Post operative atrial fibrilation (POAF) : What do the ... Perioperative atrial...Circulation is...

Post operative atrial fibrilation

(POAF) :

What do the Guidelines say ?

Pr. Dan Longrois, Department of Anesthesia and Intensive Care

Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, University Paris 7, Denis Diderot, Unité INSERM U1148, Paris, France

[email protected]

CEEA Kosice 2016

mailto:[email protected]

Male, 68 Years, J2 post pneumectomy,asymptomatic POAF,

Amiodarone (IV, 2 + 6 Amp/ 24h)

THANK YOU FOR YOUR

ATTENTION AND SEE YOU

NEXT YEAR !

In fact…• AF in general

• Epidemiology/pathophysiology of POAF

– Cardiac surgery/ thoracic surgery/ other types of

surgery

• Treatment

– HD instability/ symptoms

– HR control

– Return to sinus rhythm

– Prevention of re-occurrence of POAF

– Anticoagulation ?

• Duration of postoperative anticoagulation ?

AF

« Medical »POAF

Cardiac

surgery

POAF non-

cardiac

surgery

Thoracic non-cardiac surgeryOther types of surgery

ICU

Lancet 2012; 379: 648–61

J Am Coll Cardiol 2011;57:e101–98

CHEST 2012; 141(2)(Suppl):e531S–e575S

ISSN: 1524-4539 Copyright © 2011 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online

72514Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX

DOI: 10.1161/CIR.0b013e31820f14c0 published online Feb 14, 2011; Circulation

Richard L. Page, David J. Slotwiner, William G. Stevenson and Cynthia M. Tracy Michael D. Ezekowitz, Warren M. Jackman, Craig T. January, James E. Lowe,

L. Samuel Wann, Anne B. Curtis, Kenneth A. Ellenbogen, N.A. Mark Estes, III, Guidelines

Cardiology Foundation/American Heart Association Task Force on PracticeAtrial Fibrillation (Update on Dabigatran): A Report of the American College of

2011 ACCF/AHA/HRS Focused Update on the Management of Patients With

http://circ.ahajournals.org/cgi/content/full/CIR.0b013e31820f14c0/DC1Data Supplement (unedited) at:

http://circ.ahajournals.org

located on the World Wide Web at: The online version of this article, along with updated information and services, is

http://www.lww.com/reprintsReprints: Information about reprints can be found online at

[email protected]. E-mail:

Fax:Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters

http://circ.ahajournals.org/subscriptions/Subscriptions: Information about subscribing to Circulation is online at

at INSERM U-541 on February 17, 2011 circ.ahajournals.orgDownloaded from

Circulation. 2011;123:104 –123

ESC GUIDELINES

2016 ESC Guidelines for the management of atrial

fibrillat ion developed in collaboration with EACTS

The Task Force for the management of at r ial fibr illat ion of the

European Society of Cardiology (ESC)

Developed with the special contr ibut ion of the European Heart

Rhythm Associat ion (EHRA) of the ESC

Endorsed by the European Stroke Organisat ion (ESO)

Authors/Task Force Members: Paulus Kirchhof (Chairperson) (UK/Germany),*

Stefano Benussi*1 (Co-Chairperson) (Switzer land), Dipak Kotecha (UK),

Anders Ahlsson1 (Sweden), Dan Atar (Norway), Barbara Casadei (UK),

Manuel Castella1 (Spain), Hans-Chr istoph Diener2 (Germany), Hein Heidbuchel

(Belgium), Jeroen Hendr iks (The Nether lands), Gerhard Hindr icks (Germany),

Antonis S. Manolis (Greece), Jonas Oldgren (Sweden), Bogdan Alexandru Popescu

(Romania), Ulr ich Schot t en (The Nether lands), Bart Van Putte1 (The Nether lands),

and Panagiot is Vardas (Greece)

Document Reviewers: Stefan Agewall (CPG Review Co-ordinat or) (Norway), John Camm (CPG Review

Co-ordinator ) (UK), Gonzalo Baron Esquivias (Spain), W erner Budts (Belgium), Scipione Carer j (Italy),

Filip Casselman (Belgium ), Antonio Coca (Spain), Raffaele De Cater ina (Italy), Spir idon Deftereos (Greece),

Dobromir Dobrev (Germany), Jose M. Ferro (Portugal), Gerasimos Filippatos (Greece), Donna Fitzsimons (UK),

* Correspondingauthors: Paulus Kirchhof, Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHBNHStrusts, IBR, Room 136, Wolfson Drive, Birmingham

B15 2TT, United Kingdom, Tel: + 44 121 4147042, E-mail: [email protected]; Stefano Benussi, Department of Cardiovascular Surgery, University Hospital Zurich, Ramistrasse

100, 8091 Zurich, Switzerland, Tel: + 41(0)788933835, E-mail: [email protected] ing the European Associat ion for Cardio-Thoracic Surgery (EACTS)2Represent ing the European Stroke Associat ion (ESO)

ESC Committee for Pract ice Guidelines (CPG) and National Cardiac Societ ies Reviewers can be found in the Appendix.

ESC ent it ies having part icipated in the development of this document:

Associat ions: European Association for Cardiovascular Prevention and Rehabilitation (EACPR), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm

Association (EHRA), Heart Failure Association (HFA).

Councils: Council on Cardiovascular Nursing and Allied Professions, Council for Cardiology Practice, Council on Cardiovascular Primary Care, Council on Hypertension.

W orking Groups: Cardiac Cellular Electrophysiology, Cardiovascular Pharmacotherapy, Grown-up Congenital Heart Disease, Thrombosis, Valvular Heart Disease.

Thecontent of theseEuropean Society of Cardiology (ESC) Guidelineshasbeen published for personal and educational useonly.No commercial use isauthorized.No part of theESC

Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of awritten request to Oxford Uni-

versity Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC ([email protected]).

Disclaimer .The ESC Guidelines represent the viewsof the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at

the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom-

mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour-

aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or

therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and

accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor

do theESC Guidelinesexempt health professionals from takinginto full and careful consideration the relevant official updated recommendations or guidelines issued by thecompetent

public health authorities, in order to manage each patient’scase in light of the scientifically accepted datapursuant to their respective ethical and professional obligations. It isalso the

health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.

& The European Society of Cardiology 2016. All rights reserved. For permissions please email: [email protected].

doi:10.1093/europace/euw295

Europace (2016) 18, 1609–1678

by g

ue

st o

n N

ove

mb

er 2

7, 2

01

6D

ow

nlo

ad

ed

from

YancyMurray, Ralph L. Sacco, William G. Stevenson, Patrick J. Tchou, Cynthia M. Tracy and Clyde W.

T.E. Cigarroa, Jamie B. Conti, Patrick T. Ellinor, Michael D. Ezekowitz, Michael E. Field, Katherine Craig T. January, L. Samuel Wann, Joseph S. Alpert, Hugh Calkins, Joseph C. Cleveland, Jr, Joaquin

Association Task Force on Practice Guidelines and the Heart Rhythm SocietyExecutive Summary: A Report of the American College of Cardiology/American Heart

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation:

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2014 American Heart Association, Inc. All rights reserved.

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation published online March 28, 2014;Circulation.

http://circ.ahajournals.org/content/early/2014/04/10/CIR.0000000000000040.citation

World Wide Web at: The online version of this article, along with updated information and services, is located on the

http://circ.ahajournals.org/content/suppl/2014/04/10/CIR.0000000000000040.DC3.html http://circ.ahajournals.org/content/suppl/2014/03/24/CIR.0000000000000040.DC2.html http://circ.ahajournals.org/content/suppl/2014/03/24/CIR.0000000000000040.DC1.html

Data Supplement (unedited) at:

http://circ.ahajournals.org//subscriptions/

is online at: Circulation Information about subscribing to Subscriptions:

http://www.lww.com/reprints Information about reprints can be found online at: Reprints:

document. Permissions and Rights Question and Answer available in the

Permissions in the middle column of the Web page under Services. Further information about this process isOnce the online version of the published article for which permission is being requested is located, click Request

can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office.Circulation Requests for permissions to reproduce figures, tables, or portions of articles originally published inPermissions:

by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from by guest on September 1, 2014http://circ.ahajournals.org/Downloaded from

guideline-directed medical therapy (GDMT) to represent optimal medical therapy

as defined by ACC/AHA guideline (primarily Class I)-recommended therapies

Clin. Cardiol. 37, 1, 7–13 (2014)

2014 AATS guidelines for the prevention and management of

per ioperative atr ial fibr illation and flutter for thoracic

surgical procedures

Gyorgy Frendl, MD, PhD,aAlissa C. Sodickson, MD,aMina K. Chung, MD,b Albert L. Waldo, MD, PhD,c,d

Bernard J. Gersh, MB, ChB, DPhi,eJames E. Tisdale, PharmD,f Hugh Calkins, MD,g Sary Aranki, MD,h

Tsuyoshi Kaneko, MD,h Stephen Cassivi, MD,i Sidney C. Smith, Jr, MD,j Dawood Darbar, MD,k

Jon O. Wee, MD,l Thomas K. Waddell, MD, MSc, PhD,m David Amar, MD,n and Dale Adler, MDo

Supplemental material is available online.

PREAMBLE

Our mission was to develop evidence-based guidelines for

theprevention and treatment of perioperative/postoperative

atrial fibrillation and flutter (POAF) for thoracic surgical

procedures. Sixteen experts were invited by the American

Association for Thoracic Surgery (AATS) leadership: 7 car-

diologists and electrophysiology specialists, 3 intensivists/

anesthesiologists, 1 clinical pharmacist, joined by 5

thoracic and cardiac surgeons who represented AATS (see

Online Data Supplement 1 for the list of members and

OnlineData Supplement 2 for theconflict of interest decla-

ration online).

Methods of Review

Membersweretaskedwithmakingrecommendationsbased

onareview of theliterature, withgradingthequality of theev-

idence supporting the recommendations, and with assessing

the risk-benefit profile for each recommendation. The level

of evidence was graded by the task force panel according to

standards published by the Institute of Medicine (Table 1).

For thedevelopment of theguidelineswefollowedtherecom-

mendationsof TheInstituteof Medicine(IOM) 2011Clinical

PracticeGuidelinesWeCan Trust: Standardsfor Developing

Trustworthy Clinical Practice Guidelines; www.iom.edu/

cpgstandards.1Effortsweremadetominimizerepetitionof ex-

istingguidelines2-4; rather wefocusedonnew informationand

advances in diagnosis and therapy, and present these current

guidelines within the framework of the new IOM

recommendations. In order to meet these standards, most

societies (American Heart Association and AATS included)

initiated therevision2,3 of existing guidelines.

Task force subgroups were formed and tasked with pre-

paring a summary of the available literature for each sub-

topic. Literature searches were conducted using PubMed,

focused on articles published since 2000 except in rare cir-

cumstances. Both the summaries and original articles were

made available to each task force member via a shared

electronic folder. The subgroup summaries as well as the

original literature were presented and discussed at 9 sched-

uled teleconferences. Theconferenceswere recorded. Arti-

cleswereselected for inclusion based on consensusopinion

by task force members. Writing groups were formed to

develop the draft guidelines for each subtopic, with 3 to 7

members and a leader for each group. Group recommenda-

tions were submitted before being presented for discussion

and voting at a 1-day face-to-face conference.

Members were specifically asked to assess the applica-

bility of the available evidence to patients undergoing

thoracic surgery. All recommendations were subjected to

a vote. Acceptance for the final document required greater

than 75% approval of each of the recommendations.

A final draft was prepared by the chairman of the task

force and madeavailable in awritten form to each member

for final comments. Subsequently, the recommendations

were posted for public comments for AATS members (via

REDCap), and then peer reviewed by outside experts

selected by the AATS Council.

From the Department of Anesthesiology,aPerioperativeCritical Care and Pain Med-

icine, Brigham and Women’sHospital and Harvard Medical School, Boston, Mass;

Department of Cardiovascular Medicine,b Heart and Vascular Institute, Depart-

ment of Molecular Cardiology, Lerner Research InstituteCleveland Clinic, Lerner

College of Medicine of Case Western Reserve University Cleveland Clinic, Cleve-

land, Ohio; Division of Cardiovascular Medicine,c Department of Medicine, Case

Western Reserve University, Cleveland, Ohio; Harrington Heart & Vascular Insti-

tute,dUniversity HospitalsCaseMedical Center, Cleveland, Ohio; Division of Car-

diovascular Diseases and Internal Medicine,e Department of Medicine, Mayo

Clinic College of Medicine, Rochester, Minn; Department of Pharmacy Practice,f

College of Pharmacy, Purdue University and Indiana University School of Medi-

cine, Indianapolis, Ind; Department of Medicine,g Cardiac Arrhythmia Service,

Johns Hopkins University, Baltimore, Md; Division of Cardiac Surgery,h Depart-

ment of Surgery, Brigham and Women’s Hospital and Harvard Medical School,

Boston, Mass; Division of Thoracic Surgery,i Department of Surgery, Mayo Clinic

College of Medicine, Rochester, Minn; Center for Heart and Vascular Care,j

Department of Medicine, University of North Carolina, Chapel Hill, NC; Division

of Cardiovascular Medicine,k Department of Medicine, Arrhythmia Service, Van-

derbilt University School of Medicine, Nashville, Tenn; Division of Thoracic Sur-

gery,l Department of Surgery, Brigham and Women’s Hospital and Harvard

Medical School, Boston, Mass; Division of Thoracic Surgery,mDepartment of Sur-

gery, University of Toronto, Toronto, Ontario, Canada; Memorial Sloan-Kettering

Cancer Center,n Department of Anesthesiology and Critical Care Medicine, New

York, NY; Division of Cardiovascular Medicine,o Department of Medicine, Brig-

ham and Women’s Hospital and Harvard Medical School, Boston, Mass.

Disclosures: See Online Data Supplement 2.

Received for publication June 9, 2014; accepted for publication June 10, 2014.

Address for reprints: Gyorgy Frendl, MD, PhD, Department of Anesthesiology, Peri-

operativeand Pain Medicine, Brigham and Women’sHospital, CWN-L1, 75 Fran-

cis St, Boston, MA 02115 (E-mail : [email protected]).

J Thorac Cardiovasc Surg 2014;148:e153-93

0022-5223/$36.00

Copyright Ó 2014 by The American Association for Thoracic Surgery

http://dx.doi.org/10.1016/j.jtcvs.2014.06.036

The Journal of Thoracic and Cardiovascular Surgery c Volume 148, Number 3 e153

Frendl et al Clinical Guidelines

Thorac Cardiovasc Surg 2014;148:e153-93

Risk factors of AF (1)

• Clinical risk factors

– Age, HTN, diabetes, obesity, OAS, smoking,

alcohol, hyperthyroidia, familiy Hx,

– Cardiopathies (ischemic, valvular)

– Heart failure

– Cardiothoracic surgery

– European descent

– Genetic predisposition

Circulation. 2014;129: – .

NONE OF THEM IS AVOIDABLE

Other risk factor of AF (2)

• ECG

– LVH

• Echocardiography

– Dilatation of LA

– Altered LVEF

• Biomarkers

– Increased BNP/ CRP

Circulation. 2014;129: – .

NONE OF THEM IS AVOIDABLE

Pathophysiology of AF

Physiol Rev 91: 265–325, 2011;

Physiol Rev 91: 265–325, 2011;

Europace (2012) 14, 159–174

REVIEW

Post-operat ive atr ial fibrillat ion: a maze

of mechanisms

Bart Maesen 1,2, Jan Nijs1, Jos Maessen 1, Maur its Allessie 2, and Ulr ich Schot ten 2*

1Department of Cardiothoracic Surgery, University Hospital of Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands; and 2Department of Physiology, University

Maastricht, PO Box 616, 6200 MD Maastricht, The Netherlands

Received 24 March 2011; accepted after revision 7 June 2011; online publish-ahead-of-print 6 August 2011

Post-operative atrial fibrillation (POAF) is one of the most frequent complications of cardiac surgery and an important predictor of patient

morbidity aswell asof prolonged hospitalization. It significantly increases costs for hospitalization. Insights into the pathophysiological factors

causing POAFhave been provided by both experimental and clinical investigations and show that POAFis ‘multi-factorial’. Facilitating factors

in the mechanism of the arrhythmia can be classified asacute factors caused by the surgical intervention and chronic factors related to struc-

tural heart disease and ageing of the heart. Furthermore, some proarrhythmic mechanisms specifically occur in the setting of POAF. For

example, inflammation and beta-adrenergic activation have been shown to play a prominent role in POAF, while these mechanisms are

less important in non-surgical AF. More recently, it has been shown that atrial fibrosis and the presence of an electrophysiological substrate

capable of maintaining AF also promote the arrhythmia, indicating that POAF has some proarrhythmic mechanisms in common with other

forms of AF. The clinical setting of POAF offers numerous opportunities to study its mechanisms. During cardiac surgery, biopsies can be

taken and detailed electrophysiological measurements can be performed. Furthermore, the specific time course of POAF, with the delayed

onset and the transient character of the arrhythmia, also provides important insight into its mechanisms.

This review discusses the mechanistic interaction between predisposing factorsand the electrophysiological mechanisms resulting in POAF

and their therapeutic implications.- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Keywor ds Atrial fibrillation † Post-operative atrial fibrillation † Inflammation † Sympathetic activation † Oxidative stress †

Atrial remodelling † Fibrosis † Ageing

Int roduct ion

Atrial arrhythmias and atrial fibrillation (AF) in particular are well-

known complications after cardiac surgery with a reported inci-

dence between 10 and 60%.1–17 The incidence ishigher in patients

undergoing valve surgery than in patients undergoing coronary

artery bypass surgery (CABG).1,2,7,8,10,11,17,18 Post-operative atrial

arrhythmias also occur after non-cardiac surgery, especially after

oesophagectomy,19 lung surgery,20–24 and large abdominal

surgery.25–27 The incidence after non-cardiac surgery is,

however, lower with incidences ranging from 0.3 to 29%.22,28,29

Postoperative atrial arrhythmias are associated with prolonged

hospital stay, haemodynamic instability, an increased risk of

stroke, and increased mortality.2–4,6,10,12,13,24,28,30–33

The exact pathophysiological mechanisms responsible for the

onset and perpetuation of post-operative atrial arrhythmias are

incompletely understood. Factors facilitating post-operative AF

(POAF) can be classified in acute factors directly related to

surgery (e.g. adrenergic stimulation) and factors that are reflecting

a chronic and progressive process of remodelling or ageing of the

heart (e.g. left atrial enlargement).14,15 These predisposing factors

can on the one hand provoke triggers able to initiate the arrhyth-

mia and on the other hand enhance the development of a sub-

strate capable of perpetuating AF.

The association of POAF with specific kinds of surgery and the

time course of the arrhythmia can help to better understand its

mechanisms. First, the association of POAF with cardiac surgery

and degree of structural heart disease suggests a direct role for

* Corresponding author. Tel: + 31 43 3881077; fax: + 3143 3884166, Email: [email protected]

Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2011. For permissions please email: [email protected].

The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of thisarticle

for non-commercial purposes provided that the original authorship is properly and fully attributed; the Journal, Learned Society and Oxford University Press are attributed as the

original place of publication with correct citation details given; if an article is subsequently reproduced or disseminated not in itsentirety but only in part or as aderivative work this

must be clearly indicated. For commercial re-use, please contact [email protected].

Europace (2012) 14, 159–174

doi:10.1093/europace/eur208

at Inserm

/Disc o

n N

ov

ember 1

6, 2

01

3http

://euro

pace

.ox

ford

jou

rnals.o

rg/

Do

wn

load

ed

from

Europace (2012) 14, 159–174

Peaks of incidence different between POAF in

cardiac and non-cardiac surgery

Europace (2012) 14, 159–174

EPIDEMIOLOGY of POAF:

Cardiac surgery: 30-40 %

What is the incidence of POAF

after non-cardiac surgery ?

Incidence of POAF• Non-cardiac thoracic surgery: 30 %

– Exploratory thoraco/segmentectomy: 4 %

– lobectomies, bilobectomies,

pneumonectomies : 10-33 %

– Single/double lung transplantation: 40 %

– Oesophagectomy: 13-25 % of rhythm

abnormalities including POAF.

• TAVI 10-20%

J Cardiothorac.Vasc.Anesth. 2010; 24: 752-61

J Cardiothorac.Vasc.Anesth. 2011;

Anesthesiol.Clin. 2008; 26: 325-35

Epidemiology of AF in ICU patients (outside of

the cardiac surgery context)

• AF : relatively frequent in ICU patient

Surgical ICU:

3 - 25% POAFChung & al, Crit Care Med 2000

Beck-Nielsen & al, Acta Med Scand 1973

Goodman & al, Chest 1978

Medical ICU :

6.5% - 20% Ledingham & al, Lancet 1978

Reinelt & al, Intensive Care Med 2001

Annane & al, AJ Respiratory and Crit Care Med 2008

Incidence of POAF (non-

thoracic surgery)• General surgery: 2-4 % rhythm

disturbances including POAF

• Surgical ICU, 5-8 % have POAF

– In patients with severe sepsis/septic shock,

46 % have a POAF

Crit Care Med. 2004; 32: 722-6

Crit Care. 2010; 14: R108

Frequent spontaneous conversion to sinus rhythm

Is POAF a « severe »

complication ? • Yes in cardiac surgery

– POAF is an independent risk factor for short

term/long term mortality and for postoperative

stroke

– This statistical association justifies prevention/

treatment

Association between POAF and

complications (chronology not taken into

account)

• post-op stroke : OR 2.23 [1.78-2.80] P <.00001

• Resp failure: OR 2.30 [1.71-3.11] P <.00001

• Card failure: OR 1.82 [0.78-4.23] P = 0.2

• MI : OR 0.98 [0.56-1.71] P= 0.9

• LOS: OR 1.48 [1.09–1.87] P <.00001

J Thorac Cardiovasc Surg 2011;141:1305-12

And in the other types of

surgery ?

• Incidence: 29% (65/224 patients)

• Emphysema: 37% / Mucoviscidosis:27%

• Bi pulmonary: 56%

• Amiodarone: in 56% of patients with POAF

Henri C et al. Circ Arrhythm Electrophysiol. 2012;5:61-7

Risk factors for mortality (multivariate analysis)

Bronchial leak: 3.8 (1.4-10.2); P = 0.007

Vasoconstrictors during surg 2.3 (0.9-7.9); P = 0.06

POAF 1.5 (0.5-4.6); P= 0.4

Lack of statistical power very probable



surgical procedures






PREAMBLE











ration online).

Methods of Review


onareview of theliterature, withgrading thequality of theev-





































force and madeavailable in awritten form to each member





From the Department of Anesthesiology,aPerioperative Critical Care and Pain Med-



ment of Molecular Cardiology, Lerner Research Institute Cleveland Clinic, Lerner

College of Medicine of Case Western Reserve University Cleveland Clinic, Cleve-



tute,dUniversity Hospitals CaseMedical Center, Cleveland, Ohio; Division of Car-
























0022-5223/$36.00





Management of POAF


Attempt to get a preoperatoy EKG

(pre-excitation, long QTc)

Severe symptoms of POAF ?

Why control HR before

cardioversion ?

• Low primary success of cardioversion (35 %)

• In medical cardiology seting amiodarone vs placebo => 64

% of return to SR at 24h in the placebo group 1

• Re-occurrence of POAF , 38 - 62 % of cases at 24h and

48h 2

1 Fuster V et al. Circulation 2011; 123: e269-3672 Mayr A et al. Crit Care Med 2003; 31: 401-3



surgical procedures






PREAMBLE











ration online).

Methods of Review


onareview of theliterature, withgradingthequality of theev-





































force and made available in awritten form to each member





From the Department of Anesthesiology,aPerioperativeCritical Care and Pain Med-



ment of Molecular Cardiology, Lerner Research InstituteCleveland Clinic, Lerner

Collegeof Medicine of Case Western Reserve University Cleveland Clinic, Cleve-



tute,dUniversity Hospitals CaseMedical Center, Cleveland, Ohio; Division of Car-
























0022-5223/$36.00





The Journal of Thoracic and Cardiovascular Surgery c Volume 148, Number 3

What drugs/doses to be used to

treat POAF ?

J Am Coll Cardiol 2014;64:660–8

• Dose-dependance :

– 1st prescriptions (> 400mg/j) : toxicity 5 à 15%

– Doses < 400mg/j : toxicity 1,6 à 2%

– NO non-toxic doses2

• Cumulative doses are to be taken into consideration

• Risk factors for pulmonary toxicity: male gender, age1

• Ethnic factor ?

• Oxygenotherapy, mech ventilation, after cardiac surgery

Pulmonary toxicity of amiodarone:

1 L. Pilote, Am J Cardiol 20112 Int J Cardiol. 2011 Nov.

• Prospective randomized study 100 pneumectomies and 200

lobectomies

• Comparaison: amiodarone/verapamil versus Placebo

• Amiodarone:150 mg IV in 2 min then 1200 mg/j for 3 days

• Study interrupted: too many side effects in the amiodarone arm

Van Mieghem W et al. Chest 1994; 105:1642-5

Amiodarone and the Development of ARDS After

Lung Surgery

• Retrospective study of 310 lobectomies and 242 pneumonectomies on

5 years

• Incidence of POAF: 19%

• ARDS:

– 11% of patients treated with amiodarone vs 1.8% (P<0,0001) in

patients without amiodarone

– pneumonectomies > lobectomies

• Pathophysiology not known

Amiodarone nor recommanded in patients with

pneumonectomy ++

Van Mieghem W et al. Chest 1994; 105:1642-5

Amiodarone and the Development of ARDS After

Lung Surgery

Anticoagulation of POAF

High risk of TE for medical AF

CHADS2

ICC 1

Hypertension 1

Age ≥75 years 1

Diabetes 1

Stroke/TIA/TE 2

Maximum 6

Recommandations for anticoagulation of

medical AF

Risk of bleeding

ESC GUIDELINES

2016 ESC Guidelines for the management of atrial

fibrillat ion developed in collaboration with EACTS

The Task Force for the management of at r ial fibr illat ion of the

European Society of Cardiology (ESC)

Developed with the special contr ibut ion of the European Heart

Rhythm Associat ion (EHRA) of the ESC

Endorsed by the European Stroke Organisat ion (ESO)

Authors/Task Force Members: Paulus Kirchhof (Chairperson) (UK/Germany),*

Stefano Benussi*1 (Co-Chairperson) (Switzer land), Dipak Kotecha (UK),

Anders Ahlsson1 (Sweden), Dan Atar (Norway), Barbara Casadei (UK),

Manuel Castella1 (Spain), Hans-Chr istoph Diener2 (Germany), Hein Heidbuchel

(Belgium), Jeroen Hendr iks (The Nether lands), Gerhard Hindr icks (Germany),

Antonis S. Manolis (Greece), Jonas Oldgren (Sweden), Bogdan Alexandru Popescu

(Romania), Ulr ich Schot t en (The Nether lands), Bart Van Putte1 (The Nether lands),

and Panagiot is Vardas (Greece)

Document Reviewers: Stefan Agewall (CPG Review Co-ordinat or) (Norway), John Camm (CPG Review

Co-ordinator ) (UK), Gonzalo Baron Esquivias (Spain), W erner Budts (Belgium), Scipione Carer j (Italy),

Filip Casselman (Belgium ), Antonio Coca (Spain), Raffaele De Cater ina (Italy), Spir idon Deftereos (Greece),

Dobromir Dobrev (Germany), Jose M. Ferro (Portugal), Gerasimos Filippatos (Greece), Donna Fitzsimons (UK),

* Correspondingauthors: Paulus Kirchhof, Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHBNHStrusts, IBR, Room 136, Wolfson Drive, Birmingham

B15 2TT, United Kingdom, Tel: + 44 121 4147042, E-mail: [email protected]; Stefano Benussi, Department of Cardiovascular Surgery, University Hospital Zurich, Ramistrasse

100, 8091 Zurich, Switzerland, Tel: + 41(0)788933835, E-mail: [email protected] ing the European Associat ion for Cardio-Thoracic Surgery (EACTS)2Represent ing the European Stroke Associat ion (ESO)

ESC Committee for Pract ice Guidelines (CPG) and National Cardiac Societ ies Reviewers can be found in the Appendix.

ESC ent it ies having part icipated in the development of this document:

Associat ions: European Association for Cardiovascular Prevention and Rehabilitation (EACPR), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm

Association (EHRA), Heart Failure Association (HFA).

Councils: Council on Cardiovascular Nursing and Allied Professions, Council for Cardiology Practice, Council on Cardiovascular Primary Care, Council on Hypertension.

W orking Groups: Cardiac Cellular Electrophysiology, Cardiovascular Pharmacotherapy, Grown-up Congenital Heart Disease, Thrombosis, Valvular Heart Disease.

Thecontent of theseEuropean Society of Cardiology (ESC) Guidelineshasbeen published for personal and educational useonly.No commercial use isauthorized.No part of theESC

Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of awritten request to Oxford Uni-

versity Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC ([email protected]).

Disclaimer .The ESC Guidelines represent the viewsof the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at

the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom-

mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour-

aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or

therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and

accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor

do theESC Guidelinesexempt health professionals from takinginto full and careful consideration the relevant official updated recommendations or guidelines issued by thecompetent

public health authorities, in order to manage each patient’scase in light of the scientifically accepted datapursuant to their respective ethical and professional obligations. It isalso the

health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.

& The European Society of Cardiology 2016. All rights reserved. For permissions please email: [email protected].

doi:10.1093/europace/euw295

Europace (2016) 18, 1609–1678

by g

ue

st o

n N

ove

mb

er 2

7, 2

01

6D

ow

nlo

ad

ed

from

Messages (1)

• Level of knowledge/ stength of

recommandations

– Medical AF> POAF cardiac surgery > POAF

thoracic (non cardiac) surgery > POAF other

surgeries> AF in ICU patients

• Present day extrapolations from cardiac

surgery not always warranted +++++

– Especially anticoagulation of transient POAF

(risk scores for TE/Bleeding)

Messages (2)

• As compared to widespread practice:

– HR control and return to SR are different

goals with different drug strategies

– Do not forget/underestimate the toxicity of

amiodarone

• Contra-indicated in patients who underwent

pneumonectomy/other severe lung lesions ?

• Continue anti-arhythmia therapy for 1

month

Messages (3)

• The most difficult part concerns the

indications/duration of anticoagulation

– Risks of TE/Bleeding extrapolated from the

medical literature

– When to start anticoagulation ?

– Choice of anticoagulants/doses

– Duration: 1 month after return to SR

• Cardiac surgery

• Non-cardiac surgery

Messages (end)

• The complexity of managing POAF is such

that it renders the “Heart Team” necessary

– Prophylaxis, treatment

• Anticoagulation ?

• Multidisciplinary decisions

– Including the surgeon and the patient (if

possible)

• Well traced in the medical record with

information provided to the family/patient

Ann Thorac Surg 2011;92:421–7

European Heart Journal doi:10.1093/eurheartj/ehu282

Thank you for your attention

AND DO NOT FORGET:

>> Register now <<

Abstract Submissions:

1 November – 15 December 2016

www.esahq.org

Post operative atrial fibrilation (POAF) : What do the ... Perioperative atrial...Circulation is...

Documents

Transcript of Post operative atrial fibrilation (POAF) : What do the ... Perioperative atrial...Circulation is...