Page 125 - Read Online

Page 4 of 9 Kuruvilla et al. Vessel Plus 2022;6:45 https://dx.doi.org/10.20517/2574-1209.2021.122

POST-OPERATIVE ATRIAL FIBRILLATION [POAF] INCIDENCE IN TAA REPAIR
Specifically focusing on TAA repair, new-onset POAF is significantly associated with increased short-term
and long-term adverse outcomes. New-onset POAF in thoracic aortic procedures ranged in incidence from
17.1% to 53.9% [11,12] . Further, multiple studies noted that a large proportion of the new-onset AF population
reverts to sinus rhythm (SR) upon discharge or long-term follow-up based upon cardioversion or
[13]
antiarrhythmic drug therapy. In one study 65.8% (n = 88/134) of new-onset POAF patients returned to SR
as compared to another study that noted 100% (n = 33) TAA patients with new-onset POAF returned to
[13]
sinus rhythm . Incidence rates of POAF from population-based studies are summarized in [Table 1].

TAA PATIENTS’ RISK FACTORS PREDISPOSING TO POAF
As many as fifty percent of patients undergoing thoracic surgery develop new-onset POAF . Given the
[11]
high prevalence of this adverse outcome, researchers have studied whether any baseline characteristics are
associated with its development. Matsuura et al. studied patients undergoing total arch repair for
[9]
atherosclerotic aortic arch aneurysm or aortic dissection, and found that advanced age was the primary risk
factor that correlated with post-operative atrial fibrillation development. He et al. studied patients with
[11]
aortic aneurysm, or dissection of the ascending, arch, thoracic, or abdominal aorta; their study again
documented advanced age as an important risk characteristic; in multivariable analysis, however, cardiac
dysfunction was an independent POAF predictor in addition to older age.

Nishi et al. evaluated Japanese patients in their Adult Cardiac Surgery database; of these patients receiving
[13]
a variety of cardiac surgical procedures, patient age [odds ratio (OR) = 1.55 for each decade with 95%
confidence interval (CI) from 1.30 to 1.85], any blood product transfusion (OR = 2.09, 95%CI: 1.03 to 4.26),
and a thoracic aortic procedure (OR = 2.08, 95%CI: 2.12 to 3.55) were the most important multivariable
model POAF predictors.

Other studies have examined the impact of TAA patient’s baseline risk factors on the development of new-
onset POAF, including age, history of smoking, operation urgency, chronic obstructive pulmonary disease,
diabetes, hypertension, perioperative myocardial infarction, thoracic surgery, and concomitant non-elective
coronary artery bypass graft (CABG) surgery [12,14-16] . Compared to abdominal aortic procedures,
[16]
Perzanowski et al. identified, using multivariable modeling, thoracic aortic repair procedures as
particularly vulnerable to POAF, as well as patients with thoracic aortic repairs who were also hypertensive
represented a special “at risk” patient sub-group. See [Table 2] for the list of multivariable risk factors that
were statistically significant POAF predictors.

OUTCOMES OF POST-OPERATIVE ATRIAL FIBRILLATION (POAF) IN TAA REPAIR
The outcomes of post-operative atrial fibrillation in TAA repair are favorable, depending upon how early
TAA management measures are implemented. One of the best-known prophylactic treatments for atrial
fibrillation is B-blocker therapy, and this same treatment has also been utilized for post-operative atrial
fibrillation . Interestingly, however, no significant difference in POAF rates was documented between
[13]
TAA patients with and without pre-operative beta-blocker therapy. A study was conducted that compared
outcomes following aortic root replacement in octogenarians versus non-octogenarians. It was found that
octogenarians could safely undergo this surgery with moderately worse but acceptable perioperative
mortality and late survival. Several post-operative complications were reported, including POAF and
reoperation for bleeding, stroke, respiratory failure, new need for continuous renal replacement therapy,
myocardial infarction, and new permanent pacemaker. The octogenarians had a significantly higher rate of
POAF (60.6% octogenarians versus 38.5% non-octogenarians, P < 0.01). Even though there was a higher
octogenarian POAF rate, there was no statistically significant difference in the post-TAA procedural