Saina Attaran MRCS, Prakash P Punjabi, Jon Anderson FRCS.
Cardiothoracic Department, Hammersmith Hospital, Imperial College, London, UK .
Corresponding Author: Saina Attaran 46, Queen of Denmark Court, Finland Street London, SE16 7TB UK.
Post cardiac surgery atrial fibrillation is common after cardiac surgery. Despite the advances
in medical and surgical treatment, its incidence remains high and unchanged for decades. The
aim of this review was to summarize studies published in 2011 on identifying factors, prevention strategies,
A review was performed on Medline, Embase and Chocrane on all of the English-language,
peer-reviewed published clinical studies on POAF; studies investigating the mechanism of developing
POAF, prevention, treatment and outcome were all included and analyzed. Case reports, studies on persistent/preoperative
impact factor of the journal and their limitations.
Overall 62 studies were reviewed and analyzed; 26 on POAF predictive factors, 31 on preventative
only 2.8 ranging between
0.5 and 14.5.
Post cardiac surgery atrial fibrillation is a multi-factorial and complex condition. Cardiac
surgery may be a risk factor for developing POAF in patients already susceptible to this condition and
may not be a complication of cardiac surgery. Future studies should mainly focus on histological changes
in the conductive tissue of atrium and related treatment strategies rather than predictive factors of
POAF and more funding should be made available to study this condition from new and entirely different
Post Operative Atrial fibrillation (POAF) is common
after cardiac surgery. POAF predisposing
factors are unclear and its incidence is reported
to be between 15-50%.1,2
POAF is considered a favorite
research topic and hundreds of original articles
and reviews investigate POAF every year.
These studies focus on predictive and risk factorsof developing POAF, strategies to prevent POAF,
treatment options and effect of POAF in short and
long-term, on the outcome and survival of the patients
In this review, we have assessed all the published
studies in 2011 investigating POAF; we aimed to
create a summary of all the recent studies published
in one year and also we have evaluated them and
their contribution to the current literature. We also
discussed possible future studies that may add benefit
A review was performed on Medline, Embase
and Chocrane on all the English-language, peerreviewed
published clinical studies on POAF as
primary or secondary endpoint. Animal models,
studies on chronic/persistent AF, case reports and
AF after congenital cardiac surgery, thoracic surgery
They were divided into three main categories (Figure
1); A) Predictive/identifying factors, B) Preventative
We also developed a scoring system to assess these
studies based on their originalities; The studies
were scored.1,2 or 3
based on their originality, 3)
Original topic that has never been studied previously
have been reviewed in cardiac patients and
in general but it is the first time that the hypothesis
is being investigated in cardiac surgery, (1)
Studies that have been assessed in cardiac surgery
before and data has been published several times
with similar or different conclusion (Table 1).
Figure 1: Publications on POAF in 2011
Summary of the publications are listed in Table
1. There were only two original articles (scoring
3), 10 scored 2 (studies preformed on cardiac patients
and general population but not on POAF),
and the rest or 50 papers were studies and reports
that were not original and were performed several
institutions reporting similar results as the
previous ones with only minor differences. The
average impact factor of the journals that these
articles were published was only 2.83 ranging between.
Of all the 62 studies, 26 were on POAF
predictive factors (A), 30 on prevention (B), and 6
on the outcome (C). In all of these studies POAF
rate has been reported to be between 3 to 50%.
Table 1: Comparison of Apixaban with Dabigatran and Rivaroxaban
In 2011, over 40% of studies on POAF were analyzing
factors of developing
POAF and are
in three categories:
A1. Patient factors
The main patient related predictive factor studied
in 2011 was the effect of race on POAF; studies were
performed on over 30,000 North American patients
who underwent cardiac surgery. They have emphasized
/race and atrial fibrillation in the normal
population as well as POAF.3-5
All of these reports
have concluded that despite higher incidences of
preoperative co-morbidities in black people and
African/Americans, the risk of developing POAF is
30-40% less compared to the European/Americans
Besides genetic association, another explanation
Other preoperative patient factors such as history
of high blood pressure, heart failure, and
age, as well as, operative and postoperative features such as mitral valve surgery, prolonged cross-clamp and
cardio-pulmonary bypass time, use of cardioplegia, inotropic use
and intra-aortic balloon pump have all have been reported again
and shown to be associated with higher incidence of POAF.7-9
Most of these studies were retrospective, single institutional
reports and on a small number of patients undergoing cardiac
surgery. They have also shown that the use of opium preoperatively
and postoperative complications such as pneumonia, renal
impairment and transfusion rate can all increase POAF.
Another important patient related factor is body mass index
(BMI) and reports in over 20,000 patients showed higher incidence
of POAF with high BMI.
The mechanism of this
association have been reported to be increased plasma volume
and left ventricular mass, ventricular diastolic dysfunction,
increased basal sympathetic tone, and a hypercoagulable
state in obese patients that promotes systemic inflammation
that are known to be responsible for POAF in obese patients.12
Despite these frequently published studies on POAF, one paper has
focused on POAF post discharge; the authors have concluded a significant
before cardiac surgery. Although
of post discharge AF was also shown to be associated with the presence
of postoperative arrhythmias as well as early onset POAF.14
A2. Cardiac factors
Studies in this category investigated cardiac related predisposing
factors. The association between POAF with preoperative ECG
specifications, echocardiographic and angiographic features, as
well as some histological changes were investigated: Kinoshita et
al investigated standard deviation of all normal-to-normal QRS
complexes (SDNN) and square root of mean of sum of squares of
differences between adjacent normal-to-normal QRS complexes
(RMSSD) of the patients admitted days before their cardiac operations
and concluded that reduced heart rate variability decreases
the rate of POAF significantly.
In over 13,000 patients undergoing
cardiac surgery P-wave amplitude in leads aVR and V(1) and
a less negative P-wave amplitude in aVR were strong predictors
The differences in the ECG patterns seen in these patients
of the cardiac chambers and some studies have focused
on identifying the predictors of POAF based on the echocardiographic
features; left ventricular diastolic dysfunction, decreased
ventricular compliance, left ventricular segmental kinetic disturbances,
in the morphology and compliance of cardiac muscles can result in stretch of the pulmonary veins and increase in
their arrhythmogenic activity.20, 21
It has also been
shown that proximal lesion in the right coronary
artery, increases the risk of developing POAF.
Another study has compared left ventricular
electro-mechanical delay (LVEMD) by echocardiogram
and Doppler imaging postoperatively
and concluded that despite comparable LVEMD
preoperatively, LVEMD is prolonged postoperatively
in patients who develop POAF.
from these findings can be rather confusing
as some studies suggest preoperative differences
in cardiac morphology that can result in POAF
and the other group showed change in postoperative
characteristics that can predict developing
POAF. Latter was done on only 16 patients.23
and will require further studies prior to a concrete
conclusion and preoperative characteristics
have been found to be more important than
postoperative parameters in developing POAF.
Based on these findings, some investigators have
analyzed atrial samples for any identifiable differences
factors for developing POAF.
left atrial samples have shown changes in 19 special
proteins, proinflammatory state and apoptosis to
be different between patients who develop POAF
and patients with no AF.
These studies further
stress the theory of the presence of an organic factor
studies have indicated variants in 4q25 to
be associated with higher incidence of POAF.
A3. Biochemical markers
Presence of higher level of certain circulatory biochemical
markers preoperatively in patients with
POAF compared to those in SR also has attracted
investigators' interest for years. In 2011 alone,
several studies were published on this topic and
results showed, not for the first time, that high circulatory
Brain Natriuretic Peptide (BNP), tropnin
I, C-reactive protein (pre and postoperatively) and
Docosahexaenoic acid (DHA) was associated with
increased POAF rare.
Conversely, circulatoryArachidoinc acid levels are shown to be lower pre
and postoperatively in patients with POAF.31
was a novel finding. However prostaglandin series
In addition, lower Hemoglobin A1C (HbA1C)
preoperatively was shown to increase POAF.
This was in accordance with another study from
2008 on a large number of patients undergoing
cardiac surgery; Halkos et al revealed that high
levels of HbA1C results in more postoperative
morbidities, but less POAF.
surprisingly contradicts with studies showing
higher incidence of POAF in diabetic patients
and studies on the general population that supports
a positive and independent relationship
between HbA1C levels and incidence of AF.
Despite no clear etiological factor for POAF, in
2011, more studies (n=29) were conducted investigating
prevention from POAF. They mainly
focused on medical therapy (B1) and some
on surgical techniques (B2) to reduce POAF
B1. Medical therapy
Several reports focused on long-chain, omega
3 fatty acids; prevciously there were some initial
promising results with preoperative use
of Omega-3 in reducing POAF, however further
analyzes and studies on larger population
showed no statistically proven benefit of this
group of fatty acids in reducing POAF. In 2011,
one report on a small group showed positive results36
, however another study
and two meta-
analysis published in 2011 showed no real place
for Omega-3 in decreasing the risk of POAF.
Other groups investigated the effect of medications
that reduces inflammation; Postoperative Colchicine
has been tried which showed POAF reduction
Naproxen, despite being
to have no effect in the reduction of POAF but its
preoperative use has decreased POAF duration.
The inflammation theory has encouraged the investigators
to use corticosteroids but no reduction in
POAF in patients who underwent OPCAB.
observed, however its use postoperatively showed
reduction in POAF after a study in all cardiac procedures.
The authors believed that in OPCAB due
to a less inflammatory response, no major effect of
these anti-inflammatory steroids can be observed.
Another group of medications with anti-inflammatory
is Statins. In 2011, of five studies and one
meta-analysis on the role of pre and postoperative
Statins in POAF, except in one retrospective
, all have concluded that Statin reduces
In the study that showed no benefit
with the use of Statin patients with preoperative
AF were also included which may
have influenced the results. Overall, Statins
have been shown to have a great role in prevention
from POAF, however treatment with
Statins failed to eradicated POAF completely.
Angiotensin-converting enzyme inhibitors (ACEI)
and alpha-receptor blockers (ARB) are another
group of medications that have been assessed for
the prevention of POAF. Their anti-inflammatory
properties alongside several other characteristics
such as lowering blood pressure and reducing
volume overload were expected to reduce POAF,
however results from several studies were conflicting;
On the other hand, a retrospective
were not excluded and higher number of AF
patients were on ACEI, which could have affected
These two studies published in 2011
were contradictory to the previous reviews that
showed a statistically significant decrease in POAF
recurrence but no benefits with the use of ARBs.
Benefits of antioxidants such as vitamins C and
E have been studied extensively; a meta-analysis
on five randomized controlled trials (RCT) and
a RCT have shown reduction in POAF [53, 54].
These findings were in accordance with previously
published data, however data on cost effectiveness
and the duration required for the
use of these vitamins are yet to be determined.
Amongst all the medications that have been
tried in prevention of POAF, the value of antiarrhythmic
medications in the prevention and
treatment of POAF remains invincible and the
evidence has been considered (I) and (IIa) for
beta-blockers and Amiodarone respectively.55
Studies continue to explore new and old antiarrhythmic
agents and different regimes; Bisoprolol
This is possible
that its greater beta selectivity increases its
anti-arrhythmogenic effects. Landilol, an ultra
short acting beta-blocker, with very high beta1
selectivity has been infused intra-operatively
and which showed a significant POAF reduction
compared to saline.
but did not compare
Landilol with other beta-blockers. Landilol
was introduced in 2002 however data regarding
its clinical usage is yet to be investigated
Another treatment against POAF that has been
tried recently is Ranolazine, an antianginal agent
that inhibits abnormal late sodium channel current
However, in that study patients
in the Amiodarone group had lower ejection
fraction compared to the patients on Ranolazine,
which could have affected the results. It is well
known that Amiodarone is one of the best antiarrhythmic
Besides the studies on medical agents, a metaanalysis
on the infusion of glucose/insulin/potassium
(GIK) pre- intra- and postoperatively,
has shown that POAF decreased in patients
with diabetes but the incidence of POAF in the
rest of the patients was unchanged.
results of this report and the study on hemoglobin
A1C described earlier.
, no conclusion
can be drawn from these contradictory results,
one showing worse diabetic control preoperatively
and the other one confirms
better diabetic control peri-operatively
to decrease POAF.
Finally, in this category
a small study investigated the role of holistic
therapy preoperatively on a small group
of patients and found no effect on POAF.
B2. Surgical strategies
Despite the importance of different surgical strategies,
this topic; posterior pericardiotomy is one of
the well-known techniques to decrease POAF,
and another RCT in 2011 has shown POAF to be as
low as 3% .
Despite, its usefulness the technique
is not widely adopted by the cardiac surgeons
and care must be taken to make a small incision
to prevent cardiac herniation. Significant POAF
reduction has also been reported with minimized
and extracorporeal vacuum
on small group of patients.
The authors have concluded less hemodilution,
transfusion requirement and less inflammatory
marker release with short circuit and better organ
perfusion with vacuum device that result in better
outcome and less POAF. Changes on cardioplegia
have been tried and despite the myocardioprotective
effects of magnesium a study by Caputo
magnesium in warm blood cardioplegia.65
Interestingly, same authors found a two-fold decrease
in POAF with high Magnesium in warm
blood cardioplegia in a study published in 2002.
Despite POAF being a short-lived and self-limiting
complication, it has been shown to affect
the outcome after cardiac surgery in short- and
long-term and result in devastating complications.
Postoperative delirium has been shown to
be associated with several factors one of them
POAF. Delirium was previously related to preoperative
, however a direct link between
POAF and developing delirium postoperatively
that was reported in this study is questionable as
POAF commonly occurred on the third postoperative
et al was observed prior to that
and during their stay at intensive care unit .68
Other studies, showed statistically significant association
between POAF and stroke.
on over 17000 all cardiac patients by the author
of this manuscript showed significantly lower
survival rate in patients who develop POAF at
five and ten years. However, after propensity
matching for the preoperative characteristics only
some patients and not all dev
first time. The low impact factor of the journals that
these articles were published in also signifies that
this important morbidity that occurs or manifest
after cardiac surgery is not studied widely from
new perspective and not many laboratories and
research funds are dedicated to investigate POAF
in the recent years.
Based on this review and several other publications
from previous years, we know that POAF
is a common complication that despite all the advances
it has yet been identified. The main reason is
that POAF is a multi-factorial condition and unanswered
all types of atrial fibrillation including
POAF. Up to date and without any conflicting results,
developing AF is one in four.
Other factors such
as valvular heart disease, ischemic heart disease,
heart failure, high blood pressure, and several
other co-morbidities increase the risk even more.
Some investigators believe the mechanism of
the POAF is completely different from that of AF
in the community.
This theory and many other
authors and investigators believe that POAF is
a complication of cardiac surgery. However, by
reviewing the published studies, we believe that
atrial fibrillation is a complex disease that can
manifest itself after certain conditions, one of
them being cardiac surgery.
Several studies each year investigate POAF from
different angles, some hope to offer new strategies
to prevent POAF and some still report predictive
factors of POAF. Of the studies investigating the
topic this year, only the ones assessing the histological
changes within atrial samples were original
This is an unexplored area, which can influence
manifestation of changes in automaticity levels
atrial appendage sizes described in this review.
, decreased cardiac compliance stretching
atria and pulmonary vasculature all affect cellular
Presence of circulatory markers, on the other hand, has shown varying degree of
association with POAF, therefore the effect of cardiac
surgery, inflammation, inflammatory markers
and the use of cardiopulmonary bypass can
all be considered predisposing factors of POAF.
Based on these findings, cell membrane stabilisers
and medications decreasing sympathetic activities
such as beta-blockers are considered best
prevention for POAF.
Furthermore, low survival rate in CABG patients
who develop POAF was significantly affected by
It is hard to accept that a condition that
may have lasted only a few hours to a few days
can increase the mortality rate even after 10 years.
It is clear that POAF is the result of preoperative
changes in the atrial tissue and maybe these patients
at some point in the future but this is a
theory that cannot easily be investigated.
In conclusion, we believe that studies should
move away from just reporting AF rate and common
factors, as they do not offer a lot
of benefit, and concentrate on changes at the histological
AF, and hopefully treatment options
that aim to improve, revert or slow down these
changes. With POAF still being a common post
cardiac surgery morbidity that can increase the
cost of treatment postoperatively with devastating
funds and research laboratories should be
dedicated to investigate POAF.
No disclosures relevant to this article were made by the authors.
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