**10. References**


Postoperative Atrial Fibrillation (POAF), Coronary artery bypass graft (CABG), SinoAtrial (SA) node, AtrioVentricular (AV) node, Electrocardiogram (ECG), Ventricular tachycardia (VT), Ventricular fibrillation (VF), Angiotensin converting enzyme inhibitor (ACE I), Cardio Pulmonary Bypass (CPB), Implantable cardiac defibrillator (ICD), Permanent Pacemaker (PPM), American college of Cardiology (ACC), American Heart Association (AHA), European society of Cardiology (ESC), Advanced cardiovascular life support (ACLS).

[4] Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential

[5] Sloan SB, Weitz HH. Postoperative arrhythmias and conduction disorders. Med Clin

[6] Forrest JB, Cahalan MK, Rehder K, Goldsmith CH, Levy WJ, Strunin L, Bota W, Boucek

[7] Lauer MS, Eagle KA, Buckley MJ, DeSanctis RW. Atrial fibrillation following coronary artery bypass surgery. Prog Cardiovasc Dis. 1989 Mar-Apr; 31(5):367-78. [8] Goldman L. Supraventricular tachyarrhythmias in hospitalized adults after surgery.

[9] Lahey SJ, Campos CT, Jennings B, Pawlow P, Stokes T, Levitsky S. Hospital readmission

[10] Maisel WH, Rawn JD, Stevenson WG; Atrial fibrillation after cardiac surgery; Ann

[11] Pavri BB, O'Nunain SS, Newell JB, Ruskin JN, William G. Prevalence and prognostic

[12] Creswell LL, Schuessler RB, Rosenbloom M, Cox JL. Hazards of postoperative atrial

[13] Mathew JP, Fontes ML, Tudor IC, Ramsay J, Duke P, Mazer CD, Barash PG, Hsu PH,

[14] Aranki SF, Shaw DP, Adams DH, Rizzo RJ, Couper GS, VanderVliet M, Collins JJ Jr, Cohn

trends and impact on hospital resources. Circulation. 1996 Aug 1; 94(3):390-7 [15] Ambrosetti M, Tramarin R, Griffo R, De Feo S, Fattirolli F, Vestri A, Riccio C, Temporelli

diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991

CD, Cucchiara RF, Dhamee S, et al. Multicenter study of general anesthesia. II.

Clinical correlates in patients over 40 years of age after major noncardiac surgery.

after cardiac surgery. Does "fast track" cardiac surgery result in cost saving or cost

significance of atrial arrhythmias after orthotopic cardiac transplantation. J Am

Mangano DT; Investigators of the Ischemia Research and Education Foundation; Multicenter Study of Perioperative Ischemia Research Group. A multicenter risk index for atrial fibrillation after cardiac surgery. JAMA. 2004 Apr 14; 291(14):1720-9

LH, Burstin HR. Predictors of atrial fibrillation after coronary artery surgery. Current

PL; on behalf of the ISYDE and ICAROS investigators of the Italian Society for Cardiovascular Prevention, Rehabilitation and Epidemiology (IACPR-GICR). Late postoperative atrial fibrillation after cardiac surgery: a national survey within the cardiac rehabilitation setting. J Cardiovasc Med (Hagerstown). 2011 Jun; 12(6):390-395

[1] Ganong WF. Review of Medical Physiology. 22nd Edition.

North Am. 2001 Sep; 85(5):1171-89

Chest. 1978 Apr; 73(4):450-4.

[3] Conover MB. Understanding Electrocardiography. 8th Edition.

Results. Anesthesiology. 1990 Feb; 72(2):262-8.

Intern Med. 2001 Dec 18; 135(12):1061-73

Coll Cardiol. 1995 Jun; 25(7):1673-80

shifting? Circulation. 1998 Nov 10; 98(19 Suppl):II35-40.

arrhythmias. Ann Thorac Surg. 1993 Sep; 56(3):539-49

**9. Abbreviations** 

**10. References** 

[2] Huff J. ECG work out. 5th Edition.

May; 83(5):1649-59.


Post Operative Arrhythmias 255

[44] Cummings JE, Gill I, Akhrass R, Dery M, Biblo LA, Quan KJ. Preservation of the

[46] Rader F, Gajulapalli RD, Pasala T, Einstadter D. Effect of Early Statin Therapy on Risk

[47] Lee JK, Klein GJ, Krahn AD, Yee R, Zarnke K, Simpson C, Skanes A, Spindler B. Rate-

[48] Camm AJ, Kirchhof P, Lip GY, Schotten U, et al. Guidelines for the management of

[50] Reddy P. Does prophylaxis against atrial fibrillation after cardiac surgery reduce length

[51] Zimmer J, Pezzullo J, Choucair W, Southard J, Kokkinos P, Karasik P, Greenberg MD,

[52] Crystal E, Garfinkle MS, Connolly SS, Ginger TT, Sleik K, Yusuf SS. Interventions for

[53] Chung MK. Cardiac surgery: postoperative arrhythmias. Crit Care Med. 2000 Oct; 28(10

[54] Chung E, Martin D. Management of post operative arrhythmias, Surgical Intensive care

[55] Smith RC, Leung JM, Keith FM, Merrick S, Mangano DT. Ventricular dysrhythmias in

[56] Rho RW, Bridges CR, Kocovic D. Management of postoperative arrhythmias. Semin

[57] Pinto RP, Romerill DB, Nasser WK, Schier JJ, Surawicz B. Prognosis of patients with

after coronary artery bypass graft surgery. Clin Cardiol. 1996 Apr; 19(4):321-4 [58] King FG, Addetia AM, Peters SD, Peachey GO. Prophylactic lidocaine for postoperative

[59] Rousou JA, Engelman RM, Flack JE 3rd, Deaton DW, Owen SG. Emergency

postoperative cardiac arrest. Circulation. 1994 Nov; 90(5 Pt 2):II280-4

of stay or hospital costs? Pharmacotherapy. 2001 Mar; 21(3):338-44

Concomitant Valve Surgery. Am J Cardiol. 2011 May 3.

randomized pilot study. Am Heart J. 2000 Dec; 140(6):871-7

fibrillation in humans. J Am Coll Cardiol. 2004 Mar 17; 43(6):994-1000. [45] White CM, Sander S, Coleman CI, Gallagher R, Takata H, Humphrey C, Henyan N,

Cardiol. 2007 Jan 23; 49(3):298-303.

Thorac Surg. 2006 Aug; 82(2):515-23

Am J Cardiol. 2003 May 1; 91(9):1137-40

Suppl):N136-44

Medicine 2010

1990 Apr; 37(3):363-8

Cochrane Database Syst Rev. 2004 Oct 18; (4):CD003611

Research Group. Am Heart J. 1992 Jan; 123(1):73-81.

Thorac Cardiovasc Surg. 2000 Oct; 12(4):349-61

anterior fat pad paradoxically decreases the incidence of postoperative atrial

Gillespie EL, Kluger J. Impact of epicardial anterior fat pad retention on post cardiothoracic surgery atrial fibrillation incidence: the AFIST-III Study. J Am Coll

of Atrial Fibrillation After Coronary Artery Bypass Grafting With or Without

control versus conversion strategy in postoperative atrial fibrillation: a prospective,

atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010 Oct; 31(19):2369-429. [49] Kollar A, Lick SD, Vasquez KN, Conti VR. Relationship of atrial fibrillation and stroke

after coronary artery bypass graft surgery: when is anticoagulation indicated? Ann

Singh SN. Meta-analysis of antiarrhythmic therapy in the prevention of postoperative atrial fibrillation and the effect on hospital length of stay, costs, cerebrovascular accidents, and mortality in patients undergoing cardiac surgery.

preventing post-operative atrial fibrillation in patients undergoing heart surgery.

patients undergoing coronary artery bypass graft surgery: incidence, characteristics, and prognostic importance. Study of Perioperative Ischemia (SPI)

frequent premature ventricular complexes and nonsustained ventricular tachycardia

coronary artery bypass patients, a double-blind, randomized trial. Can J Anaesth.

cardiopulmonary bypass in the cardiac surgical unit can be a lifesaving measure in


[31] Crystal E, Connolly SJ, Sleik K, Ginger TJ, Yusuf S. Interventions on prevention of

[32] Eagle KA, Guyton RA, Davidoff R, Edwards FH et al. ACC/AHA 2004 guideline

[34] Kowey PR, Taylor JE, Rials SJ, Marinchak RA. Meta-analysis of the effectiveness of

[36] Hazelrigg SR, Boley TM, Cetindag IB, Moulton KP, Trammell GL, Polancic JE, Shawgo

[37] Gomes JA, Ip J, Santoni-Rugiu F, Mehta D, Ergin A, Lansman S, Pe E, Newhouse TT,

[38] Patti G, Chello M, Candura D, Pasceri V, D'Ambrosio A, Covino E, Di Sciascio G.

[39] Davis EM, Packard KA, Hilleman DE. Pharmacologic prophylaxis of postoperative

[40] Blommaert D, Gonzalez M, Mucumbitsi J, Gurné O, Evrard P, Buche M, Louagie Y,

[41] Maisel WH, Epstein AE; American College of Chest Physicians. The role of cardiac

[42] Athanasiou T, Aziz O, Mangoush O, Weerasinghe A, Al-Ruzzeh S, Purkayastha S,

coronary artery bypass grafting? Ann Thorac Surg. 2004 May; 77(5):1567-74 [43] Wijeysundera DN, Beattie WS, Djaiani G, Rao V, Borger MA, Karkouti K, Cusimano RJ.

coronary artery bypass grafting. Am J Cardiol. 1992 Apr 1; 69(9):963-5 [35] Shiga T, Wajima Z, Inoue T, Ogawa R. Magnesium prophylaxis for arrhythmias after

Bypass Graft Surgery). J Am Coll Cardiol. 2004 Sep1; 44(5):e213-310 [33] Aasbo JD, Lawrence AT, Krishnan K, Kim MH, Trohman RG. Amiodarone prophylaxis

meta-analysis. Ann Intern Med. 2005 Sep 6; 143(5):327-36

controlled study. J Am Coll Cardiol. 1999 Aug; 34(2):334-9

Pharmacotherapy. 2010 Jul; 30(7):749, 274e-318e.

analysis. Circulation. 2002 Jul 2; 106(1):75-80

Sep 1; 117(5):325-33

2006 Oct 3; 114(14):1455-61

Cardiol. 2000 May; 35(6):1411-5

Aug; 128(2 Suppl):36S-38S.

6;46(5):872-82

77(3):824-30

postoperative atrial fibrillation in patients undergoing heart surgery: a meta-

update for coronary artery bypass graft surgery: Summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery

reduces major cardiovascular morbidity and length of stay after cardiac surgery: a

prophylactic drug therapy in preventing supraventricular arrhythmia early after

cardiac surgery: a meta-analysis of randomized controlled trials. Am J Med. 2004

TS, Quin JA, Verhulst S. The efficacy of supplemental magnesium in reducing atrial fibrillation after coronary artery bypass grafting. Ann Thorac Surg. 2004 Mar;

Chao S. Oral d, l Sotalol reduces the incidence of postoperative atrial fibrillation in coronary artery bypass surgery patients: a randomized, double-blind, placebo-

Randomized trial of atorvastatin for reduction of postoperative atrial fibrillation in patients undergoing cardiac surgery: results of the ARMYDA-3 (Atorvastatin for Reduction of Myocardial Dysrhythmia After cardiac surgery) study. Circulation.

atrial fibrillation in patients undergoing cardiac surgery: beyond beta-blockers.

Eucher P, Jamart J, Installé E, De Roy L. Effective prevention of atrial fibrillation by continuous atrial overdrive pacing after coronary artery bypass surgery. J Am Coll

pacing: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery. Chest. 2005

Pepper J, Amrani M, Glenville B, Casula R. Do off-pump techniques reduce the incidence of postoperative atrial fibrillation in elderly patients undergoing

Off-pump coronary artery surgery for reducing mortality and morbidity: metaanalysis of randomized and observational studies. J Am Coll Cardiol. 2005 Sep


**11** 

*UK* 

**Surgery for Atrial Fibrillation** 

*Wessex Cardiothoracic Centre, Southampton* 

Hunaid A. Vohra, Zaheer A. Tahir and Sunil K. Ohri

Atrial Fibrillation (AF) is characterised by rapid and disorganised depolarisation of the atria resulting in uncoordinated atrial contraction. It is the most common cardiac arrhythmia encountered in clinical practice increasing in prevalence with age and the presence of heart disease1 It is estimated that it affects 2.5 million people in the United States and 4.5 million in the European Union.2,3 The actual incidence of the arrhythmia may be much higher owing to undetected or asymptomatic patients within the population. Since it is an age-associated arrhythmia its incidence has steadily risen over the past decade and will continue to increase due to a growing population of the elderly in the western world. Contributing risk factors include hypertension, diabetes, coronary artery disease, valvular disease, electrolyte imbalance.4 Patients with atrial fibrillation have a higher risk for stroke, heart failure and death.5Given the significant morbidity and mortality associated with AF and its associated economic burden, it is not surprising that there has been great interest in developing

Atrial fibrillation is a supraventricular arrhythmia where uncoordinated rapid atrial contractions produce an irregular ventricular response. The atria may discharge between 300-600 beats per minute but not all these impulses are conducted by the AV node. Ventricular response can be between 100-160 beats per minute in untreated patients with normal AV conduction. This chaotic rhythm disrupts normal movement of blood through the heart reducing cardiac output and increasing the risk for thromboembolism such as

The serious morbidity and mortality associated with AF are attributed to three detrimental

 Loss of the coordinated atrioventricular contraction and "atrial kick" compromising cardiac haemodynamics and can lead to varying levels of ventricular dysfunction Stasis and pooling of stagnant blood that can lead to intra-atrial thrombus formation

Medical therapy remains the most common and first line treatment for patients with AF but frequently ineffective at restoring sinus rhythm leaving the patient susceptible to cardiovascular morbidity and mortality. Therefore, the goal of pharmacological therapy is often shifted from rhythm control (maintenance of sinus rhythm) to rate control (slowing

The Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) trial demonstrated no survival benefit of rhythm control strategy over a rate control strategy.

**1. Introduction** 

effective treatments for it.

the ventricular response to AF).7

consequences:

stroke as a consequence of stasis of blood in the atria.6

Palpitations causing significant patient discomfort and anxiety

and resulting in increased risk of thromboembolism

