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Having Surgery? Beware of Post-Operative A-Fib & Protocols to Prevent it

Updated 7/17/22 Did you know after almost any type of cardiac surgery, it’s all too common to develop Post-Operative Atrial Fibrillation (POAF)? (Other major surgeries can lead to Post-Operative A-Fib as well.)

Beware! If you or a loved one are having surgery, anticipate developing post-operative A-Fib. Some consider it an inevitable complication of surgery.

Both Short and Long-Term Consequences

Post-Operative A-Fib (POAF) is associated with prolonged hospital stays, higher healthcare-related costs, increased mortality, increased risk of cerebrovascular accidents (CVA), and re-hospitalization.

If you do develop A-Fib after cardiac surgery, both your short-term and long-term prognosis is poor. Increased short and long-term mortality is likely caused by heart failure, cerebrovascular accidents (CVA), and bleeding complications. Even after 10 years, you can develop “late recurrent A-Fib”.

The most common cardiac surgery in the U.S. is bypass surgery with more than 200,000 surgeries performed annually. And what’s the most frequent complication? If you guessed A-Fib, you’d be right. Rates of post-operative A-Fib after surgery range from 10%-to-50%. Those aren’t very good odds.

The Research: Post-Operative A-Fib is Dangerous

Post-operative A-Fib can be really nasty. (Don’t listen to people who say POAF is harmless and goes away soon.)

From Finland (Waterford and Ad), in a study of cardiac surgery, POAF produced a 36.5% occurrence of stroke.

In another study of over 2 million patients, POAF was associated with increased risk of early and late mortality. POAF is a strong predictor of long-term development of A-Fib (9-fold increase of the development of A-Fib more than 30 days after surgery).

From the Netherlands (Kuar, H. et al), in a small study, researchers used implantable loop recorders in cardiac surgery patients to record both early and late post-operative A-Fib (POAF). (Early POAF=within 5 days, POAF=after this period.) Over an average follow-up of 29 months, 34% of patients had early POAF, while 67% experienced late POAF.

From the University of Pittsburgh (Bianco et al), in a study involving 12,227 cardiac patients, 4,300 developed post-operative A-Fib (35.2%). These patients had significantly higher rates of re-operation, transfusions, sepsis, prolonged ventilation, pneumonia, renal failure and dialysis. On long-term follow-up, they had worse morbidity, lower survival, and more readmissions for heart failure.

From Weill Cornell Medicine, New York (Goyal et al)  

“Post-operative A-Fib (POAF) occurs in up to 40% of patients undergoing heart surgery and 2% of patients undergoing non-cardiac surgery,” In an observational retrospective study of nearly 3 million patients at 11 acute care hospitals across the U.S.,18.8% of patients who underwent heart surgery developed post-operative A-Fib. “…and the risk of hospitalization for heart failure increased by a third compared to patients who did not develop AF.” Doctors tend to view POAF as a benign event, triggered by the stress of the surgery. But accoring to the authors of this study, “evidence is emerging that post-operative A-Fib is linked to longer term problems such as stroke and death from any cause.”

In an editorial by Melissa Middeldorp and Christine Albert (Cedars Sinai, Los Angeles), they suggest that POAF “is not just a transient response to surgery but may be reflective of underlying atrial and myocardial structural changes that not only predispose to the acute AF event but to other potentially related adverse events, such as Heart Failure hospitalization.”

The most disturbing point of this study is that A-Fib may itself contribute to heart failure, “post-operative AF is associated with future heart failure hospitalizations.”

Patients with A-Fib undergoing noncardiac surgery (NCS) were associated with higher risks of mortality, heart failure, and stroke. The study included 8,635,758 Medicare patients admitted for noncardiac surgery and focused on 16.4% of these patients who had A-Fib at the time of their surgery. “Pre-existing AF is independently associated with postoperative adverse outcomes after NCS.” (Prasadam S, et al) (Thanks to David Holzman for calling our attention to this research.)

Protocol to Prevent Post-Operative A-Fib

In the post-operative period, anticoagulants aren’t enough. Anticoagulation after cardiac surgery can be dangerous with a high risk of bleeding and thromboembolism (stroke).

A better stroke prevention strategy is to prevent the occurrence of POAF in the first place.

The researchers, Waterford and Ad, state that preoperative oral amiodarone is the single most powerful intervention to dramatically reduce rates of POAF.

Protocols to prevent POAF: They recommend a protocol of 400 mg oral amiodarone per day for 3 days prior to surgery, followed by 200 mg per day for 10 days through and following the operation regardless of whether or not POAF developed. They also recommend that a patient be on a beta-blocker or a statin whenever possible.

They also advise limiting blood transfusions. Red blood cell transfusion is associated with an increased rate of POAF. The mechanism is likely that red blood cell transfusion induces a pro-inflammatory state, which is known to underlie POAF.

They also urge the use of anti-inflammatory medicines such as colchicine (see my colchicine article: How to Reduce Post-Surgery A-Fib Inflammation? ).

Other Protocols: Some doctors use a beta blocker protocol before surgery such as propranolol and carvedilol plus N-acetyl cysteine which work by “attenuating the sympathetic tone.”

Study results showed that both amiodarone and beta blocker protocols had similar results in reducing poet-operative A-Fib, and that their combined use was more effective than just beta blockers (Tzoumas, A. et al).

Treatment of Post-Operative A-Fib: Some surgeons routinely discharge patients while they are still in A-Fib or Flutter. But others insist on discharging patients in sinus rhythm using electrical cardioversion. The authors, Waterford and Ad, state that electrical cardioversion “should be used more liberally.”

Editor's Comments about Cecelia's A-Fib storyEditor’s Comments
Our Friend’s Bypass Surgery: On a personal note, a friend of ours recently had bypass surgery. We drove him to the hospital and were with him whenever we could. He had a hard time. He had to be put on a ventilator and was in a medically induced coma for 5 days. But he recovered and is now doing well!
I warned him about the chances of developing A-Fib after cardiac surgery, which is exactly what happened to him. But after the surgery, his surgeon got him on an amiodarone protocol which did help.
The surgeon did not use pre-operative amiodarone treatment to prevent him from developing A-Fib in the first place. That’s unfortunately what most cardiac surgical patients experience.
A-Fib After Surgery Not Benign and Transient: In the past, A-Fib after surgery was considered benign and transient. But we now know better. As described in the above research, post-operative A-Fib causes many health problems and even death.
Amiodarone Effective But Toxic and Dangerous: Amiodarone, though effective, is a very toxic drug that should only be used for a short time and under close monitoring.
Out friend was able to finally get off of amiodarone. See Amiodarone: Most Effective and Most Toxic and Toxic Effects of Amiodarone—What Could Have Prevented this Death?
Why Do So Few Surgeons Use Pre-Operative Protocols? Almost every surgeon knows that surgery often causes and/or predisposes patients to develop A-Fib. Then why do so few use pre-operative protocols to prevent post-operative A-Fib? Numerous studies show that post-operative A-Fib can be dramatically reduced by pre-operative oral amiodarone (53% to 25%) (Waterford and Ad)
Sending Patients Home in A-Fib: It’s shocking that surgeons often send their patients home while still in A-FibWHAT? How can they cause and/or be responsible for their patients developing a serious, dangerous heart illness like A-Fib and not do anything about it? Will your surgeon protect you from developing post-op A-Fib?
Are You Having Any Kind of Surgery? Before you have surgery, you have to ask your surgeons if they do anything to prevent you from developing A-Fib after the surgery. If you’re not confident or satisfied with their response, find another surgeon. Don’t hesitate to travel if necessary.

Developing Post-Operative A-Fib doesn’t
have to be a roll of the dice.

Talk to your surgeon about protocols to prevent it.
you should settle for nothing less.

References
• Waterford and Ad. 7 Pillars of Postoperative Atrial Prevention. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. Editorial. November 25, 2021. https://pubmed.ncbi.nlm.nih.gov/34823388/ doi: 10.1177/15569845211043485.

• Develops A-Fib After Appendectomy Surgery; Lifestyle Changes and Meds Restore Normal Sinus Rhythm. Personal A-Fib story. A­-Fib.com https://a-fib.com/after-appendectomy-surgery-develops-a-fib-amiodarone-damages-thyroid/

• Tzoumas, A. et al. Atrial fibrillation following coronary artery bypass graft: Where do we stand? Cardiovascular Revascularization Medicine, December 16, 2021. https://www.sciencedirect.com/science/article/abs/pii/S1553838921008046

• Kaur, H. et al. New-onset perioperative atrial fibrillation in cardiac surgery patients: transient trouble or persistent problem? EP Europace, euab316, December 24, 2021. https://academic.oup.com/europace/advance-article-abstract/doi/10.1093/europace/euab316/6482023  https://doi.org/10.1093/europace/euab316

• Bianco, V. et al. The Long-Term Impact of Thoracic and Cardiovascular Surgery. Science Direct, February 1, 2022. https://www.jtcvs.org/article/S0022-5223(22)00103-9/fulltext DOI:https://doi.org/10.1016/j.jtcvs.2021.10.072

• Goyal, P. et al. AF after surgery is linked to an increased risk of heart failure hospitalization. Cardiac Rhythm News, June 29, 2022. https://tinyurl.com/yc5mm2tu

• Prasadam S. et al. Preoperative Atrial Fibrillation and Cardiovascular Outcomes After Noncardiac Surgery. JACC Journals, Vol. 79 No. 25. https://www.jacc.org/doi/10.1016/j.jacc.2022.04.021

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