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Bilfinger. Vessel Plus 2022;6:40 https://dx.doi.org/10.20517/2574-1209.2021.118 Page 3 of 5

[13]
not necessarily opened and many surgeons prefer less invasive approaches . Other studies however report
efficacy rates similar to mitral valve procedures. While lesion sets and the use of different energy sources are
hotly debated issues, the guidelines for instance do not address when during the conduct of an operation the
AF should be dealt with (before or after the index procedure, combination). The lowest denominator with
some consensus for the minimal intervention seems to be to exclude the left atrial appendage with a clip or
[14]
sutures and that stapling the appendage is unreliable and should not be done .
Aside from technical aspects, further considerations are how to handle antiarrhythmic drugs. Short of beta
blockers which we know should not be interrupted, how to handle class III antiarrhythmics is less clear. If at
all and when they should be held and if for instance amiodarone should be loaded pre or intra-op, the latter
being a common practice, has not been studied well although European Association for Cardio-Thoracic
Surgery (EACTS) and American College of Cardiology (ACC) have prophylaxis guidelines. Also not well
studied is if a patient on pre-op amiodarone should receive an extra intra-op loading dose or just a
maintenance dose or nothing due to the long half-life. Suffice it to say amiodarone is often continued for 2
to 3 months post-op .
[15]
POST-OP CONSIDERATIONS IN PATIENTS WITH PREEXISTING AF
Up until recently the demonstration of a long-term survival benefit for concomitant operations for AF
patients has been difficult. The amount of data showing a benefit is however increasing, although the
argument made by the guidelines is still that the addition of ablative surgery is not inferior/detrimental to
the patient and improves quality of life [10,16,17] . From a practical stand-point the next question to be answered
is: when should anticoagulation be reinstituted and with what? The Society of Thoracic Surgeons (STS)
guidelines state it is reasonable to reinstitute anticoagulation for 2 to 3 months. The perioperative
management of patients on chronic oral anticoagulant therapy (now including not only Warfarin but also
NOAC’s) is a common but complex clinical problem with little high quality data for the practitioner . The
[2]
[4]
subject is addressed in the EACTS guidelines . In the US, a common practice is to start anticoagulation
after 48 to 72 hours post-op . This time point is empiric and there exists no randomized data looking at
[6]
timing in this patient subset. The same is true for dosing, if the patient was on warfarin, the pre-op dose is
commonly restarted. If the patient was on a NOAC it has been proposed to restart the same at 72 hours
although a lot of teams would use low molecular weight heparin (LMWH) for bridging until discharge .
[5]
There is data particularly from Scandinavia suggesting that dual antiplatelet therapy particularly in the case
of CABG in this patient subset is not justified as increased bleeding is already recognized.

What to do with the patient who either remains in AF or goes back into AF in the early post-op phase is
also unclear. The STS guidelines suggest that it is common to start the patient on amiodarone in the
operating room. They further suggest that if the patient is in AF after 3 months consideration to a catheter
AF ablation should be given. If for instance an attempt at cardioversion while still in the hospital or the
application of additional amiodarone loading doses are reasonable in this circumstance has never been
systematically looked at although we know that in the post-op de-novo AF population rhythm control has
no advantage over rate control .
[18]
QUESTIONS IN POAF
POAF is the most common complication after cardiac surgery. It has been reported in 20% to 40% of cases
and a recent large meta-analysis found an incidence of 23.7% . As a matter of fact, it occurs so frequently
[19]
that a lot of physicians don’t think of it as a complication and for instance no International Classification of
Diseases (ICD)-10 code is assigned to POAF. Historically it has been thought of as a nuisance which had to
be dealt with, but was self-limiting. This assumption was based on the finding that POAF is predominantly