Prognostic factors of atrial fibrillation following elective coronary artery bypass grafting: the impact of quantified intraoperative myocardial ischemia

Journal of Cardiothoracic Surgery

Efstratios Apostolakis¹  Dimitrios Dougenis⁵  Nikolaos Anastasiou³  Nikolaos Panagopoulos⁵  Matthew Panagiotou⁴  Panagiotis Dedeilias²  James R Crockett⁴  Christos Prokakis⁵  Efstratios N Koletsis⁵ 

[1] Department of Cardiac Surgery, University of Ioannina, School of Medicine, Ioannina, Greece;1st Cardiac Surgery Department. "Evangelismos" General Hospital, Athens, Greece;Department of Thoracic Surgery, 1st IKA Hospital, Athens, Greece;Cardiac Surgery Department, Athens Medical Center, Greece;Cardiothoracic Surgery Department, University of Patras, School of Medicine, Patras, Greece

关键词: predictors;    postoperative supraventricular arrhythmias;    Myocardial Ischemia Index;    CABG;    coronary artery bypass grafting;    cardiopulmonary bypass;    post-CABG atrial fibrillation;   

Others  :  1153789
DOI  :  10.1186/1749-8090-6-127

 received in 2011-05-24, accepted in 2011-10-03,  发布年份 2011

【 摘 要 】

Background

Atrial fibrillation (AF) occurs in 28-33% of the patients undergoing coronary artery revascularization (CABG). This study focuses on both pre- and peri-operative factors that may affect the occurrence of AF. The aim is to identify those patients at higher risk to develop AF after CABG.

Patients and methods

Two patient cohorts undergoing CABG were retrospectively studied. The first group (group A) consisted of 157 patients presenting AF after elective CABG. The second group (group B) consisted of 191 patients without AF postoperatively.

Results

Preoperative factors presenting significant correlation with the incidence of post-operative AF included: 1) age > 65 years (p = 0.029), 2) history of AF (p = 0.022), 3) chronic obstructive pulmonary disease (p = 0.008), 4) left ventricular dysfunction with ejection fraction < 40% (p = 0.015) and 5) proximal lesion of the right coronary artery (p = 0.023). The intraoperative factors that appeared to have significant correlation with the occurrence of postoperative AF were: 1) CPB-time > 120 minutes (p = 0.011), 2) myocardial ischemia index < 0.27 ml.m²/Kg.min (p = 0.011), 3) total positive fluid-balance during ICU-stay (p < 0.001), 4) FiO₂/PO₂ > 0, 4 after extubation and during the ICU-stay (p = 0.021), 5) inotropic support with doses 15-30 μg/Kg/min (p = 0.016), 6) long ICU-stay recovery for any reason (p < 0.001) and perioperative myocardial infarction (p < 0.001).

Conclusions

Our results suggest that the incidence of post-CABG atrial fibrillation can be predicted by specific preoperative and intraoperative measures. The intraoperative myocardial ischemia can be sufficiently quantified by the myocardial ischemia index. For those patients at risk we would suggest an early postoperative precautionary anti-arrhythmic treatment.

【 授权许可】

   
2011 Koletsis et al; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Zaman AG, Archbold RA, Helft G, Paul EA, Curzen NP, Mills PG: Atrial fibrillation after coronary artery bypass surgery: a model for preoperative risk stratification. Circulation 2000, 101:1403-1408.
• [2]Mathew JP, Fontes ML, Tudor IC, Ramsay J, Duke P, Mazer CD, Barash PG, Hsu PH, Mangano DT, Investigators of the Ischemia Research and Education Foundation; Multicenter Study of Perioperative Ischemia Research Group: A multicenter risk index for atrial fibrillation after cardiac surgery. JAMA 2004, 291:1720-1729.
• [3]Aranki SF, Shaw DP, Adams DH, Rizzo RJ, Couper GS, VanderVliet M, Collins JJ Jr, Cohn LH, Burstin HR: Predictors of atrial fibrillation after coronary artery surgery. Current trends and impact on hospital resources. Circulation 1996, 94:390-397.
• [4]Creswell LL, Schuessler RB, Rosenbloom M, Cox JL: Hazards of postoperative atrial arrhythmias. Ann Thorac Surg 1993, 56:539-549.
• [5]Maisel WH, Rawn JD, Stevenson WG: Atrial fibrillation after cardiac surgery. Ann Intern Med 2001, 135:1061-73.
• [6]Podrid PJ: Prevention of postoperative atrial fibrillation: what is the best approach? J Am Coll Cardiol 1999, 34:340-342.
• [7]Kowey PR: Atrial arrhythmias after cardiac surgery: Sisyphus revisited? J Am Coll Cardiol 1999, 34:348-350.
• [8]Hogue CW Jr, Creswell LL, Gutterman DD, Fleisher LA, American College of Chest Physicians: Epidemiology, mechanisms and risks: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery. Chest 2005, 128(2 suppl):9S-16S.
• [9]Ishii Y, Schuessler RB, Gaynor SL, Yamada K, Fu AS, Boineau JP, Damiano RJ Jr: Inflammation of atrium after cardiac surgery is associated with inhomogeneity of atrial conduction and atrial fibrillation. Circulation 2005, 111:2881-2888.
• [10]Liu L, Nattel S: Differing sympathetic and vagal effects on atrial fibrillation in dogs: role of refractoriness heterogeneity. Am J Physiol 1997, 273:H805-H816.
• [11]Hogue CW Jr, Domitrovich PP, Stein PK, Despotis GD, Re L, Schuessler RB, Kleiger RE, Rottman JN: PP interval dynamics before atrial fibrillation in patients after coronary artery bypass graft surgery. Circulation 1998, 98:429-434.
• [12]Kalus JS, Caron MF, White CM, Mather JF, Gallagher R, Boden WE, Kluger J: Impact of fluid balance on incidence of atrial fibrillation after cardiothoracic surgery. Am J Cardiol 2004, 94:1423-1425.
• [13]Sideris DA, Toumanidis ST, Tselepatiotis E, Kostopoulos K, Stringli T, Kitsiou T, Moulopoulos SD: Atrial pressure and experimental atrial fibrillation. Pacing Clin Elettrophysiol 1995, 18:1679-1685.
• [14]Everett TH, Li H, Mangrum JM, McRury ID, Mitchell MA, Redick JA, Haines DE: Electrical, morphological and ultrastructural remodeling and reverse remodeling in a canine model of chronic atrial fibrillation. Circulation 2000, 102:1454-1460.
• [15]Osranek M, Fatema K, Qaddoura F, Al-Saileek A, Barnes ME, Bailey KR, Gersh BJ, Tsang TS, Zehr KJ, Seward JB: Left atrial volume predicts the risk of atrial fibrillation after cardiac surgery. J Am Coll Cardiol 2006, 48:779-786.
• [16]Vardas PE, Vemmos K, Sideris DA, Moulopoulos SD: Susceptibility of the right and left canine atria to fibrillation in hyperglycemia and hypoglycemia. J Electrocardiol 1993, 26:147-153.
• [17]Klemperer JD, Klein IL, Ojamaa K, Helm RE, Gomez M, Isom OW, Krieger KH: Triiodothyronine therapy lowers the incidence of atrial fibrillation after cardiac operations. Ann Thorac Surg 1996, 61:1323-1327.
• [18]Smith PK, Buhrman WC, Levett JM, Ferguson TB Jr, Holman WL, Cox JL: Supreventricular conduction abnormalities following cardiac operations: a complication of inadequate atrial preservation. J Thorac Cardiovasc Surg 1983, 85:105-115.
• [19]Kolvekar S, D'Souza A, Akhtar P, Reek C, Garratt C, Spyt T: Role of atrial ischemia in development of atrial fibrillation following coronary artery bypass surgery. Eur J Cardiothorac Surg 1997, 11:70-75.
• [20]Carmelo M, Smith P: Critical Care for the Adult Cardiac Patient. In Sabiston and Spencer Surgery of the Chest. 7th edition. Edited by Sellke F, del Nido P, Swanson S. Philadelphia, Elsevier/Saunders; 2005:1043-1045.
• [21]Chen XZ, Newman M, Rosenfeldt FL: Internal cardiac cooling improves atrial preservation: electrophysiological and biochemical assessment. Ann Thorac Surg 1988, 46:406-411.
• [22]Mullen JC, Khan N, Weisel RD, Christakis GT, Teoh KH, Madonik M, Mickle DA, Ivanov J: Atrial activity during cardioplegia and postoperative arrhythmias. J Thorac Cardiovasc Surg 1987, 94:558-565.
• [23]Creswell LL, Alexander JC Jr, Ferguson TB Jr, Lisbon A, Fleisher LA, 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. Chest 2005, 128(2 suppl):28S-35S.
• [24]Jidéus L, Blomström P, Nilsson L, Stridsberg M, Hansell P, Blomström-Lundqvist C: Tachyarrhythmias and triggering factors for atrial fibrillation after coronary artery by pass operation. Ann Thorac Surg 2000, 69:1064-1069.
• [25]Mathew JP, Parks R, Savino JS, Friedman AS, Koch C, Mangano DT, Browner WS, et al.: Atrial fibrillation following coronary artery bypass graft surgery: predictors, outcomes and resource utilization. Multicenter Study of Perioperative Ischemia Research Group. JAMA 1996, 276:300-306.
• [26]Caretta Q, Mercanti CA, De Nardo D, Chiarotti F, Scibilia G, Reale A, Marino B: Ventricular contraction defects and atrial fibrillation after coronary artery bypass grafting. Multivariate analysis of preoperative, intraoperative and postoperative variables. Eur Heart J 1991, 12:1107-1111.
• [27]Almassi GH, Schowalter T, Nicolosi AC, Aggarwal A, Moritz TE, Henderson WG, Tarazi R, Shroyer AL, Sethi GK, Grover FL, Hammermeister KE: Atrial fibrillation after cardiac surgery. A major morbid event? Ann Surg 1997, 226:501-511.
• [28]Nakai T, Lee RJ, Schiller NB, Bellows WH, Dzankic S, Reeves J, Romson J, Ferguson S, Leung JM: The relative importance of left atrial function versus dimension in predicting atrial fibrillation after coronary artery bypass graft surgery. Am Heart J 2002, 143:181-186.
• [29]Knotzer H, Mayr A, Ulmer H, Lederer W, Schobersberger W, Mutz N, Hasibeder W: Tachyarrhythmias in a surgical intesive care unit: a case controlled epidemiologic study. Intesive Care Med 2000, 26:908-914.
• [30]Place DG, Peragallo RA, Carroll J, Cusimano RJ, Cheng DC: Postoperative atrial fibrillation: A comparison of off pump coronary artery bypass surgery and conventional coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 2002, 16:144-148.
• [31]Amar D, Shi W, Hogue CW Jr, Zhang H, Passman RS, Thomas B, Bach PB, Damiano R, Thaler HT: Clinical prediction rule for atrial fibrillation after coronary artery bypass grafting. J Am Coll Cardiol 2004, 44:1248-1253.
• [32]Villareal RP, Hariharan R, Liu BC, Kar B, Lee VV, Elayda M, Lopez JA, Rasekh A, Wilson JM, Massumi A: Postoperative atrial fibrillation and mortality after coronary artery bypass surgery. J Am Coll Cardiol 2004, 43:742-748.
• [33]Auer J, Weber T, Berent R, Ng CK, Lamm G, Eber B: Risk factors of postoperative atrial fibrillation after cardiac surgery. J Card Surg 2005, 20:425-431.
• [34]Allessie MA, Boyden PA, Camm AJ, Kléber AG, Lab MJ, Legato MJ, Rosen MR, Schwartz PJ, Spooner PM, Van Wagoner DR, Waldo AL: Pathophysiology and prevention of atrial fibrillation. Circulation 2001, 103:769-777.
• [35]Mayr A, Knotzer H, Pajk W, Luckner G, Ritsch N, Dünser M, Ulmer H, Schobersberger W, Hasibeder W: Risk factors associated with new onset tachyarrhytmias after cardiac surgery - a retrospective analysis. Acta Anaesthesiol Scand 2001, 45:543-549.
• [36]Mendes LA, Connelly GP, McKenney PA, Podrid PJ, Cupples LA, Shemin RJ, Ryan TJ, Davidoff R: Right coronary artery stenosis: an independent predictor of atrial fibrillation after coronary artery bypass surgery. J Am Coll Cardiol 1995, 25:198-202.