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

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 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.

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

2022 AF Symposium Abstract: Inhaler Can Stop A-Fib Attack in Minutes

This abstract further elaborates on an 2021 AF Symposium Spotlight session by Dr. Jeremy Ruskin of Massachusetts General Hospital. He showed safety data from the InCarda Phase 2 study (INSTANT) which he thought very promising. This abstract details a small clinical trial.

This InCarda inhaler is an incredible medical innovation for A-Fib patients! (It’s still in development.)

Imagine: A patient is having an A-Fib episode. The patient self-administers the InCarda inhaler, it produces a flecainide-containing aerosol which the patient inhales. This results in a rapid absorption of flecainide via the lungs into the heart.

It can terminate an A-Fib attack in as little as 8 minutes. (The tablet form of Flecainide takes around 1−3 hours to work.)

For more read my short report: Trial II of InCarda Orally Inhaled Flecainide.

2022 AF Symposium: Spherical Array Catheter Case with Video

Note: This was a very early, first-in-human use of this Spherical Array PFA catheter not yet approved by the FDA.

Dr. Vivek Reddy from Mount Sinai Medical Center in New York City, NY, showed a fascinating video of how the spherical PFA catheter emerged from the catheter sheath and formed itself into a spherical array, then locked itself into shape.

Click image to see Spiral Array catheter open

It was like watching a magic trick. How could they design a catheter sheath from which would emerge a complex spherical shaped catheter that would come together so smoothly?

On the video, we watched as Dr. Reddy and his team performed a Pulsed Field Ablation using the Spherical Array Catheter. The patient was a 31-year-old male diagnosed with paroxysmal A-Fib in 2020.

How the Spherical Array Catheter Works

Once fully deployed, the spherical PFA catheter has a diameter of 30 mm. It contains 122 gold-plated electrodes on 16 splines around the sphere. Continue reading about the Spherical Array catheter and the Pulsed Field Ablation for this patient.

A-Fib Patients Study: After Brain Hemorrhage, Back on Anticoagulation?

Sometimes I just can’t understand some of the research studies done about Atrial Fibrillation such as this one. I can not wrap my head around this recent study from the Netherlands (APACHE-AF).

They studied A-Fib patients who survived intracerebral hemorrhage after being treated with anticoagulation for atrial fibrillation. Their hemorrhagic stroke was “anticoagulant-associated”. Seven to 90 days after their hemorrhage, patients were either put back on anticoagulation (50 patients) or avoided anticoagulation.

WHAT?! How can you put someone back on an anticoagulant which probably caused their hemorrhagic stroke in the first place?
These researchers certainly knew the alternative options to taking anticoagulants.

This study was done at 16 hospitals in the Netherlands but was nevertheless very small. Most patients who did suffer a hemorrhagic stroke either died or were severely disabled. Few survived. That’s why there were so few patients in the study.

Further Damage From Anticoagulation

Not surprisingly, after a minimum follow-up of 6 months (a very short follow-up), 26% of the apixaban group had non-fatal strokes or vascular death. The patients on antiplatelet therapy (26) or no anticoagulation didn’t do very well either.

The researchers themselves concluded, “Patients with atrial fibrillation who had an intracerebral hemorrhage while taking anticoagulants have a high subsequent annual risk of non-fatal stroke or vascular death.”

Did I Miss Something?

How can you put someone back on an anticoagulant, even Eliquis, when anticoagulants probably caused their hemorrhagic stroke in the first place? This seems both ethically wrong and wrong-headed.

Did I miss something important? If anyone wants to share their view of this study with me, send me an email.

Reference
Schreuder, F. et al.  Apixaban versus no anticoagulation after anticoagulation-associated intracerebral haemorrhage in patients with atrial fibrillation in the Netherlands (APACHE-AF): a randomized, open-label, phase 2 trial. The Lancet Neurology, November 2021.  https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(21)00298-2/fulltext DOI:https://doi.org/10.1016/S1474-4422(21)00298-2

2022 AF Symposium Spotlight: Innovation in Development to Seal the Left Atrial Appendage

The CLASS LAAO

Sometimes the method to close off the Left Atrial Appendage, doesn’t make a complete closure. It can leak. I’m very excited about this new product. Dr. Jamie Kim of the Catholic Medical Center in Manchester, NH, presented one of the most innovative and promising new developments for patients to close off their LAA.

Instead of relatively hard, rigid structures which don’t always conform perfectly to the LAA opening and thus may leak, the CLASS LAAO system from Conformal Medical, Inc. uses a different type of conformable foam-based fabric to seal off the LAA. Read this short Spotlight summary for more about this promising new device.

Go to my 2022 AF Symposium page with all my reports.

2022 AF Symposium: Procedural Anticoagulation with LAA Closure Devices for A-Fib Patients

In this report from the 2022 AF Symposium, Dr. Luigi Di Biase of the Albert Einstein College of Medicine, Bronx, NY gave a presentation on “Peri and Post Procedural Anticoagulation with LAA Closure Devices―An Evolving Story”.

In particular, he is talking about the Watchman occlusion device to close off an A-Fib patient’s Left Atrial Appendage. His focus is on the anticoagulation protocol following the procedure involving, that is, the drug regime for patients in the months afterward. e.g., DOACs, aspirin and clopidogrel.

This is a short report, a quick read, go to Procedural Anticoagulation with LAA Closure Devices―An Evolving A-Fib Story.

Exercise to Maintain Normal Heart Rhythm and Ease Symptoms―But Doesn’t Cure A-Fib

In a study from Australia (ACTIVE-AF), a six-month exercise program helped maintain normal heart rhythm and reduced the severity of symptoms in patients with atrial fibrillation.

In the ACTIVE-AF study, 120 symptomatic paroxysmal or persistent A-Fib patients were randomly assigned to a six-month exercise program or a program of usual care (control group). The average age of patients in the study was 65 years and 43% were women.

The exercise program included supervised exercise weekly for three months, then every two-weeks for three months.

The exercise group also had an individualized weekly exercise plan to follow at home. The goal was to increase aerobic exercise up to 3.5 hours a week. The six-month exercise program was followed up by another six months of observation.

Study Results

According to lead author was Dr. Adrian Elliott of the University of Adelaide, Adelaide, Australia, the A-Fib recurrence rate was significantly lower in the exercise group (60%) vs the control group (80%).

Patients in the exercise group also had a significant reduction in the severity of their symptoms at 12 months compared to the control group (less severe palpitations, shortness of breath, and fatigue).

ACTIVE-AF Conclusions

“The ACTIVE-AF trial demonstrates that some patients can control their arrhythmia through physical activity, without the need for complex interventions such as ablation or medications to keep their heart in normal rhythm,” said study author Dr. Adrian Elliott.

Recommendations for patients with symptomatic paroxysmal or persistent A-Fib:

• Aerobic exercise should part of the treatment plan, alongside the use of medications and the management of obesity, hypertension, and sleep apnea;
• Patients should strive to build up to 3.5 hours per week of aerobic exercise;
• Some higher intensity activities should be incorporated to improve cardiorespiratory fitness.

Editor’s Comments

Editor's Comments about Cecelia's A-Fib story

We know from many other studies that exercise is recommended for patients with coronary heart disease and heart failure, but also for overall heart fitness and health.
This small study shows that exercise is good for A-Fib patients as well. Though sometimes it just isn’t possible with symptomatic A-Fib. (e.g., When I had A-Fib years ago, my heart rate would get very high when I’d try to jog. I’d have to stop and walk home.)
Relying on exercise to “cure” A-Fib is probably a false hope. Exercise alone won’t eliminate your A-Fib. But for those who are symptomatic, exercise can improve your A-Fib symptoms and reduce “recurrence” of your A-Fib (i.e., after being symptom-free for a period of time).

Take Away for A-Fib Patients: Aerobic exercise to improve cardiorespiratory fitness should become a regular habit. Even after one is cured of A-Fib (i.e., by catheter ablation, etc.) because exercise helps prevent recurrence of A-Fib.

References
• Exercise maintains normal heart rhythm in patients with atrial fibrillation. European Society of Cardiology. August 23, 2021. https://www.medscape.com/viewarticle/957322

• ESC 2021: ACTIVE-AF finds benefits for exercise programme in AF patients. Cardiac Rhythm News. 23rd August 2021. https://cardiacrhythmnews.com/esc-2021-active-af-finds-benefits-for-exercise-programme-in-af-patients/.

2022 AF Symposium: Challenging Cases: The Patient has the Last Say

My new report from the 2022 AF Symposium is about one of the “Challenging Cases” presentations. This is when some of the world’s leading Electrophysiologists (EPs) describe the most difficult Atrial Fibrillation cases they had to cope with through the year. Frankness prevails.

Normal Ejection Fraction should be 50 to 75 percent to indicate the heart is pumping well.

Dr. Erik Prystowsky of St. Vincent’s Hospital, Indianapolis, IN, described a 65-year-old man with Atrial Fibrillation, shortness of breath, and a critically low Ejection Fraction (10%). And a severely enlarged left atrium (5.4 cm).

The patient was offered a catheter ablation procedure but would not accept even after the most persuasive attempts to convince him—it would likely fix his A-Fib, improve his Ejection Fraction, and reduce the size of his left atrium. To learn how this patient’s health evolved over the next 5-6 years, read my full report: Challenging Cases—The Patient has the Last Say.

Browse our Personal A-Fib Stories of Hope

2022 AF Symposium: Calculating Left Atrium Wall Thickness

Dr. Saman Nazarian

Spotlight Sessions feature products or devices still in development or not yet FDA approved. They give us a glimpse into the future of A-Fib treatments. This year 17 Spotlight products and treatments were presented in 5 minute talks. 

In this very short report from the 2022 AF Symposium, I summarize a 5-minute Spotlight session: “Personalization AF Ablation Based on CT Wall Thickness”.  Dr. Saman Nazarian, U of Penn, talks about use of Computerized Tomography (CT) to assist during a catheter ablation.

The Issue: The left atrium wall thickness varies from 1 mm to over 5 mm in the roof area. If one applies too much RF ablation power to a thin wall, this can produce steam pops, esophagus damage, or phrenic nerve damage. If too little RF energy is applied to thicker left atrium wall areas, this can lead to Pulmonary Veins (PV) reconnection….to continue reading, go to my very short report.

Personal A-Fib stories at A-Fib.com

Go to Personal A-Fib stories of Hope

(Finally) A Head-to-Head Comparison of Anticoagulants for A-Fib: Eliquis vs Xarelto

The most commonly prescribed direct-acting anticoagulants (DOACs) for A-Fib patients are Eliquis (generic name: apixaban) and Xarelto (generic name: rivaroxaban).

Direct-acting anticoagulants (DOACs) were introduced in the early 2010s, but most of the testing has been against warfarin, not against other DOACs. Finally, thanks to the researchers of two retrospective studies, A-Fib patients now have a head-to-head comparison of Eliquis versus Xarelto.

Study 1: Stroke and Bleeding Risks

A recent retrospective study (Fralick, M. et al) looked at 6 years of prescription data for atrial fibrillation patients from the Nationwide Healthcare Claims Database (NPIC). A-Fib patient group sizes were matched (39,351 each). Mean age was 69 years, 40% were women and follow up was 288–291 days.

Significant Findings 

Eliquis patients had significantly lower incidence of major bleeding (12.9 vs 21.9 events-per-1K-person-yrs.)

1. Eliquis patients had significantly lower rates of stroke or systemic embolism (6.6 vs 8.0 events per 1000 person-years) compared to Xarelto.

2. Eliquis patients had a significantly lower incidence of major bleeding, defined as gastrointestinal bleeding or intracranial hemorrhage (12.9 vs 21.9 events per 1000 person-years).

Researchers Conclusion (Fralick, M. et al): In routine care, adults with atrial fibrillation prescribed apixaban had a lower rate of both ischemic stroke or systemic embolism and bleeding compared with those prescribed rivaroxaban.

Study 2: Stroke and Bleeding Risks

A second retrospective study (Ray, W. et al) looked at 581,451 atrial fibrillation patients 65 years or older who were enrolled in Medicare from 2013–2018. A-Fib patient group sizes were Rivaroxaban, 227,572 and Apixaban, 353,879. Follow up was for 4 years, through November 30, 2018. Mean age was 77.0 years; 50.2% were women (291 966).

Significant Findings 

Xarelto had substantially more nonfatal extracranial bleeding (39.7 vs 18.5 events-per-1K-person-yrs.)

1. Xarelto patients had more hemorrhagic events including fatal extracranial bleeding (1.4 vs 1.0 per 1000 person-years)

2. Xarelto had more nonfatal extracranial bleeding (39.7 vs 18.5 per 1000 person-years)

3. Xarelto had more fatal ischemic/hemorrhagic events (4.5 vs 3.3 per 1000 person-years)

4. Xarelto had more “total mortality” (44.2 vs 41.0 per 1000 person-years)

Researchers Conclusions and Relevance (Ray, W. et al):  Among Medicare beneficiaries 65 years or older with atrial fibrillation, treatment with rivaroxaban compared with apixaban was associated with a significantly increased risk of major ischemic or hemorrhagic events.

Eliquis vs Xarelto…and the Winner is…

Eliquis (apixaban)! In routine care, Eliquis was found to be both more effective and safer than Xarelto.

As patients, we should pay particular attention to the fact that Eliquis had significantly lower incidence of major bleeding (gastrointestinal bleeding or intracranial hemorrhage) than Xarelto (12.9 vs 21.9 events). And that Xarelto had increased nonfatal extracranial bleeding (39.7 vs 18.5 events) compared to Eliquis.

These differences in bleeding weren’t just “statistically significant” but were really alarming. Major, red flag warning important. Particularly for older people who are more prone to bleeding problems.

Alert: There is anecdotal evidence that some healthcare insurers are pushing patients to switch from Eliquis to Xarelto, despite the above research.

Be Your Own Best Patient-Advocate

Whether or not to take anticoagulants and which one is one of the most difficult decisions you and your doctor must make.

All the results cited above were “significant” and should be taken into account when choosing an anticoagulant.

If you are taking Xarelto, you should talk with your doctor about switching to Eliquis.

Learn all you can about your health conditions. A well-informed patient is welcomed by your doctors and healthcare caregivers. (If not, consider changing doctors.)
References
• Fralick, M. et al. Effectiveness and Safety of Apixaban Compared With Rivaroxaban for Patients With Atrial Fibrillation in Routine Practice: A Cohort Study. APC Journals, Annals of Internal Medicine. April 7, 2020. https://www.acpjournals.org/doi/10.7326/M19-2522

• Ray, W. et al. Association of Rivaroxaban vs Apixaban With Major Ischemic or Hemorrhagic Events in Patients with Atrial Fibrillation. JAMA. 2021;326(23):2395-2404. https://jamanetwork.com/journals/jama/article-abstract/2787319 doi:10.1001/jama.2021.21222

• Dressler, D. et al. Apixaban Might Be Safer and More Effective Than Rivaroxaban for Atrial Fibrillation. NEJM Journal Watch, Ann Intern Med 2020 Mar 9. https://www.jwatch.org/na51065/2020/03/09/apixaban-might-be-safer-and-more-effective-rivaroxaban

• The FH NPIC (National Private Insurance Claims) database. Includes information found on medical and dental claim forms for billions of services billed through private health insurance. https://www.fairhealth.org/custom-solutions/claims-data 

 

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