How to prevent the most common complication after heart surgery
New-onset postoperative atrial fibrillation (POAF) remains the most common complication following cardiac surgery, typically developing within four days of treatment. While it often resolves on its own, POAF is also associated with longer hospitalizations, higher healthcare costs and an increased risk of poor clinical outcomes, including long-term mortality.
How can care teams work to minimize a patient’s risk of developing POAF? What is the best way to manage POAF once it develops? To answer those very questions, the Society of Thoracic Surgeons (STS) gathered a committee of cardiac surgeons, cardiologists, anesthesiologists and intensivists who specialize in POAF. The group reviewed years of data, including randomized trials and contemporary treatment guidelines, and landed on a total of 15 recommendations for reducing the risk of POAF after cardiac surgery. This included eight preventive strategies, three intraoperative techniques and four postoperative treatments.
The committee’s report, first presented at the STS annual meeting in New Orleans, is now published in full in The Annals of Thoracic Surgery.[1]
“Based on expert panel deliberation and a comprehensive review of current evidence, this clinical practice guideline provides clinicians with evidence-based recommendations for the prevention and management of new-onset POAF after cardiac surgery,” wrote first author Subhasis Chatterjee, MD, writing group co-chair and a cardiothoracic surgeon with Baylor College of Medicine, and colleagues. “Whereas several existing atrial fibrillation guidelines address POAF only briefly, this document serves as a focused, current, and comprehensive resource specifically dedicated to guiding its prevention and treatment after cardiac surgery.”
A bit of context about POAF
Chatterjee et al. noted that POAF occurs in up to 50% of patients following combined coronary artery bypass grafting (CABG) and valve procedures. The POAF rates are smaller, but still quite high, after isolated CABG (20-30%) or an isolated valve procedure (30-40%).
The group also noted that older age, left atrial enlargement, obesity, obstructive sleep apnea, left ventricular systolic/diastolic dysfunction, prior asymptomatic supraventricular arrhythmias, chronic obstructive pulmonary disease, diabetes, chronic kidney disease and beta-blocker withdrawal are all preoperative factors associated with an increased risk of POAF. When it comes to intraoperative factors, on the other hand, they pointed to cardiopulmonary bypass, a prolonged cross-clamp time and complex surgeries as things that may increase a patient’s POAF risk. Finally, intravenous inotrope use and aggressive diuresis following treatment are also linked to a higher risk.
15 expert recommendations to manage POAF
The committee’s recommendations were all researched and evaluated thoroughly. Chatterjee and colleagues provided detailed evidence to support each point.
1. In patients undergoing cardiac surgery, perioperative oral amiodarone administration is indicated to prevent new-onset POAF.
2. In patients undergoing cardiac surgery, perioperative beta-blocker administration is reasonable to prevent new-onset POAF.
3. In patients undergoing cardiac surgery, perioperative use of nondihydropyridine calcium channel blockers may be reasonable to prevent new-onset POAF.
4. In patients undergoing cardiac surgery, the use of perioperative glucocorticoids may be considered to prevent new-onset POAF.
5. In patients undergoing cardiac surgery, perioperative intravenous magnesium may be considered to prevent new-onset POAF.
6. In patients undergoing cardiac surgery, colchicine may be effective in preventing new-onset POAF.
7. In patients undergoing cardiac surgery, routine potassium repletion is not recommended to prevent new-onset POAF.
8. In patients undergoing cardiac surgery, high-dose antioxidant vitamin or metabolic supplement regimens are not recommended for prevention of new-onset POAF.
9. In patients undergoing cardiac surgery, creation of a left posterior pericardiotomy should be considered at the time of cardiac surgery to prevent new-onset POAF.
10. In patients undergoing cardiac surgery, biatrial pacing may be considered for prevention of new-onset POAF.
11. In patients undergoing cardiac surgery, injection of botulinum toxin into epicardial fat pads is not recommended to prevent new-onset POAF.
12. Among patients who develop POAF with hemodynamic instability, electrical cardioversion is recommended.
13. Among patients with hemodynamically stable POAF, a strategy of rate control versus rhythm conversion may be reasonable.
14. In patients without prior history of atrial fibrillation undergoing cardiac surgery who develop new-onset POAF, oral anticoagulation may be considered to prevent thromboembolic events while weighing the risk of bleeding.
15. In patients without prior history of atrial fibrillation undergoing cardiac surgery who develop new-onset POAF and anticoagulation is initiated, direct oral anticoagulants may be considered to reduce the risk of bleeding compared with vitamin K antagonists.
Final thoughts on an important topic
“In conclusion, POAF is common and clinically consequential after cardiac surgery and is associated with perioperative morbidity as well as heightened risks of late atrial fibrillation, stroke, and heart failure hospitalization,” the authors wrote. “Preventive strategies, meticulous rhythm surveillance, and individualized anticoagulation can mitigate these risks, but multidisciplinary collaboration and sustained evidence generation through registries and pragmatic trials will be necessary. Key priorities include clarifying modifiable variables, refining prediction tools, and measuring arrhythmia burden—efforts that will be pivotal to translating mechanistic insights into durable system-wide improvements in patient outcomes.”
Click here to read the full document, including the detailed explorations of each and every recommendation, in The Annals of Thoracic Surgery.
Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.