization both in ICU hours and postoperative length of stay.
ACCEPTED MANUSCRIPT
From these data it is clear that POAF remains an unsolved clinical problem with high cost in both resource utilization and worse clinical outcomes. To date, the only clinical guidelines for prevention of POAF are pre- and post-operative beta-blocker therapy in
RI PT
patients undergoing CABG (3). Despite adherence to this guideline, the incidence of POAF remains high and there are no specific guidelines for more complex cases.
These data suggest that a more aggressive approach for the prevention of POAF is
SC
warranted. Clearly, patients at high risk for POAF should be considered for more aggressive prophylaxis.
M AN U
How can we identify these patients and how should they be treated? These data reveal that the most complex cases are at the highest risk, and that patient factors such as COPD and increased left-atrial size increase this risk. Newer technology such as highresolution ECG has been shown to be of predictive value in POAF (4).
TE D
Prophylaxis may include perioperative amiodarone in combination with betablockade.(5) A recent randomized control trial revealed that bi-atrial pacing is an effective strategy for the prevention of POAF(6). Another interesting trial utilizing a
EP
spray hydrogel containing amiodarone decreased the rate of POAF from 30% in the control group to 8% in the study group without producing measurable blood levels of the
AC C
drug (7).
I believe that it is time to move some of these findings into clinical practice. We
should take a quality-initiative approach using multimodal therapies and clinical strategies to lower the impact of POAF, as well as work on establishing guidelines for all cardiac surgery cases for prevention of POAF. We should carefully and fully determine the risk of POAF in cardiac surgery patients, in addition to the risk of morbidity and
ACCEPTED MANUSCRIPT
mortality. Preoperative echo evaluation for left-atrial size should be included in the work up these patients. In the future, high-resolution ECG analysis may be used predict this risk for patients.
RI PT
We may also attempt to minimize the effect of complex surgery by adopting a
hybrid tactic in patients with both valvular and coronary disease when appropriate. Offpump CABG may be used judiciously in younger males. Use of perioperative
SC
amiodarone in combination with beta-blockade should be considered in high-risk patients. Bi-atrial pacing may also be considered in these patients.
M AN U
We should encourage the development of new therapies such as hydrogel spray with amiodarone. Only with a comprehensive approach including thorough preoperative evaluation to determine the risk of POAF, multimodality prophylaxis in higher risk patients, and carefully planned surgical strategies, will we have an impact on the
AC C
EP
TE D
persistent high rate of POAF and its high cost in both lives and resource utilization.
ACCEPTED MANUSCRIPT
1)Emmanuel Akintoye1, MD, MPH; Frank Sellke, MD; Roberto Marchioli, MD; Luigi Tavazzi, MD; Dariush Mozaffarian, MD, DrPH Factors Associated with Postoperative Atrial Fibrillation and Other Adverse 1 Events after Cardiac Surgery
RI PT
2)OPERA Trial Clinicaltrials.gov Unique identifier: NCT00970489al 3) ACC Clinical guidelines
SC
4) Jurij M. Kalisnik, MD, PhD1, Viktor Avbelj, PhD2, Jon Vratanar3, Tilen Tumpaj, MD4, Janez Zibert, PhD5. Reliable Prediction of Postoperative Atrial Fibrillation from Highresolution ECG-based Assessment of Cardiac Autonomic Derangement and altered Heart Rhythm Dynamics Poster ISMICS 2016
M AN U
5) Johann Auer, Thomas Weber, Robert Berent, Rudolf Puschmann, Peter Hartl, ChoiKeung Ng, Christian Schwarz, Ernst Lehner, Ulrike Strasser, Elisabeth Lassnig, Gudrun Lamm, Bernd Eber A comparison between oral antiarrhythmic drugs in the prevention of atrial fibrillation after cardiac surgery: the pilot study of prevention of postoperative atrial fibrillation (SPPAF), a randomized, placebo-controlled trial; American Heart Journal Volume 147, Issue 4, April 2004, Pages 636-6436)
TE D
6)Bidar E; Maesen B; Nieman F; Verheule S; Schotten U; Maessen JG. Heart Rhythm 2014 Jul;11(7):1156-62 A prospective randomized controlled trial on the incidence and predictors of late-phase postoperative atrial fibrillation up to 30 days and the preventive value of biatrial pacing.
AC C
EP
7)Wang W; Mei YQ; Yuan XH; Feng XD. Clinical efficacy of epicardial application of drug-releasing hydrogels to prevent postoperative atrial fibrillation. J Thorac Cardiovasc Surg 2016 Jan;151(1):80-5
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT