Atrial Fibrillation Following Surgical Management of Ischemic Heart Disease; One Year, Single Center, Single Surgeon Results

Öz

Introduction: Postoperative atrial fibrillation is the most common arrhythmia following bypass surgery with significant morbidity, mortality and increased healthcare costs. The aim of this study is to determine the incidence and timing of atrial fibrillation, identify the risk factors covering preoperative and intraoperative periods, evaluate rate of return to sinus rhythm by disharge, and explore the impact on postoperative outcomes in a large group of patients operated in a single center by a single surgeon. Patients and Methods: Between January 2011 and January 2012, 418 patients on preoperative sinus rhythm were operated for ischemic heart disease and associated complications (left ventricle aneurysm repair and ischemic mitral insufficiency) in a single center, by a single surgeon. The preoperative, intraoperative and postoperative variables were studied. Results: The mean age of the patients were 61.92 ± 10.05, and 77.5% were male. Atrial fibrillation developed in 68 (16.3%) patients. The incidence peaked at second day. Patients with atrial fibrillation were older (p< 0.001). Gender, preoperative comorbidities, ejection fraction, left atrial diameter, preoperative beta-blocker use, leukocyte count, type of operation and intraoperative variables did not affect its occurence. Intensive care unit and hospital length of stay were longer (p< 0.05). 95.5% (n= 65) of patients were in normal sinus rhythm at discharge. Conclusion: Postoperative atrial fibrillation is a popular subject with unknowns and controversial results which may lead to wrong interpretations. We believe that every center has its own risk factors related with the population of that region. Discussion will last, but simple precautions and close monitoring will help to minimize adverse outcomes.

Anahtar Kelimeler

• Atrial fibrillation; coronary artery disease; risk factors

İskemik Kalp Hastalığı Cerrahi Tedavisi Sonrası Gelişen Atriyal Fibrilasyon; Bir Yıllık, Tek Merkez, Tek Cerrah Sonuçlarımız

Öz

Giriş: Postoperatif atriyal fibrilasyon, koroner baypas sonrası en sık görülen; ciddi morbidite, mortalite ve artmış sağlık harcamalarına neden olan bir ritim bozukluğudur. Bu çalışmanın amacı; tek merkez, tek cerrah tarafından yapılan geniş bir hasta grubunda atriyal fibrilasyon insidansının ve zamanlamasının belirlenmesi, preoperatif ve intraoperatif risk faktörlerinin belirlenmesi, taburculukta sinüs ritmine dönüşün saptanması ve postoperatif sonuçlara etkisinin değerlendirilmesidir. Hastalar ve Yöntem: Ocak 2011-Ocak 2012 tarihleri arasında, preoperatif sinüs ritminde olan 418 hasta iskemik kalp hastalığı ve komplikasyonları için (sol ventrikül anevrizma tamiri, iskemik mitral yetmezliği) tek merkezde, tek cerrah tarafından opere edilmiştir. Preoperatif, intraoperatif ve postoperatif değişkenler çalışılmıştır. Bulgular: Hastaların ortalama yaşı 61.92 ± 10.05 yıldı ve %77.5'i erkekti. Altmış sekiz (%16.3) hastada atriyal fibrilasyon gelişti, ikinci günde pik yaptı. Atriyal fibrilasyon gelişen hastalar daha yaşlı idi (p< 0.001). Cinsiyet, preoperatif komorbiditeler, ejeksiyon fraksiyonu, sol atriyum çapı, preoperatif beta-bloker kullanımı, beyaz küre sayısı, operasyon tipi ve intraoperatif değişkenler atriyal fibrilasyon oluşumunu etkilemedi. Atriyal fibrilasyon gelişen hastalarda yoğun bakım ve hastanede kalış süreleri daha uzundu (p< 0.05). Taburculukta hastaların %95.5 (n= 65)'i sinüs ritminde idi. Sonuç: Postoperatif atriyal fibrilasyon çok bilinmeyenli, çelişkili sonuçlara sahip ve halen popülerliğini koruyan bir konudur, bu sebeple yanlış yorumlara açıktır. Biz her ülkenin ve her merkezin kendine has risk faktörleri olduğunu düşünüyoruz. Bu konu ile ilgili tartışmalar hiç sona ermeyecektir, ancak basit önlemler ve yakın takiple olumsuz sonuçlardan kaçınılabilir

Anahtar Kelimeler

• Atriyal fibrilasyon
• koroner arter hastalığı
• risk faktörleri

Kaynakça

1. Echadidi N, Pibarot P, O’Hara G, Mathieu P. Mechanisms, preven- tion, and treatment of atrial fibrillation after cardiac surgery. J Am Coll Cardiol 2008;51:793-801.
2. Villareal RP, Hariharan R, Liu BC, Kar B, Lee VV, Elayda M, et al. Postoperative atrial fibrillation and mortality after coronary artery bypass surgery. J Am Coll Cardiol 2004;43:742-8.
3. Uzun K, Erdoğan T. Yeni bir merkezde yapılan ilk 500 kalp ame- liyatının erken dönem sonuçlarının değerlendirilmesi. Kosuyolu Kalp Derg 2011;14:79-85.
4. Mathew JP, Fontes ML, Tudor IC, Ramsay J, Duke P, Mazer CD, et al. A multicenter risk index for atrial fibrillation after cardiac sur- gery. JAMA 2004;291:1720-9.
5. Banach M, Rysz J, Drozdz J, Okonski P, Misztal M, Barilyski M, et al. Risk factors for atrial fibrillation following coronary artery bypass grafting: a preliminary report. Circ J 2006;70:438-41.
6. Diker E. Atriyal fibrilasyonun epidemiyolojik verileri, eşlik eden kar- diyovasküler risk faktörleri, tedavi stratejilerinin değerlendirilmesi ve güncel atriyal fibrilasyon kayıt çalışması: Realise AF. Turk Kar- diyol Dern Arş 2011;39:166-75.
7. Hogue CW Jr, Hyder ML. Atrial fibrillation after cardiac operations: risks, mechanisms and treatment. Ann Thorac Surg 2000;69:300-6.
8. Nisanoglu V, Erdil N, Aldemir M, Ozgur B, Berat Cihan H, Yologlu S, et al. Atrial fibrillation after coronary artery bypass grafting in elderly patients: incidence and risk factor analysis. Thorac Cardio- vasc Surg 2007;55:32-8.

9. Koutlas TC, Elbeery JR, Williams JM. Myocardial revascularizati- on in the elderly using beating heart coronary artery bypass sur- gery. Ann Thorac Surg 2000;69:1042-7.
10. Crystal E, Connolly SJ, Sleik K, Ginger TJ, Yusuf S. Interventions on prevention of postoperative atrial fibrillation in patients under- going heart surgery: a meta-analysis. Circulation 2002;106:75-80.
11. Koniari I, Apostolakis E, Rogkakou C, Baikoussis NG, Dougenis D. Pharmacologic prophylaxis for atrial fibrillation following cardiac surgery: a systematic review. J Cardiothorac Surg 2010;5:121.
12. Workman AJ, Smith GL, Rankin SAC. Mechanisms of terminati- on and prevention of atrial fibrillation by drug therapy. Pharmacol Ther 2011;131:221-41.
13. Mitchell LB, Exner DV, Wyse DG, Connolly DJ, Prystai GD, Ba- yes AJ, et al. Prophylactic oral amiodarone for the prevention of arrhytmias that begin early after revascularization, valve replace- ment or repair: PAPABEAR: a randomized controlled trial. JAMA 2005;294:3093-100.
14. Bagshaw SM, Galbraith PD, Mitchell LB, Sauve R, Exner DV, Ghali WA. Prophylactic amiodarone for prevention of atrial fib- rillation after cardiac surgery: a meta-analysis. Ann Thorac Surg 2006;82:1927-37.
15. Çiçekoğlu F, Kervan Ü, Parlar Aİ, Ersoy Ö, Bardakçı H, Ulus AT ve ark. Koroner bypass cerrahisinden sonra gelişen atriyal fibrilasyon tedavisinde amiodaronun etkinliği. Turk Gogus Kalp Dama Cer 2009;17:77-82.
16. Anselmi A, Possati G, Gaudino M. Postoperative inflammatory re- action and atrial fibrillation: simple correlation or causation? Ann Thorac Surg 2009;88:326-33.
17. Rostagno C, La Meir M, Gelsomino S, Ghilli L, Rossi A, Carone E, et al. Atrial fibrillation after cardiac surgery: Incidence, risk factors, and economic burden. J Cardiothorac Vasc Anesth 2010;24:952-8.
18. Fontes ML, Amar D, Kulak A, Koval K, Zhang H, Shi W, et al. Inc- reased preoperative white blood cell count predicts postoperative atrial fibrillation after coronary artery bypass surgery. J Cardiotho- rac Vasc Anesth 2009;23:484-7.
19. Sood N, Coleman CI, Kluger J, White CM, Padala A, Baker WL. The association among blood transfusions, white blood cell count, and the frequency of post-cardiothoracic surgery atrial fibrillation: a nested cohort study from the atrial fibrillation suppression trials I, II, and III. J Cardiothorac Vasc Anesth 2009;23:22-7.
20. Rienstra M, Sun JX, Magnani JW, Sinner MF, Lubitz SA, Sullivan LM, et al. White blood cell count and risk of incident atrial fibrillation (From the Framingham Heart Study). Am J Cardiol 2012;109:533-7.
21. Hravnak M, Hoffman LA, Saul MI, Zullo TG, Whitman GR, Griffith BP. Predictors and impact of atrial fibrillation after isolated coro- nary artery bypass grafting. Crit Care Med 2002;30:330-7.
22. Koch CG, Li L, Van Wagoner DR, Duncan AI, Gillinov M, Blacksto- ne EH. Red cell transfusion is associated with an increased risk for postoperative atrial fibrillation. Ann Thorac Surg 2006;82:1747-57.
23. Shirzad M, Karimi A, Tazik M, Aramin H, Ahmadi SH, Davoodi S, et al. Determinants of postoperative atrial fibrillation and as- sociated resource utilization in cardiac surgery. Rev Esp Cardiol 2010;63:1054-60.
24. Ozaydin M, Peker O, Erdogan D, Kapan S, Turker Y, Varol E, et al. N-actylcysteine for the prevention of postoperative atrial fibrillati- on: a prospective randomized, placebo-controlled pilot study. Eur Heart J 2008;29:625-31.
25. Durukan AB, Erdem B, Durukan E, Sevim H, Karaduman T, Gur- buz HA, et al. May toxicity of amiodarone be prevented by an- tioxidants? A cell-culture study. J Cardiothorac Surg 2012;7:61 doi:10.1186/1749-8090-7-61.