Mnagement of Perioperative Atrial Fibrillation

1. Atrial Fibrillation (AF)
Current Evidence & Management Strategies During the Perioperative Period
Dr Samaresh Das

2. • AF is the most common sustained cardiac arrhythmia, prevalence in
England ~2%, increases with age, men >women)
• POAF the incidence of new-onset AF among surgical patients is expected to
increase with time
• Associated with increased overall risk of in-hospital morbidity & mortality,
an independent predictor of stroke
Perioperative Atrial Fibrillation (POAF)

3. Pathophysiology of AF

4. The Heart Rhythm society defines 3 types of AF
• Paroxysmal AF: MC in perioperative setting, occur and terminate spontaneously. Can
last >2 days but usually resolve within a week
• Persistent: Last >7days & will not terminate without treatment
• Permanent: will not terminate even with drug or electrical therapy
Pathophysiology of AF: Types
Current hypothesis is, the natural history of AF involves an evolution from paroxysmal to persistent to
permanent via atrial remodeling by arrhythmia itself &/or progression of underlying heart disease
Thus, preventing perioperative AF may avoid long- term development of persistent and permanent AF

5. Pathophysiology of AF

6. Causes and Risk Factors
Surgery Related Risk Factors
• Hypo/hypervolemia
• Hypoxia
• Intraoperative hypotension
• Vasopressor use
• Trauma, Pain, increase sympathetic activity
• Type of surgery
• Hypoglycemia, Electrolyte imbalance (low
Mg, K)
• Anemia, Bleeding
Patient-Related Risk Factors
• Age
• Race (lower in African Americans)
• History of AF
• HT, IHD, CHF, Valvular disease
• CRF
• Sepsis
• Asthma
• COPD
• Obstructive sleep apnea

7. Impact of POAF
• Patients who develop POAF have higher in-hospital mortality, longer stay, &
increased hospitalization costs
A 2008 POISE Study, 2014, 2019 study assessing the long-term risk of stroke
in patients after cardiac and noncardiac surgery

8. Prevention
• POAF is difficult to predict, any factors for POAF is a potential target for
intervention
• Where possible, addressing patient related factors and averting
perioperative triggers of sympathetic stimulation may not only reduce the
likelihood of developing de novo AF but also avoid precipitation of RVR in
patients with pre- existing paroxysmal and chronic AF
• Metaanalysis of 2018

9. Prevention

10. Management of POAF
Preoperative:
• ACC /AHA recommendation of new onset arrhythmias
• Decision to cancel/ postpone for workup AF should case-by-case basis and
include discussions with the surgical team
• Preexisting AF/RVR, IV diltiazem/β blocker is reasonable for heart rate control
• Rate control medications should be continued until the day of surgery
• Continuation of anticoagulation are patient & procedure dependent

11. Pts on DOAC
Risk for
bleeding
Hold DOAC
Procedural
bleeding risk
Pts on VKA
Risk for
bleeding
Procedural
bleeding risk
Procedural
bleeding risk
Don’t interrupt Interrupt InterruptClinical judgement
Low, intermediate,
high or uncertain
NO
YES
YESNO
Low, not
relevant
Intermediate,
High
Uncertain
Don’t interrupt therapy, coincide
procedure time with DOAC interval
Low, not
relevant
Intermediate,
High
Uncertain
Preop management of Anticoagulation
Major bleed /ICH within 3 months, platelets abnormality, Aspirin use, subtherapeutic INR, prior bleed during prev. bridging
Clinically unimportant

12. Bleeding Vs Stroke

13. Management of POAF
Intraoperative:
• Intraoperative AF: immediate management depends on HR & BP
• RVR with low BP refractory to vasoconstrictor therapy requires cardioversion
• RVR with adequate BP, rate control (HR < 110/min) using β-blockers or CCB
(Metoprolol is superior to diltiazem)
• Amiodarone is reasonable alternative if contraindication to β blocker or CCB
• Digoxin is less effective in case of increase sympathetic activity and having less
therapeutic/toxic window

14. • Phenylephrine is another alternative in pts with RVR with low BP
• HR <110 bpm is usually acceptable if perfusion is not impaired
• Causes of AF & modifiable risk factors should be evaluated while stabilizing
HR & BP
• Fluid status/Electrolytes
• Desflurane- associated with increased sympathetic stimulation & arrhythmias
• Position of CVC catheter can precipitate AF
Management of POAF

15. Postoperative:
• Persistent AF or Postop. AF: Preserve BP & end organ perfusion & control of HR
• Bedside ultrasound to estimate LV function & to exclude AMI &/or PE
• If patient is on β-blocker or CCB preoperatively, restart the regimen
• As with intraoperative AF, β-blockers, CCBs digoxin, and amiodarone can be used
• Patients should be discharged on rate-control agents unless contraindicated
• Antithrombotic therapy should be considered on a case-by-case basis in patients
who develop POAF
Management of POAF

16. • Avoid triggers, arrhythmogenic
drugs ** & sympathetic
stimulation
• Treat unstable AF/RVR with
cardioversion
• Stable AF with rate control
therapy
• TEE with high risk patient to
evaluate cause and guided
therapy
• Consider CPAP with OSA
• Treat unstable AF/RVR with
cardioversion
• Stable AF with rate control
therapy
• Continue rate control therapy
at discharge & follow up
• Consider anticoagulation
therapy when appropriate
Perioperative Consideration
**Ketamine, adrenergic vasopressors, desflurane, glycopyrrolate, atropine

17. Treatment for AF
AF confirmed by 12 lead ECG, If rate >150, consider AVNRT & try adenosine Investigations: FBC, UE, LFT, Mg, Ca
Coag. chest X-ray
Onset <12 hours, or 12-48 hours with a CHA2DS2-VASc score of 0? Or, anti-coagulated for >4 weeks
• HR <100: no need for rate control
• HR ≥100: METOPROLOL 5mg I/V, max 10mg (depending on BP
& clinical response, if no contra-indications)
• If beta-blocker contra-indicated, give DILTIAZEM 60mg PO DO
NOT GIVE IF BETA BLOCKER ALREADY GIVEN
• Frail/elderly/CCF patients: consider DIGOXIN 500mcg PO or I/V
• REASSESS after 1 hr., stable, no compromise, HR < 130
Rate control Rhythm control
Normal ECHO, No sign/symptoms of heart failure? Suitable for sedation
NO YES
NONO
Direct Current Cardioversion
(DCCV) 120/150/200 J
YES
• FLECANIDE 2mg/kg I/V over 30- 60mins, max
150mg
• Observe for 3 hours
• If any concerns giving flecanide then DCCV/Rate
control
YES
NSR, HR ≥60: Bisoprolol 2.5-5mg OD
If remains in AF: Bisoprolol 2.5-5mg OD
Any C/I, Diltiazem 60mg TDS
• If HR >130, repeat rate control medication
Depends on Type of AF &other health conditions.
Aim: reduce risk of clot formation, control of rate & rhythm to control symptoms

18. Conclusion
• AF is the most common perioperative arrhythmia mainly with older patients present for surgery
• Avoid perioperative triggers & optimizing patient related factors
• AF progresses from paroxysmal to persistent to permanent, therefore try to manage
perioperative paroxysmal AF more efficiently
• Surgical stimulation, bleeding, swings in vital signs, and fluctuating volume levels, management
of AF can be challenging, & the use of intraoperative TEE and transthoracic ultrasound may rule
out dangerous causes such as PE or MI and allow for early, aggressive treatment
• Postoperative continuation of rate-control therapy initiated during discharge
• Because of risk of perioperative stroke, prophylaxis should be discussed between
anesthesiologist, intensivist, surgeon & cardiologist

19. Ideas for Further Research
• Determining prevalence of permanent/paroxysmal AF in patients who develop perioperative NOAF
• Association between severity of OSA and POAF
• Use of perioperative CPAP in patients with OSA and impact on POAF incidence
• Intraoperative blood pressure goals to prevent POAF
• Influence of intraoperative vasopressor choice on POAF
• Influence of intraoperative ketamine use on POAF
• Influence of NMB reversal agents on POAF
• Optimal dose, route of administration, and timing of perioperative β-blockers to prevent AF
• β-Blockers versus CCB’s versus Amiodarone for treatment of POAF
• Optimal duration of rate-control therapy after discharge in patients who develop POAF
• Optimal type and timing of restart of anticoagulation in the postop period in patients with NOAF

20. Thanks