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

0.05) for POAF; these predictors included acute aortic events (i.e., dissection or rupture), advanced age,
body surface area, urgent surgical status, concomitant CABG procedure, concomitant valve procedure,
aortic root procedures ascending aortic arch procedures, and arch procedures. Additionally, preoperative
[14]
antiarrhythmic drugs (i.e., digitalis, beta-blockers, or nitrates) did not seem to impact POAF rates . In
Perzanowski’s study, the patients that developed new-onset POAF had higher rates of post-operative
myocardial infarctions (25%) vs. non-POAF patients (10%). Further, new-onset POAF has been associated
in studies with increased length of post-operative hospital stay and increased length of ICU stay. In their
[9]
Japanese single-center study from 1993 to 2004, Matsuura et al. identified length of stay for POAF patients
as 49 ± 76 days versus non-POAF patients of 12 ± 23 days, P < 0.01. Most importantly, this publication
concluded that good POAF patient management was required in order to assure good TAA patients’
[15]
outcomes .

INSIGHTS FROM PRACTICING CLINICIANS
Overall, it is quite remarkable how few publications have addressed the perennial AF problem for the fast-
growing TAA patient population. Remarkably, no systematic literature reviews were identified on this TAA
POAF topic. In the two recently published guidelines by Society of Thoracic Surgeons/American
Association Thoracic Surgeons (STS/AATS) regarding Type A and B dissections, pre-operative and post-
operative AF topics were not addressed [17-19] . As a concern, cardiac tamponade, acute or delayed, arising
from prolonged bleeding represents a constant challenge. Hence, there is a desire to avoid or delay
anticoagulation therapy until it is no longer possible. Given the lack of information on how to define,
prevent, and treat TAA patients with AF challenges, several clinical care questions remain outstanding:

● Should all TAA patients receive prophylactic medications to prevent new-onset POAF?

● For the sub-group of TAA patients with pre-op AF or POAF:

■ How long should anticoagulation be delayed?

■ What anticoagulation agents should be used as first-line agents?

■ What mode of administration is generally preferable (oral or intravenous)?

● For the subgroup of TAA patients with POAF:

■ Is immediate cardioversion (i.e., rhythm control) advantageous to consider?

Although this approach has been commonly used, there is randomized trial evidence for a general cardiac
surgical population documenting that there is no advantage to rhythm control over rate control . In the
[20]
most recent 2021 clinical practice guidelines reported for surgical treatment of acute type A and B aortic
dissection [17-19] , no mention is made of either pre-operative TAA AF-related risks or post-TAA POAF as a
major complication requiring attention; why is this discussion missing? Given other recent guideline
recommendations for first-line vs. second-line medical therapies, additional recommendations for
prophylaxis in this particular high-risk TAA patient population would be welcomed.

Importantly, the absence of these latest clinical practice guidelines addressing the topic of arrhythmia
complications appears to be very telling: POAF as a TAA complication has not yet hit the cardiothoracic