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Page 4 of 9 Rove et al. Vessel Plus 2022;6:55 https://dx.doi.org/10.20517/2574-1209.2021.133

Table 1. Mortality after cardiac surgery with and without postoperative atrial fibrillation, adapted from Eikelboom et al. [3]
Years after cardiac % Mortality with % Mortality with no Odds ratio mortality with POAF P value
surgery POAF POAF (95%CI)
1 6% 4% 1.7 (1.1-2.6) P = 0.02
5 15% 10% 1.6 (1.5-1.7) P <
0.0001
10 29% 23% 1.5 (1.4-1.6) P <
0.0001

cardiac surgical patients per year) results in over $1 billion per year of increased cardiac surgical
hospitalization-related costs alone, not to mention the additional costs associated with medical treatments
(e.g., anticoagulation) and post-discharge monitoring. In 2020, the Medicare total expenditures for all
[17]
hospital care were reported at $141.2 billion . Not directly reimbursed by Medicare, these POAF “unpaid”
costs are born by health care providers. As a gigantic elephant in the room, this $1 billion for estimated
post-cardiac surgical atrial fibrillation cost represents a significant (potentially preventable) burden that has
not been-as of yet-directly raised for discussion by professional societies or hospital providers.

POAF prophylaxis
Although various pharmacologic and non-pharmacologic interventions have been promoted to prevent
POAF, POAF still remains the most common complication after cardiac surgery.

Pharmacologic prophylaxis
Since 2007, the STS ACSD has incorporated a National Quality Forum endorsed quality measure for
isolated CABG related to preoperative beta-blocker administration: “Indicate whether or not the patient
[7]
received beta-blockers within 24 h preceding incision time, or if beta-blocker was contraindicated” .
Although the dose details (e.g., 12.5 mg of metoprolol within 24 h) were not required to be documented,
this quality metric was added due to evidence that beta-blockers may reduce the incidence of POAF [18-20] .
Despite the very high (90.3%) level of preoperative beta-blocker administration compliance across STS
participating centers, the incidence of STS-defined POAF remains at 26.3% . If one assumes that a large
[12]
proportion of patients are excluded by the more restrictive STS definition per the analysis by
Filardo et al. , then the POAF rate of 26.3% represents an underestimation.
[10]

In addition to beta blockade, preoperative amiodarone (Class IIa, level of evidence A), prophylactic sotalol
(Class IIb, level of evidence B) and prophylactic postoperative colchicine (Class IIb, level of evidence B) are
also recommended as pharmacologic interventions that can be considered to reduce POAF [21,22] .

Non-pharmacologic prophylaxis
Non-pharmacologic interventions that can be considered to reduce the incidence of POAF include atrial
[23]
pacing and posterior pericardiotomy. Gaudino et al. recently published a single-center randomized
controlled trial examining the effect of posterior pericardiotomy on the incidence of POAF in patients
undergoing coronary, aortic valve and or aortic surgery. POAF was significantly lower in the left
pericardiotomy group, 17% vs. 32%, P = 0.0007. Lower incidence of POAF was associated with a lower
[23]
incidence of pericardial effusion, 12% vs. 21%, relative risk 0.58 (95%CI: 0.37-0.91) .
A Cochrane systematic review evaluated randomized controlled trials of pharmacologic and non-
pharmacologic interventions and efficacy in preventing POAF or supraventricular tachycardia after cardiac
surgery . The pharmacologic interventions included in the review were amiodarone, beta-blockers, sotalol
[14]