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Reduced postoperative atrial fibrillation using multidrug prophylaxis
R A Ott1, D E Gutfinger, H Alimadadian
1Anaheim Memorial Medical Center, California, USA.
Insights
A multidrug prophylaxis significantly reduced new-onset atrial fibrillation (AFIB) after coronary artery bypass grafting (CABG) to 10.3%. This approach offers a promising strategy for preventing this common complication in cardiac surgery patients.
Area of Science:
- Cardiovascular Surgery
- Cardiac Anesthesia
- Clinical Pharmacology
Background:
- Atrial fibrillation (AFIB) is the most frequent complication after coronary artery bypass grafting (CABG), with reported incidences of 15%-30%.
- Previous efforts to decrease postoperative AFIB have been largely unsuccessful, suggesting multifactorial causes.
- A novel multidrug prophylactic regimen was developed based on agents with known individual efficacy.
Purpose of the Study:
- To prospectively evaluate a multidrug prophylaxis protocol in reducing the incidence of new-onset postoperative AFIB.
- To identify clinical features associated with an increased risk of developing AFIB post-CABG.
Main Methods:
- A cohort of 517 consecutive patients undergoing isolated CABG with cardiopulmonary bypass received a rapid recovery protocol.
- The protocol included intraoperative triiodothyronine, immediate postoperative parenteral magnesium, and parenteral thyroxine on postoperative days 1 and 2.
- Post-extubation, metoprolol was initiated, and parenteral procainamide was administered for arrhythmias. Additional treatments included digitalization, steroids, and diuresis.
Main Results:
- The overall incidence of new-onset postoperative AFIB was 10.3%, a reduction from historical rates.
- Patients with preoperative acute myocardial infarction, severe left main stenosis, or advanced age (≥70 years) were at higher risk.
- AFIB patients experienced a significantly longer hospital stay (9.9 days) compared to non-AFIB patients (5.9 days).
Conclusions:
- A multidrug prophylactic regimen effectively reduced the incidence of postoperative AFIB following CABG.
- Identifying high-risk patients (e.g., those with specific preoperative conditions or advanced age) is crucial for targeted interventions.
- Early recognition and treatment of atrial rhythm instability may further improve outcomes.
Background:
Atrial fibrillation (AFIB) is the most common complication following coronary artery bypass grafting (CABG). Despite three decades of recognition, efforts to reduce the high incidence reported (15%-30%) have been largely unsuccessful. Reasons for postoperative AFIB are likely multifactorial. As a result, we defined a multidrug prophylaxis based on agents known to be individually effective. This method was applied prospectively to a series of consecutive CABG patients with the goal of reducing the incidence of new-onset postoperative AFIB.
Methods:
Isolated CABG with cardiopulmonary bypass was performed on 517 consecutive patients. A rapid recovery protocol emphasizing AFIB multidrug prophylaxis was applied to all patients. All patients received 10 microg of triiodothyronine intraoperatively when the clamp on the aorta was released. Immediately following CABG, parenteral magnesium was administered to assure a serum magnesium > 2.2 mEq/dL. Thyroxine 200 microg was administered parenterally to all patients on postoperative days 1 and 2. Metoprolol (25 mg to 100 mg/day) was begun on all patients after extubation provided: heart rate > 85 beats/min and systolic blood pressure > 130 mmHg. Parenteral procainamide (12 mg/kg) loading dose, followed by a maintenance dose (2 mg/min), was used for patients who developed premature atrial contractions (> 1/min), nonsustained supraventricular tachycardia, or any episodes of atrial fibrillation. All patients also received postoperative digitalization, steroids, and aggressive diuresis.
Results:
The 30-day operative mortality was 3.7%. The overall incidence of new-onset postoperative AFIB was 10.3% (53 patients). There was no major difference in operative mortality (7.5% vs 3.2%, p = 0.23), Parsonnet risk score, or intraoperative variables between AFIB patients and the non-AFIB patients. Patients presenting with a preoperative acute myocardial infarction (p < 0.05), left main stenosis > or = 70% (p < 0.01), and advanced age > or = 70 years (p < 0.05) were at increased risk of developing AFIB. The length of stay for patients with AFIB was 9.9 +/- 9.6 days versus 5.9 +/- 5.2 days (p < 0.001).
Conclusion:
Application of a multidrug prophylaxis can reduce postoperative AFIB to a low incidence. Identification of associated clinical features can help predict patients at risk for postoperative AFIB. Additional strategies to target postoperative AFIB may include treatment at the earliest recognition of atrial rhythm instability.