Early atrial fibrillation after valve replacement surgery for rheumatic heart diseases Ahangar AG, Hussain Z, Wani M, Lone RA, Singh S, Dar AM, Rasool A

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ORIGINAL ARTICLE

Year : 2013 | Volume : 2 | Issue : 1 | Page : 9-13

Early atrial fibrillation after valve replacement surgery for rheumatic heart diseases

Abdul Gani Ahangar¹, Zahur Hussain¹, Mohd Lateef Wani¹, Reyaz A Lone¹, Shyam Singh¹, Abdul Majeed Dar¹, Ashufta Rasool²
¹ Department of Cardiovascular and Thoracic Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
² Department of Aneasthesia, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India

Date of Web Publication

29-May-2013

Correspondence Address:
Abdul Gani Ahangar
Department of Cardiovascular and Thoracic Surgery, SKIMS, Srinagar, Presently Director, North East Indira Gandhi Regional Institute of Medical Sciences, Shilong, Megalaya
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2278-0521.112624

Abstract

Objective: Atrial arrhythmias can lead to discomfort and hemodynamic instability. The aim of this study was to determine the incidence and timing of development of atrial fibrillation (AF) after valvular replacement surgery for rheumatic heart disease and to know various risk factors for development of these arrhythmias. Materials and Methods: The study conducted over a period of 30 months with effect from August 2006 to February 2009. Patients of rheumatic valvular disease with normal preoperative sinus rhythm undergoing valve replacement under cardio pulmonary bypass were selected for the study. Results: A total of 28 out of 80 patients (35%) developed AF during the postoperative period in the hospital. Most of the episodes (46.42%) occurred between 24-48 h in intensive care unit (ICU). Age, preoperative history of intermittent AF, systemic hypertension, left atrial size (>50 mm), left ventricular ejection fraction <50%, and aortic cross clamp time >50 min were significantly related to the development of AF in the postoperative period (P < 0.05). Conclusion: Atrial arrhythmias are most frequent in the first 2-3 days after the cardiac surgery, but they can occur at any point in the recovery period. Age, preoperative history of intermittent AF, systemic hypertension, left atrial size (>50 mm), left ventricular ejection fraction <50%, and aortic cross clamp time >50 min are the factors that lead to AF in the postoperative period.

Keywords: Atrial fibrillation, cardio pulmonary bypass, rheumatic valvular disease

How to cite this article:
Ahangar AG, Hussain Z, Wani M, Lone RA, Singh S, Dar AM, Rasool A. Early atrial fibrillation after valve replacement surgery for rheumatic heart diseases. Saudi J Health Sci 2013;2:9-13

How to cite this URL:
Ahangar AG, Hussain Z, Wani M, Lone RA, Singh S, Dar AM, Rasool A. Early atrial fibrillation after valve replacement surgery for rheumatic heart diseases. Saudi J Health Sci [serial online] 2013 [cited 2023 Jun 10];2:9-13. Available from: https://www.saudijhealthsci.org/text.asp?2013/2/1/9/112624

Introduction

Atrial tachyarrhythmia's early in the recovery period after cardiothoracic surgery are common. They develop in 11-40% of patients after coronary-artery bypass grafting, ^[1],[2],[3] and in over 50% of patients after valvular surgery. ^[2] Most episodes happen in the first few days after surgery, with peak episodes on days 2-3. Atrial fibrillations (AFs) after surgery increases complications, length of intensive care unit (ICU) stay, length of hospitalization, and medical costs. Technical advances in surgery and anesthesia as well as changing methods of myocardial protection have not decreased the incidence of postoperative atrial tachyarrhythmias. ^[1],[3],[4] Although such arrhythmias have been thought of as transient and benign, they may have important consequences. The principles of treatment for postoperative atrial tachyarrhythmias are similar to those for atrial arrhythmias in other circumstances, except that inflammation and increased sympathetic tone have an important etiological role in postoperative arrhythmias. The control of the ventricular rate, anticoagulation, and conversion to sinus rhythm are the goals of therapy.

Materials and Methods

This prospective study entitled was conducted over a period of 30 months with effect from August 2006 to February 2009. The patients of rheumatic valvular disease with normal preoperative sinus rhythm undergoing valve replacement under cardio pulmonary bypass were selected for the study.

A detailed history and clinical examination was performed with special references to cardiovascular system. Electrocardiography (ECG)- 12 standard lead ECG with rhythm strip was performed in all patients.
Echocardiography-M-mode and 2-D type echocardiography was performed in all the patients to confirm the type of valve lesion, its severity, valve calcification, presence of pulmonary arterial hypertension, and any other pathology.

Immediately after operation, all patients were monitored in the ICU. During this time, all arrhythmias were recorded on rhythm strip and documented in the bedside chart. When transferred to the ward, rhythm monitoring continued either by the same 60 patients or by 20 Holter patients. Postoperatively, results were compiled and analyzed statistically.

Exclusion criteria were irregular rhythm, any conduction disturbance on ECG, history of preoperative intake of antiarrythmic medications, electrolyte imbalance at the time of admission, hyperthyroidism, coronary artery disease, concomittent coronary artery bypass grafting (CABG), and patients undergoing redo surgery.

Statistical methods

All data were analyzed with the Statistical Package for Social Sciences (SPSS) statistical software. Variables tested were timing of AF, effect of preoperative, intraoperative and different postoperative factors on the development of AF. All these variables were tested using SPSS software and fishers exact T-test for getting their significance.

Results

This study involved 80 patients of rheumatic valvular heart disease with normal sinus rhythum who underwent mitral valve replacement (n = 30); aortic valve replacement (n = 26), and double valve replacement (n = 24) under cardiopulmonary bypass using normothermic cardioplegia. Majority of cases, i.e., 26 patients (32.5%) were in the age group of 51-60 years with a mean age of 56 ± 3.11 years and their male: Female ratio was 1.66:1. Maximum number of patients, i.e., 45 (56.25%) were in the NYHA Class III. Most of the patients, i.e., 30 (37.5%) had cardiothoracic ratio of 65-70%. Maximum number of patients, i.e., 37.5% had mitral valve disease followed by aortic and double valve disease. A total of 28 patients (35%) developed AF in the postoperative period. Out of these, a maximum of 13 (16-25%) developed between 24-48 h after the surgical procedure in ICU [Table 1]. Most of the patients had aortic cross clamp time between 30-50 min. Mean cross clamp time was 51 ± 6 min. On preoperative echocardiography, mean left atrial (LA), left ventricular end diastolic dimension (LVEDD), left ventricular end systolic dimension (LVESD), and pulmonary arterial hypertension (PAH) were 45 ± 3.31 mm, 57 ± 4.43 mm, 42.31 ± 8.39 mm, and 38 ± 3.32 mmHg, respectively [Table 2]. Age, history of preoperative intermittent AF, systemic hypertension, ejection fraction <35%, preoperative left atrial size, and duration of aortic cross clamp were significantly related to the development of AF (P < 0.05) [Table 3].

Table 1: Incidence and timing of development of postoperative atrial fibrillation

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Table 2: Preoperative echocardiographic parameters of patients (n=80)

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Table 3: Significant difference in characters between patients with and without a trial fibrillation

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Discussion

AF is the most common arrhythmia observed after cardiac operations with an incidence of 30-60%. ^{[1],[2],[3],[4]} Although postoperative mortality does not seem to be affected by this complications, AF can lead to hemodynamic compromise, bears the risk for thromboembolic events, and frequently necessitates the use of antiarrhythmic drugs. ^[1],[5],[6] Duration of ICU stay and of overall hospitalization may be prolonged by this complication, which contributes substantially to increased costs. ^[1],[2],[3]

Pharmacological interventions have been the mainstay of preventive therapy. Beta blockers have been shown to be the most effective preventive therapy, and it is recommended to continue or initiate beta blocker therapy for all patients in the perioperative period. ^[5] Amiodarone is also an effective drug, but the intravenous preparation is associated with a risk of hypotension, ^[6] and oral therapy has to be initiated several days before the surgery. ^[7] Sotalol, ^[8] magnesium, ^[9] statins, ^[10],[11] N-3 polyunsaturated fatty acids, ^[12] and anti-inflammatory agents ^[13] are the other pharmacologic measures that have been shown to be useful in various trials.

In our study, a total of 80 patients, irrespective of age and sex, of rheumatic valvular heart disease undergoing valve replacement under cardio pulmonary bypass were included in the study. This included 30 patients for mitral valve replacement, 26 for aortic valve replacement, and 24 for both aortic and mitral valve replacement. Age ranged between 19-68 years with a mean of 49 ± 3.11 years. Most of the patients were in NYHA Class III (56.25%). Of the 80, 28 patients (35%) developed AF in the postoperative period in the hospital. Most of the episodes occurred between 24-48 h in the ICU. Seven patients had recurrent episodes. These episodes were self limiting in most of the patients. Age, preoperative history of intermittent AF, systemic hypertension, left atrial size (>50 mm), left ventricular ejection fraction <50%, and aortic cross clamp time >50 min were significantly related to the development of AF in the postoperative period (P < 0.01).

When preoperative factors are considered, advanced age has been the most consistent prediction of postoperative AF. Our results showed that every 10-year increase in age is associated with 75% increase in the odds of developing AF after the fifth decade. The incidence of AF after cardiac surgery varies widely and ranges from 5-50%. ^{[1],[2],[3],[4]} A total of 28 patients (35%) developed AF in the postoperative period in our study. Although less incidence has been reported from Asian population, this relatively high incidence may be related to the intensity and duration of monitoring. Although reports, ^{[14],[15],[16],[17],[18],[19],[20]} indicate that AF occurs most often in the first 4 days after surgery, it can occur at any point in the recovery period. In previous studies, however, patients were followed-up only until their discharge from the hospital. Continuous ECG monitoring was typically used for 96-120 h up to a maximum of 240 h. ^[21] Currently, most patients are discharged from the hospital within 5 days of surgery, and many of these patients may not have continuous cardiac monitoring after the third postoperative day. We found that the first episode of AF occurred any time from the day of surgery to the time of discharge. In our series maximum patients, 13-16 patients (25%) developed AF between 24-48 h in the ICU.

When cardiac monitoring is not used after patients are discharged from the hospital, healthcare providers must rely on the patients' symptoms to identify the occurrence of AF in order to ensure prompt delivery of necessary care and to prevent possible complications associated with the arrhythmia. Although outpatient monitoring with cardiac event recorders is useful in detecting asymptomatic episodes of AF, monitoring all patients after the discharge may not be cost-effective particularly in our third world. Therefore, we examined risk factors for AF at any time after cardiac surgery up to their discharge from the hospital.

Age, preoperative history of intermittent AF, systemic hypertension, left atrial size (>50 mm), left ventricular ejection fraction <50%, and aortic cross clamp time >50 min were significantly related to the development of AF in the postoperative period (P < 0.05) in our series.

Investigators ^{[1],[2],[4],[15],[16],[17],[18],[19],[22]} evaluated the risk factors for postoperative AF, and with the exception of advanced age and preoperative withdrawal of beta blockers, no consistent trend emerged. Increasing age is the most consistent predictor of postoperative AF. ^{[1],[2],[3],[4],[15],[16],[17],[18],[19],[22]} Age-related changes in the atria, such as dilatation, muscle atrophy, and decreased conduction, may explain the strong association. ^[20],[23]

Male sex has inconsistently been associated with postoperative AF. Some researchers ^[15],[17] have found that being male was associated with AF, whereas others ^[2] did not. In our study, being male was not significantly related to AF (P = 0.80).

Although the existence of chronic AF was an exclusion criterion in our study, we included patients who had a history of intermittent AF but were in normal sinus rhythm at the time of surgery. We found that postoperative AF was more likely to develop in these patients than in patients without a history of AF. In some previous investigations, ^{[3],[15],[16]} patients with a history of AF were excluded because they are expected to be at greater risk. Other researchers ^[4],[17] also found that patients with a history of AF were at an increased risk for postoperative AF. Mathew et al. ^[17] found that a history of AF increased the risk for postoperative AF approximately two-fold. In our study, 14 patients out of 24 (58.3%) with a history of intermittent AF developed postoperative AF, while only 14 out of 56 (25%) without a history of intermittent AF developed AF. Thus, the history of intermittent AF is significantly related to the development of postoperative AF (P = 0.004).

Conclusion

Increased age, preoperative history of intermittent AF, systemic hypertension, left atrial size (>50 mm), left ventricular ejection fraction <50%, and aortic cross clamp time >50 min are significantly related to the development of AF in the postoperative period.

References

1.	Leitch JW, Thomson D, Baird DK, Harris PJ. The importance of age as a predictor of atrial fibrillation and flutter after coronary artery bypass grafting. J Thorac Cardiovasc Surg 1990;100:338-42.
2.	Banach M, Rysz J, Drozdz JA, Okonski P, Misztal M, Barylski M, et al. Risk factors of atrial fibrillation following coronary artery bypass grafting: A preliminary report. Circ J 2006;70:438-41.
3.	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;20:425-31.
4.	Mathew JP, Fontes ML, Tudor IC, Ramsay J, Duke P, Mazer CD, et al. A multicenter risk index for atrial fibrillation after cardiac surgery. JAMA 2004;291:1720-9.
5.	Crystal E, Garfinkle MS, Connolly SS, Ginger TT, Sleik K, Yusuf SS. Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery. Cochrane Database Syst Rev 2004;CD003611.
6.	Patel AA, White CM, Gillespie EL, Kluger J, Coleman CI. Safety of amiodarone in the prevention of postoperative atrial fibrillation: A meta-analysis. Am J Health Syst Pharm 2006;63:829-37.
7.	Mitchell LB, Exner DV, Wyse DG, Connolly CJ, Prystai GD, Bayes AJ, et al. Prophylactic oral amiodarone for the prevention of arrhythmias that begin early after revascularization, valve replacement, or repair: PAPABEAR: A randomized controlled trial. JAMA 2005;294:3093-100.
8.	Burgess DC, Kilborn MJ, Keech AC. Interventions for prevention of post-operative atrial fibrillation and its complications after cardiac surgery: A meta-analysis. Eur Heart J 2006;27:2846-57.
9.	Miller S, Crystal, Garfinkle M, Lau C, Lashevsky I, Connolly SJ. Effects of magnesium on atrial fibrillation after cardiac surgery: A meta-analysis. Heart 2005;91:618-23.
10.	Patti G, Chello M, Candura D, Pasceri V, D'Ambrosi A, Covino E, et al. Randomized trial of atorvastatin for reduction of postoperative atrial fibrillation in patients undergoing cardiac surgery: Results of the ARMYDA-3 (Atorvastatin for Reduction of Myocardial Dysrhythmia after Cardiac Surgery) study. Circulation 2006;114:1455-61.
11.	Dong L, Zhang F, Shu X. Usefulness of statins pretreatment for the prevention of postoperative atrial fibrillation in patients undergoing cardiac surgery. Ann Med 2011;43:69-74.
12.	Calo L, Bianconi L, Colivicchi F, Lamberti F, Loricchio ML, de Ruvo E, et al. N-3 Fatty acids for the prevention of atrial fibrillation after coronary artery bypass surgery: A randomized, controlled trial. J Am Coll Cardiol 2005;45:1723-8.
13.	Halonen J, Halonen P, Jarvinen O, Taskinen P, Auvinen T, Tarkka M, et al. Corticosteroids for the prevention of atrial fibrillation after cardiac surgery: A randomized controlled trial. JAMA 2007;297:1562-7.
14.	Amar D, Roistacher N, Burt M, Reinsel RA, Ginsberg RJ, Wilson RS. Clinical and echocardiographic correlates of symptomatic tachydysrhythmias after noncardiac thoracic surgery. Chest 1995;108:349-54.
15.	Kitzman DW, Edwards WD. Age-related changes in the anatomy of the normal human heart. J Gerontol 1990;45:M33-9.
16.	Steinberg JS, Zelenkofske S, Wong SC, Gelernt M, Sciacca R, Menchavez E. Value of the P-wave signal-averaged ECG for predicting atrial fibrillation after cardiac surgery. Circulation 1993;88:2618-22.
17.	Klein M, Evans SJL, Blumberg S, Cataldo L, Bodenheimer MM. Use of P-wave-triggered, P-wave signal-averaged electrocardiogram to predict atrial fibrillation after coronary artery bypass surgery. Am Heart J 1995;129:895-901.
18.	Smith PK, Buhrman WC, Levett JM, Ferguson TB Jr, Holman WL, Cox JL. Supraventricular conduction abnormalities following cardiac operations: A complication of inadequate atrial preservation. J Thorac Cardiovasc Surg 1983;85:105-15.
19.	Mullen JC, Khan N, Weisel RD, Christakis GT, Teoh KH, Madonik M, et al. Atrial activity during cardioplegia and postoperative arrhythmias. J Thorac Cardiovasc Surg 1987;94:558-65.
20.	Nazeri A, Razavi M, Elayda MA, Lee VV, Massumi A, Wilson JM. Race/ethnicity and the incidence of new-onset atrial fibrillation after isolated coronary artery bypass surgery. Heart Rhythm 2010;7:1458-63.
21.	Anselmi A, Possati G, Gaudino M. Postoperative inflammatory reaction and atrial fibrillation: Simple correlation or causation? Ann Thorac Surg 2009;88:326-33.
22.	Hak £, My?liwska J, Wickiewicz J, Szyndler K, Siebert J, Rogowski J. Interleukin-2 as a predictor of early postoperative atrial fibrillation after cardiopulmonary bypass graft (CABG). J Interferon Cytokine Res 2009;29:327-32.
23.	Merrick AF, Odom NJ, Keenan DJ, Grotte GJ. Comparison of propafenone to atenolol for the prophylaxis of postcardiotomy supraventricular tachyarrhythmias: A prospective trial. Eur J Cardiothorac Surg 1995;9:146-9.