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Ann Thorac Surg 2006;81:514-518
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

Prediction and Incidence of Atrial Fibrillation After Aortic Arch Repair

Kaoru Matsuura, MD, Hitoshi Ogino, MD * , Hitoshi Matsuda, MD, Kenji Minatoya, MD, Hiroaki Sasaki, MD, Akiko Kada, MPH, Toshikatsu Yagihara, MD, Soichiro Kitamura, MD

Department of Cardiovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

Accepted for publication July 18, 2005.

* Address correspondence to Dr Ogino, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, 565-8565 Osaka, Japan (Email: hogino{at}hsp.ncvc.go.jp).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
BACKGROUND: Although atrial fibrillation is often associated with increased morbidity after open heart surgery, neither the incidence nor the clinical consequences of atrial fibrillation after aortic surgery has been well investigated. The goal of this study was to elucidate the risks for incidence of postoperative atrial fibrillation after aortic arch repair.

METHODS: From January 1993 to February 2004, 483 patients with atherosclerotic aortic arch aneurysm (n = 327) or aortic dissection (n = 156) underwent total aortic arch repair. All patients operated on as elective, urgent, or emergency aortic arch repair were included. One hundred sixteen patients received surgery on an emergency basis because of rupture or acute type A dissection. Twenty-four patients had atrial fibrillation preoperatively. Potential predictors of postoperative atrial fibrillation were estimated by a logistic regression model.

RESULTS: The incidence of postoperative, new onset of atrial fibrillation was 52.7% (242 of 459). The length of postoperative hospital stay was longer in patients with postoperative atrial fibrillation (48 ± 52 days) than in patients without it (35 ± 29 days; p = 0.001). The length of intensive care unit stay was also longer in patients with postoperative atrial fibrillation (12.1 ± 23.2) than in patients without it (6.2 ± 8.8; p = 0.002). Advanced age (p = 0.007; odds ratio = 1.34; 95% confidence interval: 1.14 to 1.62, per 10 years) was the only risk factor that correlated with postoperative new onset of atrial fibrillation.

CONCLUSIONS: Atrial fibrillation was not uncommon after aortic arch repair. Advanced age was the only preoperative risk factor for postoperative atrial fibrillation.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Atrial fibrillation (AF) is a frequent complication of open heart surgery, with a reported incidence that varies from 10% to 50% [1–3]. Although it is not a life-threatening event, it is associated with hemodynamic compromise and thromboembolic events such as stroke. Moreover, it may lead to longer hospital stay and increased cost. Many factors are thought to influence the occurrence of postoperative AF [1–16]. However, the frequency and risk factors for AF after aortic repairs are not well characterized [5, 17].

The number of aortic surgical procedures has recently been increasing, and outcome has been improved by various novel operative techniques and adjuncts [18–23]. Aortic arch surgery requires circulatory arrest as well as cardiopulmonary bypass (CPB), and cardiac arrest. Atrial fibrillation after noncardiac surgery requiring CPB, cardiac arrest, and circulatory arrest has not been described. This study is the first to investigate the incidence and risk factor of new onset of AF after aortic arch repair.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patients
A total of 483 consecutive patients with atherosclerotic aortic arch aneurysm (n = 327) or aortic dissection (n = 156) underwent aortic arch surgery in the same institution between January 1993 and February 2004. All patients operated on as elective, urgent, or emergency aortic arch repair were included. One hundred sixteen patients received surgery on an emergency basis because of rupture or acute type A dissection. Baseline demographic and clinical data were available for all patients. Initial data were collected from the case notes. The average age was 68.7 ± 10.2 years.

All preoperative medications, including ß-blockers, angiotensin-converting enzyme inhibitors, and calcium antagonists, were continued up to the day of operation—except for nonsteroidal anti-inflammatory drugs, which were discontinued 1 week before surgery, and digoxin, which was discontinued 3 days before surgery.

Operation
The entire operation was performed through median sternotomy under standard anesthesia. Cardiopulmonary bypass was established with arterial cannulation and bicaval drainage. Myocardial protection was achieved using intermittent antegrade and retrograde cold-blood cardioplegia. The arterial cannulation sites were the axillary artery and femoral artery (n = 248), the femoral artery only (n = 98), the ascending aorta only (n = 65), the axillary artery and ascending aorta (n = 53), the aorta, axillary artery, and femoral artery (n = 13), or the ascending aorta and femoral artery (n = 6). For intraoperative brain protection, retrograde cerebral perfusion was applied in 26% of cases (n = 125), and selective cerebral perfusion was applied in 76% (n = 366); both types of cerebral perfusion were applied in 8 patients. The cannulation sites for selective cerebral perfusion were the right axillary artery and left carotid artery (n = 251), the right axillary artery, left carotid artery, and left subclavian artery (n = 57), the brachiocephalic artery and left carotid artery (n = 56), or the brachiocephalic artery, left carotid artery, and left subclavian artery (n = 2). The patients were cooled to a core body temperature of 15 to 28°C. All of the arch replacements were carried out in separate-anastomosis fashion using quadrifurcated grafts.

Monitoring and Follow-Up
All the medical records, including electrocardiograms and telemetry strips, were reviewed. Postoperative AF was defined as an acute, sustained episode (more than 10 minutes) requiring intervention after surgery. After the diagnosis of AF, patients were cardioverted or given one or more medical therapies, or both. If AF remained at the time of discharge or occurred frequently, warfarin therapy was started for anticoagulation. For the patients who had been followed up in other hospitals, the follow-up was completed by contacting the currently following physician. The institutional approval for this study was obtained, and each patient within the study gave informed consent for serving as a subject.

Statistical Analysis
All values are expressed as the mean ± SD or percentages. Differences between patient groups were tested by univariate analysis ({chi}2 test, two-tailed t test, Fisher's exact test, or Mann-Whitney U test as appropriate). Findings of p less than 0.05 were considered significant. A logistic regression model was used to determine predictors of postoperative AF based on the baseline characteristics. The model included variables selected based on clinical importance or significant relationship to incidence of postoperative AF on univariate analysis. Freedom from stroke was estimated using the Kaplan-Meier method. All analyses were performed using SAS statistical software (version 8.02; SAS Institute, Cary, North Carolina).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
The demographics, preoperative medications, and surgical data are presented in Table 1. Table 2 demonstrates the clinical outcome. The 30-day mortality rate was 6.4% (31 of 483). The hospital mortality rate was 7.5% (36 of 483). The remaining 447 patients were followed from 1 month to 10 years (2.85 ± 2.63 years). The actuarial survival rate was 76.4% at 5 years.


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  		Table 1. Perioperative Variables
 

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  		Table 2. Outcome
 
Twenty-four patients (5.0%) had AF preoperatively. The incidence of the postoperative new onset of AF, including both temporary and permanent, was 52.7% (242 of 459). Freedom from postoperative AF was described in Figure 1. The length of postoperative hospital stay was longer in patients with postoperative AF (49 ± 76 days) than in patients without it (12 ± 23 days; p = 0.001). The length of intensive care unit stay was also longer in patients with postoperative AF (36 ± 38) than in patients without it (5.9 ± 8.2; p = 0.002).


Figure 1
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  		Fig 1. Freedom from postoperative atrial fibrillation. (Pts = patients.)

 
Perioperative variables stratified with or without postoperative AF are shown in Table 3. The patients who had preoperative AF were excluded from this analysis. A multivariate logistic regression model was developed to examine the predictors of AF. Table 4 presents the predictors of postoperative new onset of AF. Advanced age (p = 0.007; odds ratio = 1.34; 95% confidence interval: 1.14 to 1.62, per 10 years) was the only risk factor that correlated with postoperative AF. The myocardial ischemic time, or presence of other underlying diseases were not significantly related to the incidence of postoperative AF.


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  		Table 3. Perioperative Variables Stratified With (+) or Without (–) Postoperative Atrial Fibrillation (AF)
 

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  		Table 4. Predictors of Postoperative New Onset of Atrial Fibrillation
 
The patients who had AF preoperatively remained in AF at the time of discharge, and in the late follow-up. On the other hand, 12 patients (5.0%) who did not have AF preoperatively but in whom it developed postoperatively remained in AF at the time of discharge, and 23 of those (10.6%) had AF in the late follow-up period. Thirty-six patients (7.5%) had AF at discharge, and warfarin therapy was administered for 34 of these patients (94%). The occurrence of chronic AF in the late follow-up period was also collected by contacting physicians performing close follow-up. Forty-eight patients (9.9%) had AF in the late follow-up, and warfarin therapy was performed for 36 of them (75%). The survival rate was not different between the patients with or without postoperative AF by the logrank test (p = 0.779).


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
The present study has shown that the incidence of AF is relatively high—equal to or higher than heart valve surgery [3]. Most patients with AF before surgery remained in AF for the early and late postoperative period, while the incidence of AF in patients without AF before the surgery significantly declined during the late follow-up period. It is a foregone result that preoperative AF is the most significant risk factor of postoperative and late follow-up. Furthermore, we assume that the reason for the high incidence of postoperative AF after aortic arch repair is that the patients requiring this type of aortic surgery are of advanced age. This report gives support to this assumption.

There are many reports describing other factors in the occurrence of postoperative AF after cardiovascular surgery [3, 5, 7]. Perzanowski and colleagues [17] reported that patients with thoracic repairs had a risk ratio of 4.5, compared with abdominal aortic repairs, for developing AF. They hypothesized that removal of the aortic fat pad might change the autonomic innervation to the heart, increasing the risk for AF. Also in that study, the avoidance of injury to or removal of the aortic fat pad was correlated with a significant reduction in postoperative AF. Other studies using animal models have shown the importance which those fat pads and the vagal tone may have in the induction of AF [24]. The primary mechanism of this phenomenon is shortening of the atrial refractory period by vagal stimulation [8–14]. Davis and coworkers [16] supported this assumption in a study of coronary artery bypass surgery. They concluded that retaining the aortic fat pad decreased the incidence of postoperative AF, whether the operation was done on pump or off pump [6]. On the other hand, Huang and colleagues [25] described the effect of atrial dilation on electrophysiological properties and the inducibility of atrial fibrillation. The degree of atrial dilatation would depend on the intraoperative and postoperative fluid balance. It is therefore presumed that fluid volume control is related to the incidence of postoperative AF; this is a matter for future study. Chung and colleagues [4] and Aviles and colleagues [15] reported that a high level of C-reactive protein was a risk factor for the incidence of postoperative AF, although our study was unable to address this matter.

The many remaining underlying diseases and categories of operative data, which had been identified as predictors for postoperative AF in previous reports, were found not to be related to the prevalence of postoperative AF here [1–3, 5, 17]. Valentine and colleagues [5] reported that AF is a relatively benign complication in patients undergoing elective aortic operations, and that it did not prolong the length of stay or increase the mortality and morbidity. However, our data appear to show that the prevalence of postoperative AF prolonged the postoperative stay and the intensive care unit stay. Perhaps this discrepancy depends on the more invasive nature of aortic arch surgery with respect to other aortic repairs. And, although not explored by this study, the prevalence of AF might increase the medical expense, as has been remarked in many previous reports [1, 2].

Preoperative AF is the most significant risk factor for the presence of postoperative AF [26]. In our series, most of the new onsets of AF were temporary. Only 5.0% of patients who suffered from postoperative AF remained in AF at the time of discharge. For these patients, anticoagulation therapy is essential to avoid thromboembolic events. Chronic anticoagulation with warfarin has been recommended for patients with AF at the time of discharge or for recurrent episodes of AF.

Clinical Implications
After this result is understood, we should aim to aggressively prevent postoperative AF—medically and surgically. Surgical treatment of atrial fibrillation was established by Cox and coworkers [27, 28] and has been refined during this decade. Our standard criteria for Maze procedure was described previously [29]. Postoperative use of ß-blockers or other antiarrhythmic drugs is routinely performed.

Study Limitations
We have examined patients in one institution retrospectively. The operations were performed by many surgeons, and we lack the exact criteria on which to base a preoperative and postoperative prophylactic strategy for AF. How to prevent postoperative AF and how to manage postoperative AF remain questions of great concern.

The relatively long durations of postoperative stay deserve comment. We routinely perform multidetector three-dimensional computed tomography for postoperative evaluation, after the condition of the patient improves. That has some bearing on our results.

Although the operative techniques and adjuncts are now highly developed, AF is nevertheless not uncommon after aortic arch repair, and is associated with prolonged postoperative hospital stay. Advanced age was only a preoperative risk factor for postoperative AF. An aggressive prophylactic and therapeutic approach for postoperative AF would be efficacious for patients undergoing repair of the aortic arch.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

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