ATRIAL FIBRILLATION AFTER CARDIAC SURGERY Developments in Cardiovascular Medicine 198. Antoine Lafont, Eric Topoi (eds.): ArterialRemodeling: A CriticalFactor in Restenosis. 1997 ISBN 0-7923-8008-8 199. Michele Mercuri, David D. McPherson, Hisham Bassiouny, SeymGoluarg ov evisavnl-noN:).sde( lmaging of Atherosclerosis ISBN 0-7923-8036-3 200. Walmor C. DeMello, Michiel J. Janse(eds.): Health in Communication Heart Cell and Disease ISBN 0-7923-8052-5 201. P.E. Vardas (ed.): Pacing Arrhythmias Cardiac and .ygoloisyhportcelE The Expert View. 1998 ISBN 0-7923-4908-3 202. E.E. van der Wall, P.K. Blanksma, M.G. Niemeyer, W. Vaalburg and H.J.G.M. Crijns (eds.) MRI, PET, SPECT, Artery Disease, lmaging Advanced Coronary in IVUS, EBCT. 1998 ISBN 0-7923-5083-9 203. R.L. Wilensky (ed.) Artery Syndromes, Coronary Unstable ,ygoloisyhpohtaP Diagnosis and Treatment. .8991 ISBN 0-7923-8201-3 204. J.H.C. Reiber, E.E. van derW all (eds.): What's New Imaging? Cardiovascular in 1998 ISBN 0-7923-5121-5 205. Juan Carlos Kaski, David W. Holt (eds.): Detection Early Damage Myocardial by Novel Markers. 1998. Biochemical ISBN 0-7923-5140-1 207. Gary F. Baxter, Derek M. Yellon, Preconditioning Delayed and Adaptive .noitcetorpoidraC 1998. ISBN 0-7923-5259-9 208. Bernard Swynghedauw, Cardiology Molecular for the ,tsigoloidraC Editiot Second .8991 ISBN 0-7923-8323-0 209. Geoffrey Bumstock, James G.Dobson, Jr., BrucTe. Liang, Joel Linden (eds): ralucsavoidraC Biology of Purines. 1998. ISBN: 0-7923-8334-6 210. Brian D. Hoit, Richard A. Walsh (eds): the in Physiology Cardiovascular Engineered Genetically Mouse. 1998. ISBN: 0-7923-8356-7 211. Peter Whittaker, George S. Abela (eds.): Myocardial Direct :noitaziralucsaveR ,yrotsiH Methodology, Technology 1998. ISBN: 0-7923-8398-2 212. C.A. Nienaber, R. Fattori (eds.): Diagnosis and Treatment of Aortic Diseases. .9991 ISBN: 0-7923-5517-2 213. Juan Carlos Kaski (ed.): Normal with Coronary Pain Chest :smargoignA Diagnosis Pathogenesis, and Management. 1999. ISBN: 0-7923-8421-0 214. P.A. Doevendans, R.S. Renemaannd M. Van Bilsen (eds): Cardiovascular cificepS Expression. Gene 1999 ISBN:0-7923-5633-0 215. G. Pons-Llad6, F. Carreras, X. Borrks, Subirana and L.J. Jim6nez-Borreguero (eds.): Atlas of Applications Cardiac Practical of .1RM 1999 ISBN: 0-7923-5636-5 216. L.W. Klein, J.E. Calvin, Resource noitazilitU Disease. Cardiac in 1999. ISBN:0-7923-8509-8 217. R. Gorlin, G. Dangas, P. K. Toutouzas, M.M Konstadoulakis, Contemporary in Concepts ,ygoloidraC Pathophysiology and Management. Clinical 1999 ISBN:0-7923-8514-4 218. S. Gupta, J. Camm (eds.): Chlamydia Infection, Chronic and Heart Coronary Disease. 1999. ISBN:0-7923-5797-3 219. M. Rajskina: Death. Sudden Coronary in Fibrillation Ventricular 1999. ISBN:0-7923-8570-5 220. Z. Abedin, R. Conner: Interpretation of Arrhythmias: Cardiac Self Assessment Approach. 1999. ISBN:0-7923-8576-4 221. J. E. Lock, J.F. Keane, S. B. Perry: andlnterventional Diagnostic Catheterization In Disease. Heart Congenital 2000. ISBN: 0-7923-8597-7 Previous volumes are still available KLUWER ACADEMIC PUBLISHERS - DORDRECHT/BOSTON/LONDON ATRIAL FIBRILLATION AFTER CARDIAC SURGERY edited by Jonathan S. Steinberg, MD .tS Luke's-Roosevelt Hospital Center and Columbia University College of Physicians and Surgeons t,4 Kluwer Academic Publishers Boston/Dordrecht/London Distributors for North, Central and South America: Kluwer Academic Publishers 101 Philip Drive Assinippi Park Norwell, Massachusetts 02061 USA Distributors for all other countries: Kluwer Academic Publishers Group Distribution Centre Post Office Box 322 3300 AH Dordrecht, THE NETHERLANDS Library of Congress Cataloging-in-Publication Data Atrial fibrillation after cardiac surgery/edited by Jonathan S. Steinberg. P. ; cm -- (Developments in cardiovascular medicine ; 222) Includes index. ISBN 0-7923-8655-8 (alk. Paper) .1 Atrial fibrillation. 2. Heart--Surgery--Complications. I. Steinberg, Jonathan S. II. Developments in cardiovascular medicine; v. 222 [DNLM: .1 Atrial Fibrillation--complications. 2. Cardiac Surgical Procedures. WG 330 A88165 1999] RC685.A72 A8875 1999 617.4'1201--dc21 99-047095 Copyright © 2000 by Kluwer Academic Publishers All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, mechanical, photo- copying, recording, or otherwise, without the prior written permission of the publisher, Kluwer Academic Publishers, 101 Philip Drive, Assinippi Park, Norwell, Massachusetts 02061 Printed on acid-free paper. Printed in the United States of America Dedication To my wife, Alice, and my children, Rachel and Josh, for their support and encouragement Acknowledgement The editor and authors would like to express their gratitude to Janice Q. Pelegano for her excellence in the process of editing and manuscript preparation. TABLE OF CONTENTS Preface ...................................................................................... ix Acknowledgement ........................................................................... v Index .......................................................................................... xv .1 Experimental Animal Models of Atrial Arrhythmias and their Relevance to Postoperative Atrial Arrhythmias that Occur in Humans Undergoing Cardiac Surgery Gregory K. Feld .................................................................... 1 .2 Understanding the Pathophysiology of Atrial Fibrillation From Clinical Observations Scott E. Mattson and Leonard I. Ganz ........................................ 19 3. Incidence, Timing and Outcome of Atrial Tachyarrhythmias After Cardiac Surgery L. Brent Mitchell ................................................................ 37 4. Risk Factors for the Development of Postoperative Atrial Fibrillation Frederick A. Ehlert, Dhiraj D. Narula and Jonathan S. Steinberg ......................................................................... 51 .5 The Impact of Atrial Fibrillation on Hospital Length Of Stay After Cardiac Surgery Jacqueline E. Tamis and Jonathan S. Steinberg ............................ 81 6. Prophylactic Value of Beta Blockers Javier E. Sanchez and Andrew E. Epstein ................................. 95 7. Antiarrhythmic Therapy to Prevent Atrial Fibrillation after Cardiac Surgery Bradley P. Knight and Fred Morady ....................................... 109 . Nonpharmacologic Treatment of Postoperative Atrial Fibrillation Richard J. Lewis and Jonathan S. Steinberg .............................. 119 . Therapeutic Options for Established or Recurrent Atrial Fibrillation: Focus on Antithrombotic Therapy J. H. McAnulty and Jack Kron .............................................. 133 10. Atrial Fibrillation after Noncardiac Surgery Dhiraj D.Narula and Jonathan S. Steinberg .............................. 141 Preface Atrial fibrillation (AF) is the most common arrhythmic complication after cardiac surgery, and as in other settings, represents a serious therapeutic challenge. Its importance lies not only in the clinical complications that may ensue, or the patient discomfort frequently present, but also in its substantial impact on utilization of health care resources. This in large part arises from the product of the prevalence of AF and the additional length of stay necessary for its control and treatment; in today's environment, these issues have assumed near-paramount importance. It is timely to review the specific subset of AF in the setting of cardiac surgery, and it remains useful to segegate this particular form of bY from AF in other clinical milieu. When AF occurs after cardiac surgery, there is an unusually narrow time window of risk; this unique situation lends itself to clinical intervention (risk stratification, prophylactic therapy and intensive surveillance) and clinical trial (large at-risk populations, high incidence, no loss of follow-up and well defined endpoint). However, AF after cardiac surgery has remained a persistent and stubborn problem that continues to attract the attention of individual practitioners and clinical investigators. In this book, our authors will begin by describing the electrophysiologic abnormalities that are used to create AF (and other atrial arrhythmias) in the experimental animal model; these efforts have intriguing similarity to some of the changes that the atria undergo in routine cardiac surgery. The text will go on to describe several clinical observations that suggest the development of AF in the cardiac surgical patient has some similarities to AF in other clinical settings, but that there are also some unique features that indicate AF is at least partially mediated by special postoperative circumstances. When a patient leaves the operating room, the reader will learn of the fairly well circumscribed period of risk and a varied pattern of frequency, duration and consequences of AF. Next, one wilt read of the many studies that have examined which of the many cardiac surgical patients is at greatest risk based on clinical characteristics and also some new noninvasive tools. Of course, AF is not benign in its effect on hospital resources; it may eat up length of stay when the burden on physicians and staff is to move the patients out of the ICU, telemetry unit and hospital at faster and faster rates. This important subject will be discussed in detail. How does one lessen the impact of AF? Two broad strategies will be discussed in detail. Several chapters deal with the results of different drug prophylactic schemes and with recent studies that have used atrial pacing to prevent AF. However, frequently one has to manage AF that has broken through despite attempts to prevent it and the options of cardioversion and anticoagulation will be addressed in detail. Finally, AF also occurs after noncardiac surgery. Observations gathered in this group of patients may have particular relevance to the emerging use of minimally invasive cardiac surgery. Cardiac surgery is performed on >500,000 patients each year in the U.S. alone. Because of its incidence, tenacity in the face of therapy, and consumption of precious health care resources, the focus on AF after cardiac surgery will persist among cardiologists, cardiac surgeons, anesthesiologists, nurses, hospital administrators and insurers. My colleagues and I have attempted to bring our readership a single source of information on this important problem. We hope to help health care professionals treat their patients optimally and to encourage researchers to continue their productive efforts.