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(Chest. 2005;128:28S-35S.)
© 2005 American College of Chest Physicians

Intraoperative Interventions*

American College of Chest Physicians Guidelines for the Prevention and Management of Postoperative Atrial Fibrillation After Cardiac Surgery

Lawrence L. Creswell, MD; John C. Alexander, Jr., MD, FCCP; T. Bruce Ferguson, Jr., MD; Alan Lisbon, MD, FCCP and Lee A. Fleisher, MD

* From the Division of Cardiothoracic Surgery (Dr. Creswell), University of Mississippi Medical Center, Jackson, MS; Hackensack University Medical Center (Dr. Alexander), Hackensack, NJ; the Division of Cardiothoracic Surgery (Dr. Ferguson), Louisiana State University School of Medicine, New Orleans, LA; the Department of Anesthesia and Critical Care Medicine (Dr. Lisbon), Beth Israel-Deaconess Medical Center, Boston, MA; and the Department of Anesthesia (Dr. Fleisher), University of Pennsylvania Health System, Philadelphia, PA.

Correspondence to: Lawrence L. Creswell, MD, Division of Cardiothoracic Surgery, Washington University School of Medicine, 11155 Dunn Rd, Suite 204N, St. Louis, MO 63136; e-mail: creswelll{at}msnotes.wustl.edu


   Abstract
TOP
 Abstract
Introduction
 Summary of Evidence Review
 Discussion
 Recommendations
 References
 
A comprehensive evidence review was conducted of the medical literature regarding the relationship between intraoperative interventions and the incidence of postoperative atrial arrhythmias, including, most commonly, atrial fibrillation (AF). Fifteen randomized, controlled studies and one large-scale concurrent cohort study were identified that reported on the following issues: systemic temperature during surgery (one report); "beating heart" surgery vs conventional bypass surgery (three reports); type of myocardial protection (five reports); the use of adjunctive posterior pericardiotomy (one report); the use of thoracic epidural anesthesia (TEA) [two reports]; the use of glucose-insulin-potassium (GIK) solutions (two reports); and the use of heparin-coated circuits for cardiopulmonary bypass (CPB) [two reports]. Based on a systematic review of the reported data and an analysis of the quality of the reported data, we recommend the following: (1) that mild hypothermia, rather than moderate hypothermia, may be effective in reducing the frequency of postoperative AF; (2) the use of posterior pericardiotomy may be a useful adjunct to reduce the frequency of postoperative AF; and (3) the use of heparin-coated CPB circuits is associated with less postoperative AF. Because of conflicting or inadequate data, we cannot conclude that the frequency of postoperative AF is affected by (1) the use of beating-heart techniques, (2) the type of myocardial protection strategy used, (3) the use of TEA, or (4) the use of GIK solutions perioperatively.

Key Words: arrhythmia • atrial fibrillation • heart surgery


   Introduction
TOP
 Abstract
 Introduction
Summary of Evidence Review
 Discussion
 Recommendations
 References
 
Atrial fibrillation (AF) is a common complication early after cardiac surgery. Adult patients undergoing coronary artery bypass graft (CABG) surgery experience new-onset postoperative AF in as many as 40% of cases.123 AF in this setting is often "benign," producing no lasting sequelae. Postoperative AF has been associated, however, with perioperative stroke and/or other thromboembolic complications. It is hard to determine whether postoperative AF is a "marker" or a cause of increased morbidity. Nonetheless, there is little doubt that postoperative AF, even in its most benign form, is responsible for some of the increased costs associated with an increased length of stay.123456

The etiology of AF following cardiac surgery is likely multifactorial. A variety of intraoperative factors have been proposed to reduce the frequency of postoperative AF. Postoperative AF has been studied in relationship to the following issues: the number of bypass grafts performed1234567; the use of the left internal mammary artery vs other bypass conduits1348; the use of "beating-heart" rather than conventional operative techniques with cardiopulmonary bypass (CPB)12347; concomitant heart valve surgery1235; specific venous cannulation techniques1234567891011121314151617; the duration of CPB12347; the duration of aortic cross-clamping, or ischemic time1238; techniques used for left ventricular venting129; the type and route of cardioplegia solution used for arresting the heart or other myocardial protective techniques1017181920212223; systemic temperature during CPB112425; the technique of pericardiotomy12262728; the use of thoracic epidural analgesia as an adjunct to conventional general anesthesia2930313233; the use of glucose-insulin-potassium (GIK) solutions34353637; and the use of heparin-coated circuits for CPB.38394041

The purpose of this study was to perform a comprehensive and systematic review of the relevant medical literature using an evidence-based approach in order to make clinically useful recommendations about the association between intraoperative interventions and the development of postoperative AF. Details of the methodology used is described in the "Methodological Approach" article in this supplement.

The issue of intraoperative interventions and their influence on the incidence of postoperative atrial arrhythmias was judged by the Steering Committee to be a key question. Based on the selection criteria described in the "Methodological Approach" article in this supplement, 16 articles were identified that concerned intraoperative techniques or interventions and that reported their associations with postoperative atrial arrhythmias (Table 1 ). Among these 16 reports, 1 report addressed the systemic temperature during CPB, 3 reports addressed the use of beating-heart surgery (without CPB), 5 reports addressed the type of cardioplegia solution used for arrest of the heart or for other myocardial protection techniques, 2 reports addressed the use of thoracic epidural anesthesia (TEA), 1 report addressed the use of posterior pericardiotomy, 2 reports addressed the use of GIK solution infusions, and 2 reports addressed the use of heparin-coated circuits. A summary of the study design, the results (ie, incidence of postoperative AF), and the overall quality score for each of the studies are also provided in Table 1.


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  		Table 1.. Summary of Studies on Intraoperative Interventions To Reduce the Incidence of Postoperative AF*

 

   Summary of Evidence Review
TOP
 Abstract
 Introduction
 Summary of Evidence Review
Discussion
 Recommendations
 References
 
Systemic Temperature During CPB
Adams et al24 reported a randomized, controlled trial of mild hypothermia (ie, 34°C) vs moderate hypothermia (ie, 28°C) in 65 patients undergoing CABG. These investigators found significantly (p < 0.02) less postoperative AF in patients the mild hypothermia group (21.9%) than in those in the moderate hypothermia group (48.5%).24

Beating Heart/Off-Pump CABG
Two randomized, controlled trials and one large-scale concurrent cohort study were identified that addressed the issue of beating-heart CABG. Ascione et al9 reported on 200 patients who had been randomized to undergo CABG either with or without CPB and found a significantly lower rate of postoperative AF in the off-pump CABG (OPCAB) group (11.0%) than in the on-pump CABG group (45.0%). In a large-scale (n = 7,867 patients), nonrandomized, concurrent cohort study, Hernandez et al10 reported a small but significant difference in postoperative AF favoring the OPCAB group (21.2%) compared to the on-pump CABG group (6.3%).In contrast, however, in another randomized trial of 281 patients randomized to CABG with or without CPB, Van Dijk et al11 reported no difference in the rate of postoperative AF between the two groups.

Myocardial Protection
Five randomized, controlled trials comparing different forms of cardioplegia or other methods of myocardial protection were identified. Butler et al18 reported on a trial of the influence of cold potassium cardioplegia vs intermittent aortic cross-clamping on the rate of postoperative AF. Fontan et al19 reported on a trial of a variety of formulations of cardioplegia in both CABG and valve surgery patients and the effect on the rate of postoperative AF. Hynninen et al20 reported on a trial of the use of insulin-enhanced cardioplegia. Wandschneider et al21 reported on a trial of cold-blood cardioplegia and crystalloid cardioplegia and the effect on the rate of postoperative AF. In all four of these reports, the authors noted no significant relationship between the type of cardioplegia or other myocardial preservation technique and the rate of postoperative AF. In contrast, Pehkonen et al23 reported that in a small trial of warm-blood vs cold-blood crystalloid cardioplegia the rate of postoperative AF was significantly higher (42.9% vs 18.4%, respectively) in the warm-blood cardioplegia group.

TEA
Two randomized, controlled trials of the use of TEA as an adjunct to anesthesia in CABG patients were identified. Jideus et al29 reported that there was no significant difference in the incidence or the timing of postoperative AF in CABG patients between patients who received TEA and those who did not. In contrast, Scott et al30 reported that there were significantly fewer postoperative atrial arrhythmias in patients who received TEA (10.2%) compared to those who received conventional general anesthesia alone (22.3%).

Posterior Pericardiotomy
A single randomized, controlled trial of posterior pericardiotomy on the incidence of postoperative AF was identified. Kuralay et al26 reported a significantly lower rate of postoperative atrial arrhythmias in the posterior cardiotomy group.

Perioperative GIK Solution Infusion
Two randomized, controlled trials of perioperative GIK solution infusion were identified. Wistbacka et al35 reported that the use of an intraoperative GIK solution infusion did not influence the rate of postoperative AF. In contrast, Lazar et al34 reported that the use of a GIK solution was associated with less postoperative AF in CABG patients.

Heparin-Coated CPB Circuits
Two randomized, controlled trials of heparin-coated circuits were identified; although, both focused on other outcomes, both reported on the frequency of postoperative AF. Ovrum et al38 reported an approximately 50% reduction in postoperative AF in the group using heparin-coated circuits. Svenmarker et al39 reported that among low-risk CABG patients those undergoing surgery with one brand of heparin-coated CPB circuit had a lower incidence of postoperative AF, whereas those undergoing surgery with another brand did not.


   Discussion
TOP
 Abstract
 Introduction
 Summary of Evidence Review
 Discussion
Recommendations
 References
 
Systemic Temperature During CPB
Systemic hypothermia has traditionally been used during cardiac surgical procedures to provide a degree of myocardial, cerebral, and somatic protection.42 In the past few years, however, there has been growing recognition that moderate degrees of systemic hypothermia (ie, 28°C) may not produce additional benefit over mild hypothermia (ie, 34°C) in terms of cerebral or cardiac preservation.42 As a result, there has been a trend toward the use of mild hypothermia during most cardiac surgical procedures, unless deep hypothermia (ie, <20°C) is needed for circulatory arrest.42 The single randomized, controlled trial24 of mild vs moderate hypothermia in CABG patients reported significantly less postoperative AF in the mild hypothermia group. Postoperative AF was identified only retrospectively from chart review, which leaves open the possibility that some arrhythmias were not detected, however. The data from the current trial confirm the pilot data reported by this same group of investigators25 in a much smaller group of patients. The authors speculated that significant increases in sympathetic nerve activity during rewarming may have been responsible for an increased frequency of postoperative AF in patients who experienced moderate degrees of hypothermia. There have been no studies, however, that address this possibility directly.

Beating Heart/OPCAB
In the year 2002, > 20% of all CABG operations were performed using beating-heart techniques without the use of CPB.43 A variety of beating-heart techniques for bypass surgery have been described, including minimally invasive direct coronary artery bypass with a small anterior thoracotomy incision,13 OPCAB using a conventional sternotomy incision,9101112141516 and port-access and robotically assisted CABG.4445 These techniques have been popularized based on the assumption of technically equivalent results coupled with improved short-term outcomes.

Because at least some portion of postoperative AF has been thought to be due to intraoperative atrial ischemia, there was some reason to believe that the beating-heart approach to CABG (ie, without arrest of the heart) would result in less postoperative AF. Several authors1213 have reported a reduced incidence of postoperative AF in patients undergoing beating-heart CABG. But other authors141516 have reported no difference. In the current evidence review, two randomized, controlled trials and one large-scale concurrent cohort study were identified. Ascione et al9 reported a significantly lower rate of postoperative AF in the OPCAB group than in the on-pump CABG group. In contrast, though, Van Dijk et al11 reported no difference in AF frequency for the two surgical approaches in a randomized, prospective study of similar size. The large-scale concurrent cohort study reported by Hernandez et al10 found a small but statistically significant difference in the frequency of postoperative AF between on-pump CABG patients and OPCAB patients favoring the OPCAB group.

Myocardial Protection
In conventional CABG operations with CPB and an arrested heart, the CABGs are created after cardioplegic arrest. As an alternative, intermittent aortic cross-clamping can be used to arrest the heart for short periods of time to allow for a quiet operative field during the creation of distal anastomoses. Some percentage of postoperative atrial arrhythmias are thought to be due to inadequate myocardial preservation during cardioplegic arrest.46 Several investigators have studied the effects of various methods of myocardial protection on the frequency of postoperative atrial arrhythmias, but no convincing benefit for any one particular protection strategy has been identified in retrospective reports, either in terms of postoperative AF or other conduction abnormalities.47484950 In four of the five identified randomized, controlled trials related to cardioplegia or myocardial protection strategy, Butler et al18 identified no difference between cold potassium cardioplegia and intermittent aortic cross-clamping, and Fontan et al19 found no benefit to any particular cardioplegic technique. Hynninen et al20 found no benefit to insulin-enhanced cardioplegia, and Wandschneider et al21 found no benefit to blood cardioplegia vs crystalloid cardioplegia. In a small study, Pehkonen et al23 found a lower incidence of postoperative AF in the group that received cold crystalloid cardioplegia.

TEA
The ß-adrenergic receptor antagonists have been shown in most randomized, controlled studies515253545556 to reduce the incidence of postoperative AF in cardiac surgery patients. It has been postulated that increased sympathetic tone may be one mechanism that is responsible for AF. There has been interest in the use of TEA as an adjunct to conventional anesthesia because it has been shown to decrease both heart rate and BP variability, suggesting effective sympathetic blockade. Nonrandomized studies of TEA have produced conflicting results.313233 Two randomized, controlled studies have also reported conflicting results. Jideus et al29 reported no difference in the rate of postoperative AF, but Scott et al30 reported a significant reduction in the rate of postoperative AF with the use of TEA.

Posterior Pericardiotomy
In most CABG operations, the pericardium is usually opened longitudinally in its anterior aspect. This opening provides unobstructed access to the underlying heart and proximal great vessels. The pericardium is usually left open, although some surgeons choose to close a portion of the pericardium. A second, or auxiliary, incision in the posterior pericardium has been used to facilitate the drainage of blood into the chest cavity where it can be evacuated with chest tubes. This technique has been shown in nonrandomized trials to reduce the incidence of both postoperative pericardial effusion and postoperative supraventricular tachycardia.27 In contrast, Asimakopoulos et al28 found no association between the use of posterior pericardiotomy and the incidence of postoperative AF. In the single randomized, controlled trial identified in the evidence review, Kuralay et al26 reported a significant reduction in postoperative AF for patients who underwent posterior pericardiotomy. Although this study reports a benefit, it is important to keep in mind that there are multiple other reasons why this effect could be a surrogate for other (and unidentified) intraoperative factors.

Perioperative GIK Solution Infusion
Metabolic substrate enhancement with glucose or other energy sources during periods of myocardial ischemia and reperfusion has been proposed as one strategy to limit myocardial necrosis. As early as 1965, Sodi-Pollaris et al36 noted that GIK solutions administered to patients experiencing acute myocardial infarction limited the subsequent ECG changes. In addition, animal models of myocardial ischemia/reperfusion have indicated that GIK solution infusion limited tissue necrosis, resulted in less myocardial acidosis, reduced the frequency of ventricular arrhythmias, and resulted in fewer wall motion abnormalities. Two randomized, controlled trials of GIK solution infusion in patients undergoing heart surgery were identified in the evidence review. Wistbacka et al35 reported that in patients undergoing CABG surgery there was no difference in the rate of postoperative AF associated with the use of GIK solutions and that the use of GIK solutions was associated with serious adverse effects such as hypoglycemia. In contrast, Lazar et al34 found in unstable patients with angina who were undergoing CABG that GIK infusion enhanced myocardial performance and also resulted in less postoperative AF.

Heparin-Coated CPB Circuits
CPB has long been associated with a variety of deleterious systemic inflammatory effects mediated by a generalized systemic inflammatory response.40 Heparin-coated CPB circuits have been developed to reduce the systemic inflammatory response associated with CPB, as measured by less complement activation, less leukocyte activation, a reduction in the release of cytokines, and the need for less systemic anticoagulation therapy. Proponents have postulated that the use of heparin-coated CPB circuits would result in less postoperative bleeding and fewer thromboembolic complications, but the reported results have been mixed.41 Two randomized, controlled trials of the use of heparin-coated circuits were identified. The data in these studies that addressed the impact on bleeding and neurologic injury were mixed, but both of these reports documented at least some evidence for a reduction in the rate of postoperative AF with the use of a heparin-coated circuit. Ovrum et al38 reported significantly less postoperative AF in the heparin-coated circuit group (a reduction of approximately 50%). Svenmarker et al39 studied different types of heparin-coated circuits and found that one type was associated with less postoperative AF. Both groups of investigators questioned whether their observation of less postoperative AF in the group of patients in whom heparin-coated circuit had been used was truly due to the type of circuit or to other, unmeasured factors.

Limitations
It is important to keep in mind that our recommendations are based on a relatively small number of studies. In the case of posterior pericardiotomy and the use of mild hypothermia, our recommendations are based on only single randomized controlled studies. We understand that, when making clinical decisions for the individual patient, the reader must place our recommendations in the proper context.


   Recommendations
TOP
 Abstract
 Introduction
 Summary of Evidence Review
 Discussion
 Recommendations
References
 
AF remains a significant complication following cardiac surgery. This arrhythmia is associated with an increased hospital length of stay, increased costs, and an increased risk for thromboembolic complications. On the basis of the findings of this and the other reports in this series, we suggest that a multifactorial approach, involving appropriate prophylaxis and treatment for this arrhythmia, will best serve our cardiac surgery patients. Below are the recommendations for the management of intraoperative interventions. A summary of these clinical recommendations and grades of evidence is presented in Table 2 .

  1. We recommend the use of mild, rather than moderate, hypothermia to reduce the frequency of postoperative AF (strength of recommendation, A; evidence grade, fair; net benefit, substantial).
  2. Posterior pericardiotomy may be a useful adjunct to help reduce the incidence of postoperative atrial arrhythmias; however, this recommendation is based on a single, small-scale randomized, controlled trial. Posterior pericardiotomy is not currently standard of care and is not widely used as an adjunct to reduce postoperative AF (strength of recommendation, B; evidence grade, fair; net benefit, intermediate).
  3. OPCAB cannot be recommended to decrease postoperative AF because of conflicting results reported from randomized, controlled trials or large-scale concurrent cohort studies (strength of recommendation, I; evidence grade, fair; net benefit, conflicting).
  4. No specific recommendations can be made regarding which type of cardioplegia (or intermittent aortic cross-clamping) best reduces the incidence of postoperative AF (strength of recommendation, I; evidence grade, good; net benefit, none).
  5. No recommendation can be made regarding the use of TEA as an adjunct to conventional general anesthesia to prevent postoperative AF after cardiac surgery (strength of recommendation, I; evidence grade, fair; net benefit, conflicting).
  6. We cannot recommend GIK solution infusion to prevent postoperative AF because of conflicting results from the identified randomized, controlled trials (strength of recommendation, I; evidence grade, fair; net benefit, conflicting)
  7. We recommend the use of heparin-coated circuits to reduce the rate of postoperative AF (strength of recommendation, B; evidence grade, fair; net benefit, intermediate).


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  		Table 2.. Summary of Recommendations for Intraoperative Interventions

 


   Footnotes
 
Abbreviations: AF = atrial fibrillation; CABG = coronary artery bypass graft; CPB = cardiopulmonary bypass; GIK = glucose-insulin-potassium; OPCAB = off-pump coronary artery bypass graft; TEA = thoracic epidural anesthesia


   References
TOP
 Abstract
 Introduction
 Summary of Evidence Review
 Discussion
 Recommendations
 References
 

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