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THE IMPACT OF ATRIAL FIBRILLATION IN CARDIAC SURGERY

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.

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THE IMPACT OF ATRIAL FIBRILLATION IN CARDIAC SURGERY

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  1. THE IMPACT OF ATRIAL FIBRILLATION IN CARDIAC SURGERY Wim J De Vries. DEPARTMENT CARDIOTHORACIC SURGERY UNIVERSITY OF THE FREE STATE UNIVERSITAS HOSPITAL

  2. THE IMPACT OF ATRIAL FIBRILLATION IN CARDIAC SURGERY ? Malignant Rhythm ? Benign Rhythm

  3. INTRODUCTION 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 forstroke. 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 ofbeta-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

  4. AIM AND METHODS • AIM • Incidence of post operative Atrial fibrillation • Identify patients at risk for Atrial fibrillation • Morbidity and mortality of Atrial fibrillation

  5. AIM AND METHODS.. • AIM -Incidence of post operative Atrial fibrillation • Identify patients a risk for Atrial fibrillation • Morbidity and mortality of Atrial fibrillation • Methods 5 Year period, records of patients were prospectively entered in a Departemental database .

  6. STUDY POPULATION • Total 1022 patients - OPCAB(301) - CABG(721)

  7. STUDY POPULATION • Total 1022 patients – OPCAB(29,4%) –CABG(70%) • Males (72%)

  8. STUDY POPULATION • Total 1022 patients - OPCAB(301) - CABG(721) • Males 798 – 72% • Age (33-84) Mean 60,5 years

  9. Incidence of Atial Fibrillation N = 1022 . 14,7 % Total 151

  10. RESULTS Rhythm Risk N % RR OR P 106 45 106 45 12 86 18 51 80 300 12 8 44 135 2,3 2,07 1,2 1,25 1,5 2,6 1,9 A-Fib A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus 151 151 151 871 151 871 151 871 151 871 151 871 151 871 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% Male Sex Female Age > 65 Smoking Obesity Hypertension COPD Diabetes 5,5 3,3 1,6 1,20 2,1 2,8 2,9 <0,0001 <0,0001 0,004 0,01 <0,001 0,005 0,0001

  11. RESULTS.. Rhythm Risk N % RR OR P 11 31 10 21 4 13 70 372 134 605 91 433 43 172 Renal imp Perif Vasc Pulm Hypert Previous MI Angina Unstable Stable A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus 151 871 151 871 151 871 151 871 151 871 151 871 151 871 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 0,04 0,01 NS NS <0,0001 0,01 0,01

  12. RESULTS.. Risk factor A- Fib Sinus RR OR P N=151 N=871 Renal impairm Perif Vascular Pulm Hypert Previous MI Angina Unstable Stable % % N N 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 (11) (10) (4) (70) (134) (91) (43) 7,2% 6,6% 2,6% 46,3% 88% 1,2% 1,4% (31) (21) (13) (372) (605) (433) (172) 3,5% 2,4% 1,4% 42,7% 69,4% 49,7% 19,7% 0,04 0,01 NS NS <0,0001 0,01 0,01

  13. RESULTS… Rhythm Risk N % RR OR P 82 320 108 352 65 215 23 85 31 115 Med Med CCS >= III ASA >= III NYHA >= III Emergent IABP Eject Frac A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus 151 871 151 871 151 871 151 871 151 871 151 871 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 <0,0001 <0,0001 <0,0001 0,02 0,02 NS

  14. RESULTS…. Rhythm Risk N % RR OR P 127 531 90 413 31 213 24 73 103 374 22 129 111(M) 104(M) Vessels Diseased LAD Right Sx Left Main # Dst Anas > 3 Off-Pump On Pump Perf Time A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib Sinus A-Fib A-Fib Sinus 151 871 151 871 151 871 151 871 151 871 301 721 151 871 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 0,0001 0,01 NS 0,006 <0,0001 <0,0001 NS

  15. RESULTS…. % RR OR P Hospital Stay N 151 871 8(Median) 6(Median) <0,0001 Hospital Stay A-Fib + Hospital Stay Sinus

  16. RESULTS….. % RR OR P Stroke N 151 871 10/151 21/871 8(Median) 6(Median) 6,6% 3,05% Hospital Stay A-Fib Hospital Stay Sinus Stroke A-Fib + Stroke Sinus 2,1 2,2 <0,0001 <0,03

  17. RESULTS…… Mortality N % RR OR P 151 871 10/151 22/871 17/151 21/871 8(M) 6(M) 6,6% 2,5% 11% 2.4% 2,1 4,6 2,2 5,1 Hospital Stay A-Fib Hospital Stay Sinus Stroke A- Fib + Stroke Sinus Mortality A- fib + Mortality Sinus <0,0001 <0,03 <0,001

  18. RISK PATIENTS P OR Males Age > 65 Years Peripheral Vasc Dis Angina NYHA > III ASA > III CCS > III Emergent IABP On-Pump Surgery 5,5 3,3 5,5 3,4 2,3 3,7 2,04 1,7 1,6 0,36 <0,0001 <0,0001 0,01 <0,0001 <0,0001 <0,0001 <0,0001 0,02 0,02 <0,0001

  19. RISK PATIENTS.. OR P Hypertension Smoking COPD Diabetes Renal Impairment Obesity LAD Lesion Right Lesion Left Main Disease # Distal Anastomosis >= 3 2,17 1,6 2,9 2,5 2,1 1,2 2,5 1,5 2,06 2,8 <0,001 <0,004 0,0001 0,03 0,04 0, 01 0,0001 0,01 0,006 <0,0001

  20. Conclusion : Atrial Fibrillation Incidence 14,7% Mortality 11% Median hospital stay 8 days Incidence of stroke 6,6 %

  21. Conclusion: Atrial Fibrillation.. Atrial Fibrillation is probably a marker of underlying disease Post operatively (Tip of the Iceberg). (Ears of hippopotamus) Atrial fibrillation Atrial fibrillation Age Atrial Ischemia Diabetes Atrial Ischemia Age Diabetes Hypertension On Pump On Pump Hypertension

  22. MANAGEMENT • Identify the risk patients Atrial fibrillation Age Atrial Ischemia Diabetes Hypertension On Pump

  23. MANAGEMENT. • Identify the risk patients • Non withdrawal of B Blockers

  24. MANAGEMENT.. • Identify the risk patients • Non withdrawal of B Blockers • Prophylactic use of Amidiarone and or B Blockers

  25. MANAGEMENT… • Identify the risk patients • Non withdrawal of B Blockers • Prophylactic uses of Amidiorone and B Blockers • Post operative overdrive pacing of the atrium

  26. MANAGEMENT…. • Identify the risk patients • Non withdrawalof B Blockers • Prophylactic uses of Amidiarone and B Blockers • Post operative pacing of the atrium • Aggressive Treatment of Atrium Fibrillation Post operative to prevent stroke

  27. THANK YOU!!! Ke Ya Kopa!!!

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