the impact of atrial fibrillation in cardiac surgery
DESCRIPTION
THE IMPACT OF ATRIAL FIBRILLATION IN CARDIAC SURGERY. Wim J De Vries . DEPARTMENT CARDIOTHORACIC SURGERY UNIVERSITY OF THE FREE STATE UNIVERSITAS HOSPITAL. THE IMPACT OF ATRIAL FIBRILLATION IN CARDIAC SURGERY. ? Malignant Rhythm. - PowerPoint PPT PresentationTRANSCRIPT
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THE IMPACT OF ATRIAL FIBRILLATION THE IMPACT OF ATRIAL FIBRILLATION IN CARDIAC SURGERY IN CARDIAC SURGERY
Wim J De Vries.DEPARTMENT CARDIOTHORACIC SURGERYUNIVERSITY OF THE FREE STATEUNIVERSITAS HOSPITAL
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? Benign Rhythm ? Malignant Rhythm
THE IMPACT OF ATRIAL FIBRILLATION THE IMPACT OF ATRIAL FIBRILLATION IN CARDIAC SURGERY IN CARDIAC SURGERY
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New-onset. postoperative atrial fibrillation occurs in 30% of patients undergoing CABG , with the peak incidence on the second to third postoperative day It is associated with a 2- to 3-fold increase in
postoperative risk for stroke. Patients at risk for postoperative atrial fibrillation have been identified and include those with COPD, proximal right CAD, prolonged cross-clamp time, atrial ischemia, advanced age, and withdrawal of beta-blockers. Identifying at-risk patients and directing treatment to these patients appears to be effective in reducing the incidence of nost-C ABG atrial fibrillation. And thus the morbid complication of postoperative strokes associated with this arrhythmia.Minimally invasive and .Qff pump beating-heart procedures may also reduce the incidence of postoperative atrial fibrillation
Eagle and Guyton et al. 2004
ACC/AHA Practice Guidelines
INTRODUCTIONINTRODUCTION
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AIM AND METHODSAIM AND METHODS
AIM
-Incidence of post operative Atrial fibrillation
-Identify patients at risk for Atrial fibrillation
-Morbidity and mortality of Atrial fibrillation
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Methods
5 Year period, records of patients were prospectively entered in a Departemental database .
AIM
-Incidence of post operative Atrial fibrillation
-Identify patients a risk for Atrial fibrillation
-Morbidity and mortality of Atrial fibrillation
AIM AND METHODS..AIM AND METHODS..
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Total 1022 patients - OPCAB(301) - CABG(721)
STUDY POPULATIONSTUDY POPULATION
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Total 1022 patients – OPCAB(29,4%) –CABG(70%)
Males (72%)
STUDY POPULATIONSTUDY POPULATION
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Total 1022 patients - OPCAB(301) - CABG(721)
Males 798 – 72%
Age (33-84) Mean 60,5 years
STUDY POPULATIONSTUDY POPULATION
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Incidence of Incidence of Atial FibrillationAtial Fibrillation
N = 1022N = 1022.
Total 151 14,7 %
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RESULTSRESULTS
Male
Sex Female
Age > 65 Smoking
Obesity
Hypertension COPD
Diabetes
Rhythm Risk NRhythm Risk N %% RRRR OROR
10645
106451286
185180
300128
44135
70,2%29,8%
54,9%26,5%56,9%44,2%
11,9%5,8%
52,9%34,0%13,9%5,2%29%15%
2,3
2,07
1,2
1,25
1,5
2,6
1,9
5,5
3,3
1,6
1,20
2,1
2,8
2,9
P
<0,0001
<0,0001
0,004
0,01
<0,001
0,005
0,0001
151151
151871151871
151871151871151871151871
A-Fib
A-FibSinusA-FibSinus
A-FibSinusA-FibSinusA-FibSinusA-FibSinus
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RESULTS..RESULTS..
Renal imp Perif Vasc Pulm Hypert
Previous MI
Angina Unstable
Stable
Rhythm Risk NRhythm Risk N %% RRRR OROR
1131
10214
13
70372134605
91433
43172
7,2%3,5%
6,6%2,4%2,6%1,4%
46,3%42,7%
88%69,4%60,2%49,7%28,4%19,7%
2,07
2,3
1,7
1,08
1,2
1,2
1,4
2,1
5,5
1,8
1,08
3,4
1,5
1,6
P
0,04
0,01
NS
NS
<0,0001
0,01
0,01
151871
151871151871
151871151871151871151871
A-FibSinus
A-FibSinusA-FibSinus
A-FibSinusA-FibSinusA-FibSinusA-FibSinus
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RESULTS..RESULTS..
Renal impairm Perif Vascular Pulm Hypert Previous MI
Angina Unstable
Stable
Risk factor A- Fib Sinus Risk factor A- Fib Sinus RRRR OROR
2,07
2,3
1,7
1,08
1,2
1,2
1,4
2,1
5,5
1,8
1,08
3,4
1,5
1,6
P
0,04
0,01
NS
NS
<0,0001
0,01
0,01
3,5%
2,4%
1,4%
42,7%
69,4%
49,7%
19,7%
7,2%
6,6%
2,6%
46,3%
88%
1,2%
1,4%
N=151 N=871
(11)
(10)
(4)
(70)
(134)
(91)
(43)
(31)
(21)
(13)
(372)
(605)
(433)
(172)
%%%%NN NN
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RESULTS…RESULTS…
CCS >= III ASA >= III NYHA >= III
Emergent
IABP Eject Frac
Rhythm Risk NRhythm Risk N %% RRRR OROR
82320
108352
65215
238531
115MedMed
54,3%36,7%
71,5%40,4%
43%24%
15,2%9,7%
20,5%13,2%
59% 58%
1,4
1,7
1,7
1,6
1,5
2,04
3,7
2,3
1,7
1,6
P
151871
151871151871
151871151871151871
A-FibSinus
A-FibSinusA-FibSinus
A-FibSinusA-FibSinusA-FibSinus
<0,0001
<0,0001
<0,0001
0,02
0,02
NS
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RESULTS….RESULTS….
Vessels Diseased
LAD Right Sx
Left Main
# Dst Anas > 3 Off-Pump On Pump
Perf Time
Rhythm Risk NRhythm Risk N %% RRRR OROR
127531
90413
31213
2473
103374
22129
111(M)104(M)
84%60%
59,6%47,4%
20%24,4%
13,9%8,3%
68,2%42,9%7,3%
17,8%
1,3
1,2
0,83
1,8
1,5
0,4
2,5
1,5
0,52
2,06
2,8
0,36
P
0,0001
0,01
NS
0,006
<0,0001
<0,0001
NS
151871
151871151871
151871151871301721151871
A-FibSinus
A-FibSinusA-FibSinus
A-FibSinusA-FibSinusA-Fib
A-FibSinus
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RESULTS….RESULTS….
Hospital Stay A-Fib + Hospital Stay Sinus
Hospital Stay NHospital Stay N %% RRRR OROR
8(Median)6(Median)
P
<0,0001151871
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RESULTS…..RESULTS…..
Hospital Stay A-FibHospital Stay Sinus
Stroke A-Fib + Stroke Sinus
Stroke NStroke N %% RRRR OROR
8(Median)6(Median)
6,6%3,05%
P
<0,0001
<0,03
151871
10/15121/871 2,1 2,2
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RESULTS……RESULTS……
Hospital Stay A-FibHospital Stay Sinus
Stroke A- Fib + Stroke Sinus
Mortality A- fib + Mortality Sinus
Mortality NMortality N %% RRRR OROR
8(M)6(M)
6,6%2,5%
11%2.4%
P
<0,0001
<0,03
<0,001
151871
10/151 22/871
17/15121/871
2,1
4,6
2,2
5,1
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Slide Source:Lipids Onlinewww.lipidsonline.org
Mortality in Mortality in AtrialAtrial FibrillationFibrillation
Stroke
Cardiac
Renal
Pulmonary
Vascular
Infection
Rhythm
Other
Mortality (17/151)
5
3
1
3
1
1
2
1
17
(45%)
(17%)
(5,8%)
(17.6%)
(5,8%)
(5,8%)
(6.2%)
(5,8%)
(11%)
(% )N = 151
45%45%
17%17%
17%17%
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Slide Source:Lipids Onlinewww.lipidsonline.org
Mortality Mortality inin Sinus RhythmSinus Rhythm
Stroke
Cardiac
Renal
Pulmonary
Vascular
Infection
Rhythm
Other
Mortality (21/871)
0
8
0
3
3
4
0
2
21
(0%)
(38%)
(0%)
(14%)
(14%)
(19%)
(0%)
(9,5%)
(2,4%)
(% )N = 871
38%38%
14%14%
14 %14 %
19 %
9 %
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RISK PATIENTSRISK PATIENTS
Males Age > 65 Years
Peripheral Vasc Dis
Angina
NYHA > III
ASA > III
CCS > III
Emergent
IABP
On-Pump Surgery
OROR
5,5
3,3
5,5
3,4
2,3
3,7
2,04
1,7
1,6
0,36
P
<0,0001
<0,0001
0,01
<0,0001
<0,0001
<0,0001
<0,0001
0,02
0,02
<0,0001
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RISK PATIENTS..RISK PATIENTS..
Hypertension Smoking
COPD
Diabetes
Renal Impairment
Obesity
LAD Lesion
Right Lesion
Left Main Disease
# Distal Anastomosis >= 3
OROR
2,17
1,6
2,9
2,5
2,1
1,2
2,5
1,5
2,06
2,8
P
<0,001
<0,004
0,0001
0,03
0,04
0, 01
0,0001
0,01
0,006
<0,0001
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Conclusion : Atrial FibrillationConclusion : Atrial Fibrillation
Incidence 14,7%
Mortality 11%
Median hospital stay 8 days Incidence of stroke 6,6 %
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Conclusion: Atrial Fibrillation..Conclusion: Atrial Fibrillation..
Atrial Fibrillation is probably a marker of underlying disease Post operatively (Tip of the Iceberg). (Ears of hippopotamus)
Atrial fibrillation
Age
Diabetes
HypertensionOn Pump
Atrial Ischemia
Atrial fibrillation
Age
DiabetesHypertension
On Pump
Atrial Ischemia
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MANAGEMENTMANAGEMENT
Identify the risk patients
Atrial fibrillation
Age
Diabetes
Hypertension
On Pump
Atrial Ischemia
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Identify the risk patientsNon withdrawal of B Blockers
MANAGEMENT.MANAGEMENT.
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Identify the risk patientsNon withdrawal of B BlockersProphylactic use of Amidiarone and or B Blockers
MANAGEMENT..MANAGEMENT..
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Identify the risk patientsNon withdrawal of B BlockersProphylactic uses of Amidiorone and B BlockersPost operative overdrive pacing of the atrium
MANAGEMENT…MANAGEMENT…
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Identify the risk patientsNon withdrawal of B BlockersProphylactic uses of Amidiarone and B BlockersPost operative pacing of the atriumAggressive Treatment of Atrium Fibrillation Post operative to prevent stroke
MANAGEMENT….MANAGEMENT….
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