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Arrhythmias and conduction disturbances after cardiac surgery

Arrhythmias and conduction disturbances after cardiac surgery. Anjan Gupta M.D. Milwaukee Heart Institute University of Wisconsin, Milwaukee anjangupta@pol.net. Post cardiac surgery atrial arrhythmias. INCIDENCE OF ATRIAL FIBRILLATION OR FLUTTER AFTER CABG.

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Arrhythmias and conduction disturbances after cardiac surgery

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  1. Arrhythmias and conduction disturbances after cardiac surgery Anjan Gupta M.D. Milwaukee Heart Institute University of Wisconsin, Milwaukeeanjangupta@pol.net

  2. Post cardiac surgery atrial arrhythmias

  3. INCIDENCE OF ATRIAL FIBRILLATION OR FLUTTER AFTER CABG Reference No. of Pts developing ECG Peak incidence and patients atrial fibrillation documentation (days postop) Year studied or flutter No Percent Buxton, 1981 99 29 29 COM, Holter 3 Fuller, 1989 1666 473 28 COM, Holter 2 Yousif, 1990 100 19 19 COM, ECG <3 Leitch, 1990 5807 999 17 COM, ECG - Crosby, 1990 418 115 27 COM -

  4. INCIDENCE OF ATRIAL FIBRILLATION OR FLUTTER AFTER CABG Reference No. of Pts developing ECG Peak incidence atrial fibrillation and patients or flutter documentation (days postop) Year studied No Percent Klein, 1995 54 16 30 COM, ECG - Frost, 1995 128 38 30 COM, Holter - Frost, 1995 120 35 29 COM, ECG - Mendes,1995 168 57 34 COM, Holter 3 Augostini ‘96 33 9 24 COM, ECG -

  5. FACTORS ASSOCIATED WITH POST CABG ATRIAL FIBRILLATION AND FLUTTER PREOPERATIVE FACTORS Reference and No. of patients Significant predictive factors Year studied Buxton, 1981 99 P wave duration Fuller, 1989 1666 Age, preop digoxin treatment Yousif, 1990 100 Myocardial ischaemia Leitch, 1990 5807 Age, COPD, CRF, HTN, Preop diuretic, Preop beta blocker, CTR>0.5, LM or 3 vessel CAD Crosby, 1990 1990 Age

  6. FACTORS ASSOCIATED WITH POST CABG ATRIAL FIBRILLATION AND FLUTTER PREOPERATIVE FACTORS Reference and No. of patients Significant predictive factor Year studied Klein, 1995 54 P wave duration on Signal averaged ECG Frost, 1995 102 Age, low vagal tone, ectopic SV beats, NSSVT Mendes, 1995 168 Severe RCA disease, age, male gender Augostini, 1995 33 Age Asher, 1996 2196 Age, Internal mammary conduit

  7. FACTORS ASSOCIATED WITH POST CABG ATRIAL FIBRILLATION AND FLUTTER PEROPERATIVE FACTORS Reference and No. of patients Significant predictive factor Year studied Capucci,1987 50 Atrial conduction delay Yousif, 1990 100 Adj. coronary endarterectomy, topical cardiac cooling Leitch,1990 5807 More than 3 distal anastomosis Lowe, 1991 1991 Pace inducibility of atrial fibrillation

  8. FACTORS ASSOCIATED WITH POST CABG ATRIAL FIBRILLATION AND FLUTTER POSTOPERATIVE FACTORS Reference and No. of patients Significant predictive factor Year studied Fuller, 1989 1666 Postoperative beta blocker treatment, stroke Frost, 1995 128 atrial ectopics, SVT, atrial arrhythmias Augostini, 1995 33 sinus cycle length, sinus node recovery time sinoatrial conduction time

  9. SIGNIFICANT PREOPERATIVE PREDICTORS OF POSTOPERATIVE AFIB BY UNIVARIATE ANALYSIS Predictor Relative Risk (95% CI) p - value History of Atrial fibrillation 2.00 (1.75 - 2.30) <0.01 Valvular disease 1.50 (1.29 - 1.75) <0.01 CHF 1.44 (1.26 - 1.65) <0.01 Vascular disease 1.27 (1.09 - 1.47) <0.01 Mathew et al , JAMA 1996 ; 276 : 300 - 306

  10. MULTIVARIABLE PREDICTORS OF POSTOPERATIVE AFIB Predictors Odds Ratio (95% CI) p - value Hx of atrial fibrillation 2.28 (1.74 - 3.00) <0.01 Pulmonary Vein Venting 1.44 (1.13 - 1.83) <0.01 Male Sex 1.41 (1.09 - 1.81) <0.01 Age (per 5-y increase) 1.24 (1.18 - 1.31) <0.01 Mathew et al , JAMA 1996 ; 276 : 300 - 306

  11. Length of stay in hospital after postop atrial arrhythmias Creswell et al, Ann. of Thoac. Surg, 1993;56:539 - 49

  12. Incidence of V-Fib, V-Tach and stroke associated with postop atrial arrhythmias Creswell et al, Ann. of Thoac. Surg, 1993;56:539 - 49

  13. Day of onset of atrial fibrillation after CABG Klein et al.Am Ht Jn, 1995;129:895 - 901

  14. Prevalence of A-fib according to age at operation Leitch et al, Jn of Th. Card Surg,1990;100:338-342

  15. Postoperative atrial fibrillation - Treatment Ibutilide - a new drug for atrial Fibrillation and Flutter • Class III antiarrythmic drug • In a randomized trial was proven to be superior to placebo in converting post op afib ( Kowey et al ) • A-flutter responds better than A-fib • Adverse effects include development of Torsades

  16. Atrial Fibrillation MANAGEMENT OF POST CABG AFIB Post CABG Afib Unstable Stable DC cardioversion Rate control Recurrent Persists > 48 - 72 hrs AA drugs IV/oral procainamide, quinidine AA drugs Effective Anticoagulate IV/PO procainamide, quinidine Ineffective Continue therapy Effective DC cardioversion Ineffective DC Cardioversion Continue therapy Add AA drugs if needed Successful Unsuccessful DC Cardioversion Continue drug Anticoag, new drug Successful Unsuccessful Continue drug Anticoag, new drug

  17. Ventricular Tachyarrhythmias

  18. Ventricular arrhythmias EPIDEMIOLOGIC FEATURES • Ventricular ectopy, including NSVT is seen in about 50% of patients after cardiac surgery • Sustained VT and ventricular fibrillation occur rarely after cardiac surgery (0.4 - 1.4% reported in various studies)

  19. Ventricular arrhythmias STUDIES OF VT AFTER CARDIAC SURGERY Authors Patients Age (yr) Incidence EF Time from op Kron et al 18 1.4% 38 ± 15 2 days to 6 wks Topol et al 12 64 ± 8 0.72% 39 ± 10 2 days to 5 mth Sapin et al 13 62 ± 11 44 ± 16 5 hr to 7 days Tam et al 16 59 ± 10 0.68% 25 ± 4 1hr to 12 days Costeas et al 17 65 ± 8 0.41% 37 ± 11 24hr to 15 days

  20. Ventricular arrhythmias DIAGNOSIS • 12 Lead ECG • Postoperative telemetry monitoring • Bipolar atrial recording with epicardial wires

  21. Ventricular Arrhythmias MANAGEMENT OF POST CABG VT/VF Post CABG Sust. Vent. Tachyarryth. Ventricular Fibrillation Ventricular tachycardia Defib. IV Lido, Proc, Brety Identify/Treat ppt factors No Recurrence Recurrence Unstable Stable Use V-Fib Protocol IV Lido, Procain, Brety Use other IV drugs eg Amio No further AA therapy EPS guided AA therapy Treat Ppt factors, Defib Unsuccessful Successful Recurrence No recurrence Consider ICD therapy Continue the drugs No further therapy Use V Fib recurr. protocol

  22. Ventricular arrhythmias Management of PVC’s and NSVT • Simple PVC’s usually do not require Rx • Frequent PVC’s can be suppressed by atrial pacing • If frequent and symptom producing can be suppressed with beta blockers or AA • No role for prophylactic lidocaine • Patients with NSVT and EF <40% role of EP testing ?

  23. Ventricular Arrhythmias Variables POVD No POVD p - value n = 25 n = 84 Age 62.8 ±9.7 56.2 ±7.5 0.0024 EF (%) 66.2 ±9.3 66.1 ±9.6 0.95 CrossClamp time (min) 55.6 ±15 57.4 ±21.1 0.70 By-pass time (min) 111.8 ±2.5 111.0 ±33.9 0.91 Preop beta blockers 21 72 0.91 Preop Ca Ch blockers 17 66 0.41 Previous MI 8 25 0.97 LM disease 8 17 0.34 LAD disease 22 74 0.74 Perioperative MI 4 7 0.46 PAD 11 19 0.30 Other Comp 2 13 0.53 Ferraris et al, J Cardiovasc Surg 1991;32:12 - 19

  24. Post cardiac surgery arrhythmias Potential causes and precipitating factors • Myocardial ischemia or infarction • Hemodynamic instability • Electrolyte abnormalities a) Hypokalemia, b) Hypomagnesemia • Metabolic disturbances • a) Acidosis, b) Alkalosis, c) Hypoxemia • Drugs • a) Sympathomimetics, b) Antiarrhythmics, c) Anesthetic • Reperfusion effect • Tissue trauma or inflammation, indwelling catheters • Increase in catecholamines

  25. Conduction Disturbances Epidemiologic features and pathogenesis • Transient conduction disturbances can occur in 4% to 58% of patients after CABG • RBBB is the most frequently noted abnormality • Incidence of isolated AV block is low after CABG but may be higher after associated valve surgery

  26. Conduction Disturbances Risk factors associated with Post CABG conduction disturbances Studies Significant Risk Factors Emlein et al , 1993 age > 64, LBBB Flack et al, 1992 use of cold cardioplegia Caretta et al, 1991 LM disease LAD stenosis, RCA occl

  27. Conduction disturbances Intraventricular conduction defects • Incidence of postoperative fascicular conduction defects vary from 3-5% • Longterm adverse prognosis is ascribed to appearance of new LBBB and nonspecific IVCD • Postoperative LBBB has no immediate clinical impact and no specific Rx needed

  28. Conduction disturbances First Degree AV block • Most commonly due to fibrosis of AV node or toxicity of medications such as beta blockers or calcium channel blockers • Other causes include edema of AV node region after mitral and aortic valve replacement • No specific therapy is usually needed

  29. Conduction disturbances Second-Degree AV block • Mobitz Type I and Type II blocks are common after valve replacement surgery • Drug effect or toxicity should be excluded as potential causes • Temporary pacing may be needed depending on degree of AV block and HR as well as adequacy of lower escape rhythm

  30. Conduction disturbances Complete AV block • May be secondary to cardioplegia washout during immediate postoperative period or as a consequence of antiarrhythmic drug therapy • It may be seen after valve replacement secondary to trauma of surgical manipulation in the area of AV node or bundle of HIS

  31. Conduction disturbances Complete AV block • Therapy depends on underlying heart rate and adequacy of underlying ventricular escape rhythm • Discontinuation of all potentially offending drugs

  32. Conduction disturbances Complete AV block • Factors which predict low likelihood of recovery include calcified Aortic valve, delayed appearance of AV block and significant preop conduction defect • In absence of excessive calcification, and in presence of a narrow complex escape rhythm with a good heart rate, PPM placement may be delayed up to 2 wks

  33. Meta-analysis of randomized control trials of prevention of post-operative supraventricular arrhythmias Treatment RCT Total # Proportion of pts OR (95% CI) P-Val Group Patients with SVA (%) Rx Control Verapamil 3 432 18.2 18.2 0.9 (.57-1.5) 0.69 Digoxin 5 507 14.2 17.6 0.9 (.6 - 1.5) 0.88 Preop beta- 6 478 8.1 40.1 0.2 (.1 - .3) <0.01 blocker Postop beta- 12 1071 8.9 32.3 0.3 (.2 - .4) <0.01 blocker Andrews et al, Circulation 1991;84(suppl) : 236 - 244

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