Table Of ContentATRIAL FIBRILLATION AFTER CARDIAC SURGERY
Developments in Cardiovascular Medicine
198. Antoine Lafont, Eric Topoi (eds.): ArterialRemodeling: A CriticalFactor in
Restenosis. 1997 ISBN 0-7923-8008-8
199. Michele Mercuri, David D. McPherson, Hisham Bassiouny, SeymGoluarg ov
evisavnl-noN:).sde( lmaging of Atherosclerosis ISBN 0-7923-8036-3
200. Walmor C. DeMello, Michiel J. Janse(eds.): Health in Communication Heart Cell
and Disease ISBN 0-7923-8052-5
201. P.E. Vardas (ed.): Pacing Arrhythmias Cardiac and .ygoloisyhportcelE The
Expert View. 1998 ISBN 0-7923-4908-3
202. E.E. van der Wall, P.K. Blanksma, M.G. Niemeyer, W. Vaalburg and H.J.G.M.
Crijns (eds.) MRI, PET, SPECT, Artery Disease, lmaging Advanced Coronary in
IVUS, EBCT. 1998 ISBN 0-7923-5083-9
203. R.L. Wilensky (ed.) Artery Syndromes, Coronary Unstable ,ygoloisyhpohtaP
Diagnosis and Treatment. .8991 ISBN 0-7923-8201-3
204. J.H.C. Reiber, E.E. van derW all (eds.): What's New Imaging? Cardiovascular in
1998 ISBN 0-7923-5121-5
205. Juan Carlos Kaski, David W. Holt (eds.): Detection Early Damage Myocardial by
Novel Markers. 1998. Biochemical ISBN 0-7923-5140-1
207. Gary F. Baxter, Derek M. Yellon, Preconditioning Delayed and Adaptive
.noitcetorpoidraC 1998. ISBN 0-7923-5259-9
208. Bernard Swynghedauw, Cardiology Molecular for the ,tsigoloidraC Editiot Second
.8991 ISBN 0-7923-8323-0
209. Geoffrey Bumstock, James G.Dobson, Jr., BrucTe. Liang, Joel Linden (eds):
ralucsavoidraC Biology of Purines. 1998. ISBN: 0-7923-8334-6
210. Brian D. Hoit, Richard A. Walsh (eds): the in Physiology Cardiovascular
Engineered Genetically Mouse. 1998. ISBN: 0-7923-8356-7
211. Peter Whittaker, George S. Abela (eds.): Myocardial Direct :noitaziralucsaveR
,yrotsiH Methodology, Technology 1998. ISBN: 0-7923-8398-2
212. C.A. Nienaber, R. Fattori (eds.): Diagnosis and Treatment of Aortic Diseases.
.9991 ISBN: 0-7923-5517-2
213. Juan Carlos Kaski (ed.): Normal with Coronary Pain Chest :smargoignA
Diagnosis Pathogenesis, and Management. 1999. ISBN: 0-7923-8421-0
214. P.A. Doevendans, R.S. Renemaannd M. Van Bilsen (eds): Cardiovascular cificepS
Expression. Gene 1999 ISBN:0-7923-5633-0
215. G. Pons-Llad6, F. Carreras, X. Borrks, Subirana and L.J. Jim6nez-Borreguero (eds.):
Atlas of Applications Cardiac Practical of .1RM 1999 ISBN: 0-7923-5636-5
216. L.W. Klein, J.E. Calvin, Resource noitazilitU Disease. Cardiac in 1999.
ISBN:0-7923-8509-8
217. R. Gorlin, G. Dangas, P. K. Toutouzas, M.M Konstadoulakis, Contemporary
in Concepts ,ygoloidraC Pathophysiology and Management. Clinical 1999
ISBN:0-7923-8514-4
218. S. Gupta, J. Camm (eds.): Chlamydia Infection, Chronic and Heart Coronary
Disease. 1999. ISBN:0-7923-5797-3
219. M. Rajskina: Death. Sudden Coronary in Fibrillation Ventricular 1999.
ISBN:0-7923-8570-5
220. Z. Abedin, R. Conner: Interpretation of Arrhythmias: Cardiac Self Assessment
Approach. 1999. ISBN:0-7923-8576-4
221. J. E. Lock, J.F. Keane, S. B. Perry: andlnterventional Diagnostic Catheterization
In Disease. Heart Congenital 2000. ISBN: 0-7923-8597-7
Previous volumes are still available
KLUWER ACADEMIC PUBLISHERS - DORDRECHT/BOSTON/LONDON
ATRIAL FIBRILLATION AFTER CARDIAC SURGERY
edited by
Jonathan S. Steinberg, MD
.tS Luke's-Roosevelt Hospital Center
and
Columbia University College of Physicians and Surgeons
t,4
Kluwer Academic Publishers
Boston/Dordrecht/London
Distributors for North, Central and South America:
Kluwer Academic Publishers
101 Philip Drive
Assinippi Park
Norwell, Massachusetts 02061 USA
Distributors for all other countries:
Kluwer Academic Publishers Group
Distribution Centre
Post Office Box 322
3300 AH Dordrecht, THE NETHERLANDS
Library of Congress Cataloging-in-Publication Data
Atrial fibrillation after cardiac surgery/edited by Jonathan S. Steinberg.
P. ; cm -- (Developments in cardiovascular medicine ; 222)
Includes index.
ISBN 0-7923-8655-8 (alk. Paper)
.1 Atrial fibrillation. 2. Heart--Surgery--Complications. I. Steinberg, Jonathan S.
II. Developments in cardiovascular medicine; v. 222
[DNLM: .1 Atrial Fibrillation--complications. 2. Cardiac Surgical Procedures.
WG 330 A88165 1999]
RC685.A72 A8875 1999
617.4'1201--dc21 99-047095
Copyright © 2000 by Kluwer Academic Publishers
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system or transmitted in any form or by any means, mechanical, photo-
copying, recording, or otherwise, without the prior written permission of the
publisher, Kluwer Academic Publishers, 101 Philip Drive, Assinippi Park, Norwell,
Massachusetts 02061
Printed on acid-free paper.
Printed in the United States of America
Dedication
To my wife, Alice,
and my children, Rachel and Josh,
for their support and encouragement
Acknowledgement
The editor and authors would like to express their gratitude to
Janice Q. Pelegano
for her excellence in the process of editing and manuscript
preparation.
TABLE OF CONTENTS
Preface ...................................................................................... ix
Acknowledgement ........................................................................... v
Index .......................................................................................... xv
.1 Experimental Animal Models of Atrial Arrhythmias and their
Relevance to Postoperative Atrial Arrhythmias that Occur in
Humans Undergoing Cardiac Surgery
Gregory K. Feld .................................................................... 1
.2 Understanding the Pathophysiology of Atrial Fibrillation From
Clinical Observations
Scott E. Mattson and Leonard I. Ganz ........................................ 19
3. Incidence, Timing and Outcome of Atrial Tachyarrhythmias
After Cardiac Surgery
L. Brent Mitchell ................................................................ 37
4. Risk Factors for the Development of Postoperative Atrial
Fibrillation
Frederick A. Ehlert, Dhiraj D. Narula and Jonathan S.
Steinberg ......................................................................... 51
.5 The Impact of Atrial Fibrillation on Hospital Length
Of Stay After Cardiac Surgery
Jacqueline E. Tamis and Jonathan S. Steinberg ............................ 81
6. Prophylactic Value of Beta Blockers
Javier E. Sanchez and Andrew E. Epstein ................................. 95
7. Antiarrhythmic Therapy to Prevent Atrial Fibrillation
after Cardiac Surgery
Bradley P. Knight and Fred Morady ....................................... 109
. Nonpharmacologic Treatment of Postoperative Atrial
Fibrillation
Richard J. Lewis and Jonathan S. Steinberg .............................. 119
. Therapeutic Options for Established or Recurrent Atrial
Fibrillation: Focus on Antithrombotic Therapy
J. H. McAnulty and Jack Kron .............................................. 133
10. Atrial Fibrillation after Noncardiac Surgery
Dhiraj D.Narula and Jonathan S. Steinberg .............................. 141
Preface
Atrial fibrillation (AF) is the most common arrhythmic
complication after cardiac surgery, and as in other settings, represents
a serious therapeutic challenge. Its importance lies not only in the
clinical complications that may ensue, or the patient discomfort
frequently present, but also in its substantial impact on utilization of
health care resources. This in large part arises from the product of the
prevalence of AF and the additional length of stay necessary for its
control and treatment; in today's environment, these issues have
assumed near-paramount importance.
It is timely to review the specific subset of AF in the setting of
cardiac surgery, and it remains useful to segegate this particular form
of bY from AF in other clinical milieu. When AF occurs after cardiac
surgery, there is an unusually narrow time window of risk; this unique
situation lends itself to clinical intervention (risk stratification,
prophylactic therapy and intensive surveillance) and clinical trial
(large at-risk populations, high incidence, no loss of follow-up and
well defined endpoint). However, AF after cardiac surgery has
remained a persistent and stubborn problem that continues to attract
the attention of individual practitioners and clinical investigators.
In this book, our authors will begin by describing the
electrophysiologic abnormalities that are used to create AF (and other
atrial arrhythmias) in the experimental animal model; these efforts
have intriguing similarity to some of the changes that the atria
undergo in routine cardiac surgery. The text will go on to describe
several clinical observations that suggest the development of AF in
the cardiac surgical patient has some similarities to AF in other
clinical settings, but that there are also some unique features that
indicate AF is at least partially mediated by special postoperative
circumstances. When a patient leaves the operating room, the reader
will learn of the fairly well circumscribed period of risk and a varied
pattern of frequency, duration and consequences of AF. Next, one
wilt read of the many studies that have examined which of the many
cardiac surgical patients is at greatest risk based on clinical
characteristics and also some new noninvasive tools. Of course, AF is
not benign in its effect on hospital resources; it may eat up length of
stay when the burden on physicians and staff is to move the patients
out of the ICU, telemetry unit and hospital at faster and faster rates.
This important subject will be discussed in detail.
How does one lessen the impact of AF? Two broad strategies
will be discussed in detail. Several chapters deal with the results of
different drug prophylactic schemes and with recent studies that have
used atrial pacing to prevent AF. However, frequently one has to
manage AF that has broken through despite attempts to prevent it and
the options of cardioversion and anticoagulation will be addressed in
detail.
Finally, AF also occurs after noncardiac surgery.
Observations gathered in this group of patients may have particular
relevance to the emerging use of minimally invasive cardiac surgery.
Cardiac surgery is performed on >500,000 patients each year
in the U.S. alone. Because of its incidence, tenacity in the face of
therapy, and consumption of precious health care resources, the focus
on AF after cardiac surgery will persist among cardiologists, cardiac
surgeons, anesthesiologists, nurses, hospital administrators and
insurers. My colleagues and I have attempted to bring our readership
a single source of information on this important problem. We hope to
help health care professionals treat their patients optimally and to
encourage researchers to continue their productive efforts.
