POST-OP Arrhythmias
J Am Coll Cardiol. 2012 Dec 25;60(25):2664-71. doi: 10.1016/j.jacc.2012.08.1011. Epub 2012 Nov 21.
Ventricular arrhythmia after cardiac surgery: incidence, predictors, and outcomes.
POVA occurred in 1.7% of CS.
El-Chami MF, Sawaya FJ, Kilgo P, Stein W 4th, Halkos M, Thourani V, Lattouf OM, Delurgio DB, Guyton RA, Puskas JD, Leon AR.
Division of Cardiology, Emory University, Atlanta, Georgia. Electronic address:
This study sought to investigate the prevalence, predictors, and outcomes of patients with post-operative ventricular arrhythmia (POVA) in a large
cohort of patients.
New-onset POVA after cardiac surgery (CS) is uncommon and has controversial prognostic value.
A total of 14,720 consecutive patients undergoing CS at Emory University between January 2004 and July 2010 were included in the study. Data
on all-cause mortality were obtained from Social Security Administration death records. Multivariable regression models were constructed to
determine the risk factors for POVA and to estimate the independent impact of POVA on long-term survival after adjusting for 40 different
POVA occurred in 248 patients (1.7%). Patients with POVA were older (63.5 vs. 61.6 years), had lower left ventricular ejection fraction (EF) (43.7
vs. 51.3), and had greater comorbidities (Society of Thoracic Surgeons mortality risk score of 7.2% vs. 3.1%, p < 0.001). Multivariable analysis
showed that older age (odds ratio [OR]: 1.018 per 1-year increase, p < 0.001), emergent surgery (OR: 1.77, p = 0.019), and the presence of PVD
(OR: 1.41, p = 0.049) were associated with a higher incidence of POVA, whereas higher left ventricular EF (OR: 0.97 per 1% increase, p < 0.001),
mild chronic obstructive pulmonary disease (OR: 0.37, p < 0.001), and off-pump surgery (OR: O.41, p < 0.001) were associated with a lower
incidence of POVA. POVA was associated with substantially increased adjusted long-term mortality (hazard rate: 2.53, p < 0.001) over 3.5 years of
POVA is associated with increased long-term mortality after CS. Older age, PVD, lower EF, and emergent surgery are associated with a higher risk
of POVA, whereas off-pump surgery seems to be protective.

Clin Geriatr Med. 2012 Nov;28(4):729-43. doi: 10.1016/j.cger.2012.08.006.
Management of arrhythmias in the perioperative setting.
Melduni RM, Koshino Y, Shen WK.
Division of Cardiovascular Diseases, 200 First Street SW, Rochester, MN 55905, USA.
Perioperative arrhythmias are a common complication of surgery, with
incidence ranging from 4% to 20% for noncardiothoracic procedures,
depending on the type of surgery performed. The immediate postoperative period is a dynamic time and is associated with many conditions
conducive to the development of postoperative arrhythmias. The presence of postoperative atrial fibrillation is associated with increased morbidity,
ICU stay, length of hospitalization, and hospital costs. The associated burdens are expected to rise in the future, given that the population
undergoing cardiac surgery is getting older and sicker. Thousands of patients undergo major surgery each year and a major complication of these
procedures is the occurrence of perioperative arrhythmia. It is imperative for clinicians to be up-to-date on current management of these
Copyright © 2012 Elsevier Inc. All rights reserved.

Cardiol Res Pract. 2012;2012:272384. doi: 10.1155/2012/272384. Epub 2012 Jul 30.
Effect of Preoperative Atrial Fibrillation on Postoperative Outcome following Cardiac Surgery.
Al-Sarraf N, Thalib L, Hughes A, Tolan M, Young V, McGovern E.
Department of Cardiothoracic Surgery, St. James's Hospital, Dublin 8, Ireland.
Atrial fibrillation remains the commonest arrhythmia encountered in cardiac surgery. Data on the effect of preoperative atrial fibrillation on
postoperative outcome remain limited. We sought to assess the effects preoperative atrial fibrillation on patients' outcome following cardiac
surgery. This is a retrospective review of prospectively collected departmental data of all patients who underwent cardiac surgery over 8-year
period. Our cohort consisted of 3777 consecutive patients divided into atrial fibrillation (n = 413, 11%) and sinus rhythm (n = 3364, 89%).
Postoperative complications and in-hospital mortality were analysed. Univariate analysis showed significantly increased mortality and major
complications in atrial fibrillation compared to sinus rhythm patients. Using multiple logistic regression analysis and after accounting for Euro
SCORE as a confounding variable, we found that
preoperative atrial fibrillation significantly increases the risk of mortality (OR 1.7), low
cardiac output state (OR 1.3), prolonged ventilation (OR 1.4), infective complication (OR 1.5), gastrointestinal complications (OR 2.0),
and intensive care unit readmission (OR 1.6). Preoperative atrial fibrillation in cardiac surgery patients increases their risk of
mortality and major complications following cardiac surgery.
Surgical strategies such as Cox-Maze procedure may be beneficial in these

Rev Bras Cir Cardiovasc. 2011 Jul-Sep;26(3):364-72.
Atrioventricular block in the postoperative period of heart valve surgery: incidence, risk factors
and hospital evolution.
Ferrari AD, Süssenbach CP, Guaragna JC, Piccoli Jda C, Gazzoni GF, Ferreira DK, Albuquerque LC, Goldani MA.
Hospital São Lucas da Pontificia Universidade Catolica do Rio Grande do Sul,Porto Alegre, Brazil.
Disturbances of the cardiac conduction system are potential complications after cardiac valve surgery.
This study was designed to investigate the association between perioperative factors and atrio-ventricular block, the need for temporary cardiac
artificial pacing and, if necessary, permanent pacemaker implantation after cardiac valve surgery.
Retrospective analysis of the Cardiac Surgery Database - Hospital São Lucas/PUCRS. The data are collected prospectively and analyzed
Between January 1996 and December 2008 were included 1102 valve surgical procedures: 718 aortic valves (65.2%), 407 (36.9%) mitral valve
and 190 (17.2%) coronary artery bypass grafting combined with valve repair and 23 (2.1%) aortic and mitral combined surgery. 187 patients (17%)
showed clinical and electrocardiographic pattern of atrio-ventricular block requiring artificial temporary pacing. Of these, 14 patients
required permanent pacemaker implantation (1.27% of the total valve surgery patients)
. Multivariate analysis showed association of the
incidence of atrio-ventricular block and temporary pacing with
mitral valve surgery (OR 1,76; CI 95% 1.08-2.37; P = 0.002), implantation of
bioprosthetic devices (OR 1.59
; CI 95% 1.02-3.91; P = 0,039), age over 60 years (OR 1.99; CI 95% 1.352.85; P < 0.001), prior use of anti-
arrhythmic drugs (OR 1.86
; CI 95% 1.04-3.14; P = 0.026) and previous use of b-blocker (OR 1.76; CI 95% 1.25-2.54; P = 0.002). Remarkably
the presence of atrio-ventricular block did not significantly show association with increased mortality, but significantly prolonged (P < 0.0001)
hospital length-of-stay and, therefore, hospital costs.
Our study presents a group of predictive factors referring to a specific patient profile by which high risk of atrio-ventricular block and the need of
temporary cardiac pacing after cardiac valve surgery it is determined.

Europace. 2012 Feb;14(2):159-74. doi: 10.1093/europace/eur208. Epub 2011 Aug 6.
Post-operative atrial fibrillation: a maze of mechanisms.
Maesen B, Nijs J, Maessen J, Allessie M, Schotten U.
Department of Cardiothoracic Surgery, University Hospital of Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
Post-operative atrial fibrillation (POAF) is one of the most frequent complications of cardiac surgery and an important predictor of patient morbidity
as well as of prolonged hospitalization. It significantly increases costs for hospitalization. Insights into the pathophysiological factors causing POAF
have been provided by both experimental and clinical investigations and show that POAF is 'multi-factorial'. Facilitating factors in the mechanism of
the arrhythmia can be classified as acute factors caused by the surgical intervention and chronic factors related to structural heart disease and
ageing of the heart. Furthermore, some proarrhythmic mechanisms specifically occur in the setting of POAF. For example, inflammation and beta-
adrenergic activation have been shown to play a prominent role in POAF, while these mechanisms are less important in non-surgical AF. More
recently, it has been shown that atrial fibrosis and the presence of an electrophysiological substrate capable of maintaining AF also promote the
arrhythmia, indicating that POAF has some proarrhythmic mechanisms in common with other forms of AF. The clinical setting of POAF offers
numerous opportunities to study its mechanisms. During cardiac surgery, biopsies can be taken and detailed electrophysiological measurements
can be performed. Furthermore, the specific time course of POAF, with the delayed onset and the transient character of the arrhythmia, also
provides important insight into its mechanisms. This review discusses the mechanistic interaction between predisposing factors and the
electrophysiological mechanisms resulting in POAF and their therapeutic implications.
[PubMed - indexed for MEDLINE]

Am J Cardiol. 2011 Jul 1;108(1):172. doi: 10.1016/j.amjcard.2011.03.072.
African American race/ethnicity and risk of post-operative atrial fibrillation.
Novaro GM, Hernandez MB.
Comment on
•        Effect of race on the frequency of postoperative atrial fibrillation following coronary artery bypass grafting. [Am J Cardiol. 2011]
[PubMed - indexed for MEDLINE]
Vestn Khir Im I I Grek. 2011;170(2):9-13.
[Prognosis of probability of the development of atrial fibrillation after successful surgical correction of mitral valvular disease].
[Article in Russian]
Khubulava GG, Shaĭdakov ME, Marchenko SP, Averkin II, Didenko MV.
The estimation of frequency of occurence of atrial fibrillation in patients with mitral valvular diseases was made before operation and at the early
postoperative period. A logistic regressive analysis has shown that the appearance of atrial fibrillation in long-term periods is influenced by 4
independent preoperative factors: preoperative atrial fibrillation, age, anterior-posterior size of the left atrium, diagnosis of rheumatism. The
dependence of the appearance of atrial fibrillation on the preoperative status of the patient was detected. A statistical model having the prognostic
value 89.6% has been constructed. The model is good in use, reliable and can be effectively used in everyday clinical practice in order to
determine the probability of the appearance of atrial fibrillation at the postoperative period of the concrete patient and decision on necessity of
surgical ablation.

Kyobu Geka. 2011 Mar;64(3):179-83; discussion 183-6.
[Prophylactic use of amiodarone against postoperative atrial fibrillation after cardiac surgery].
[Article in Japanese]
Osawa H, Sakurada T, Sasaki J, Araki E.
Department of Cardiovascular Surgery, Sapporo Chuo Hospital, Sapporo, Japan.
We investigated the effect of amiodarone on prevention of post-operative atrial fibrillation (POAF) after cardiac surgery. Thirty cases of
amiodarone (AMD) group including elective coronary artery bypass grafting and valve operation were enrolled from January 2007 to January 2010.
The control (C) group consisted of 45 cases treated before 2007. Amiodarone was administered orally for the total of 14 days; 400 mg 7 days
before the surgery, and a half dose after the surgery. POAF occurred significantly less in AMD group (4/30 : 13.3%) than in C group (13/45 :
28.9%) [p = 0.029]. With regard to duration of POAF, that of AMD group was significantly shorter than that of C group (16.0 hours vs 40.23 hours :
p = 0.018). This research suggested that amiodarone might be effective in preventing POAF.

Thorac Cardiovasc Surg. 2011 Jun;59(4):213-6. doi: 10.1055/s-0030-1250356. Epub 2011 Mar 10.
Preoperative NT-proBNP levels: a reliable parameter to estimate postoperative atrial fibrillation in coronary artery bypass patients.
Iskesen I, Eserdag M, Kurdal AT, Cerrahoglu M, Sirin BH.
Department of Cardiovascular Surgery, Celal Bayar Univ, Manisa, Turkey.
Atrial fibrillation (AF) is one of the most common complications after coronary artery bypass grafting (CABG). This study was designed to evaluate
whether the levels of preoperative and postoperative N-terminal pro-brain natriuretic peptide (NT-proBNP) are predictors of postoperative
paroxysmal atrial fibrillation in patients who undergo coronary artery bypass surgery.
A total of 117 patients were prospectively evaluated for new-onset AF after coronary operation. Plasma NT-proBNP values in all patients were
measured at five different time points.
AF occurred during the hospitalization period in 33 patients (28.2 %). Significantly higher NT-proBNP levels in the preoperative examination were
recorded in patients who developed AF postoperatively compared with patients without postoperative AF (329.36 ± 82.93 vs. 230.67 ± 59.93
pg/ml, P < 0.05). Although we detected some higher values in the other group of patients with AF (at T1, T2, T3, T4), the difference was not
statistically significant compared to the normal rhythm group.
The main finding of the current study is a positive correlation between high levels of preoperative NT-proBNP and the risk of new-onset AF after
CABG surgery.
© Georg Thieme Verlag KG Stuttgart • New York.

Interact Cardiovasc Thorac Surg. 2011 May;12(5):772-7. doi: 10.1510/icvts.2010.243782. Epub 2011 Feb 28.
Atrial fibrillation postcardiac surgery: a common but a morbid complication.
Attaran S, Shaw M, Bond L, Pullan MD, Fabri BM.
Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool L14 3PE, UK.
Despite all the advances in cardiac surgery, atrial fibrillation (AF) remains a common postoperative complication with unclear predisposing factors.
Postoperative AF is often a short-lived and a self-limiting condition, but can result in debilitating and even lethal consequences. The aim of this
study is to assess the effect of AF on patients postcardiac surgery.
In this retrospective study, we prospectively reviewed patient data for our institution for a 10-year period; a total of 17,379 patients with
preoperative sinus rhythm (SR) who underwent cardiac surgery were included, of which 4984 (28.7%) had developed postoperative AF for any
length of time. After propensity matching for the preoperative characteristics between the two groups; the group with AF and the group who
remained in SR, postoperative complications, in-hospital mortality, mid-term survival rate (five years), and long-term survival rate (10 years) were
Before and after adjusting for the preoperative characteristics and type of the operation, postoperative complications, such as renal failure,
surgical wound infection, stroke and myocardial infarction were significantly higher in the AF group compared to the SR group (P < 0.001).
Inotropic support, use of intra-aortic balloon pump, and ventilation time were also considerably higher in the AF patients (P < 0.001). In-hospital
mortality was also higher in the AF group. Likewise, 30-day, mid-term and long-term mortality rates were found to be considerably higher in the AF
Despite all the modern anti-arrhythmic drugs, the incidence of AF remains unchanged. Patients who develop AF postcardiac surgery show a
significantly worse outcome compared to those without AF. This study also highlights the importance of anticoagulation in AF to prevent the
devastating consequences as a result of a cerebral stroke. We believe that not only immediate treatment of AF postoperatively should be
implemented, but also measures should be taken to identify the risk factors of AF and to prevent AF postcardiac surgery.

Int Heart J. 2011;52(1):7-11.
Role of preoperative atorvastatin administration in protection against postoperative atrial fibrillation following conventional
coronary artery bypass grafting.
Sun Y, Ji Q, Mei Y, Wang X, Feng J, Cai J, Chi L.
Department of Thoraco-Cardiovascular Surgery of Shanghai Tongji Hospital, Tongji University, Shanghai, China.
Atrial fibrillation (AF) is one of the most common postoperative arrhythmias in patients who undergo coronary artery bypass grafting (CABG). The
aim of this study was to evaluate the effect of preoperative atorvastatin on postoperative atrial fibrillation following coronary artery bypass grafting
with cardiopulmonary bypass (CCABG). One hundred consecutive patients undergoing elective CCABG, without history of AF or previous statin
treatment, were enrolled and randomly assigned to a statin group (atorvastatin 20 mg/d, n = 49) or a control group (placebo, n = 51) starting 7
days preoperatively. The primary endpoint was the occurrence of postoperative AF. C-reactive protein (CRP) levels were assessed in all selected
patients before surgery and every 24 hours postoperatively until discharge from hospital. Atorvastatin significantly reduced the incidence of
postoperative AF and postoperative peak CRP level versus placebo (18% versus 41%, P = 0.017; 129.3 ± 24.3 mg/L versus 149.3 ± 32.5 mg/L, P
< 0.0001). Kaplan-Meier curves confirmed a significantly better postoperative atrial fibrillation-free survival in the statin group (χ(2) = 7.466, P =
0.006). Logistic regression analysis showed preoperative atorvastatin treatment was an independent factor associated with a significant reduction
in postoperative AF (OR = 0.235, P = 0.007), whereas high postoperative CRP levels were associated with increased risk (OR = 2.421, P = 0.015).
Preoperative atorvastatin administration may inhibit inflammatory reactions to prevent atrial fibrillation following coronary artery bypass grafting with
cardiopulmonary bypass.

Am J Cardiol. 2011 Feb 1;107(3):383-6. doi: 10.1016/j.amjcard.2010.09.032.
Effect of race on the frequency of postoperative atrial fibrillation following coronary artery bypass grafting.
Lahiri MK, Fang K, Lamerato L, Khan AM, Schuger CD.
Henry Ford Hospital, Edith and Benson Ford Heart and Vascular Institute, Detroit, Michigan, USA.
Atrial fibrillation (AF) commonly complicates the postoperative course after coronary artery bypass grafting (CABG). Among the general population,
African Americans have been shown to have a lower prevalence of AF than European Americans. Although many factors have been identified to
predict risk for postoperative AF, race has not been examined. All patients aged ≥18 years who underwent CABG at Henry Ford Hospital during a
5-year period from January 1, 2004, to December 31, 2008, were included. Patients were excluded for any previous diagnosis of AF or if they had
concomitant valve surgery at the time of CABG. The incidence of AF was determined by International Classification of Diseases, Ninth Revision,
coding from postoperative hospitalization records. Overall, 1,001 patients were eligible for analysis. Of these, 731 (73%) were European American
and 270 (27%) were African American. The African American group had a higher prevalence of hypertension (75.6% vs 58.8%, p <0.001) and
heart failure (22.6% vs 15.7%, p = 0.01) and a trend toward a higher prevalence of diabetes mellitus (38.1% vs 33.4%, p = 0.159). Postoperative
AF was diagnosed in 214 European Americans (29.3%) and 50 African Americans (18.5%) (p = 0.001). In multivariate analysis adjusting for age
strata, gender, hypertension, diabetes, and heart failure, African Americans had less postoperative AF than European Americans, with an adjusted
odds ratio of 0.539 (95% confidence interval 0.374 to 0.777, p = 0.001). In conclusion, African Americans have a significantly reduced incidence of
AF compared to European Americans after CABG.
Copyright © 2011 Elsevier Inc. All rights reserved.