Postoperative Atrial Fibrillation

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Postoperative atrial fibrillation (AF) is new-onset AF occurring within 48 hours after surgery.

• The patient did not have diagnosed AF before surgery.
• This is triggered AF because it has a clear trigger.

The risk of postoperative AF is:

• 30–60 % after cardiac surgery.
• 5–30 % after major non-cardiac surgery.

As prevention of postoperative AF, discontinuation of beta-blockers before surgery is not recommended.

As prevention of postoperative AF, preoperative administration of a beta-blocker or amiodarone may be considered.

Prevention of postoperative atrial fibrillation
Timing	Drug and dose	Postoperative treatment
1 day before surgery	Metoprolol tartrate 25 – 50 mg oral twice daily	Continue for 5 days
1 – 6 hours before surgery	Amiodarone 300 mg intravenous	200 mg oral three times daily for 5 days, then 200 mg oral once daily for 5 days, then discontinue treatment

Amiodarone is not administered routinely for prevention of cardiac surgery postoperative AF,

• it is administered only in high-risk patients with an increased risk of postoperative cardiac surgery AF.

Increased risk of postoperative cardiac surgery atrial fibrillation
Age >65–70 years
Enlarged left atrium (>40 mm, or LAVI >34 ml/m2)
Pre-existing atrial fibrillation
Left ventricular dysfunction (EF <50%)
Previous cardiac surgery
Complex or prolonged cardiac surgery Combined procedures (CABG + AVR, CABG + MVR, multivalve surgery) Major valve surgery (especially mitral, tricuspid, re-do) Aortic root or ascending aorta surgery (Bentall, David, dissections) Redo operations (repeat sternotomy) Procedures with prolonged ECC/clamp time (>120 min ECC, >90 min cross-clamp)

LAVI – left atrial volume index. EF – ejection fraction. CABG – coronary artery bypass grafting. AVR – aortic valve replacement. MVR – mitral valve replacement. ECC – extracorporeal circulation (cardiopulmonary bypass).

Long-term anticoagulation therapy after cardiac surgery postoperative AF is uncertain:

• because any cardiac surgical procedure is considered a major and clear AF trigger.
• The trigger is mainly pericardial effusion.

As prevention of cardiac surgery postoperative AF, left posterior pericardiotomy is recommended.

• which reduces the incidence of postoperative AF by 47 %.

Left posterior pericardiotomy:

• After cardiac surgery, a 2–3 cm incision/opening (pericardiotomy) is made on the left posterior aspect of the heart.
• The opening serves as drainage of pericardial effusion into the left pleural cavity.
• which prevents pericardial effusion and tamponade and also serves as AF prevention.

Postoperative atrial fibrillation	Class
Amiodarone is recommended for prevention of cardiac surgery postoperative AF in patients at increased risk of postoperative cardiac surgery AF.	I
Posterior pericardiotomy should be considered as prevention of cardiac surgery postoperative AF.	IIa
Anticoagulation therapy should be considered in new-onset postoperative AF according to CHA2DS2-VA score.	IIa
Preoperative administration of beta-blockers for prevention of postoperative AF (non-cardiac) is not recommended.	III

If a patient develops postoperative AF after cardiac surgery (without premedication with amiodarone),

• then for pharmacological cardioversion, amiodarone is recommended immediately after cardiac surgery:
• 300 mg intravenous bolus, then
• 1,200 mg/24 hours infusion, then
• 200 mg oral once daily for 5 days.

These guidelines are unofficial and do not represent formal guidelines issued by any professional cardiology society. They are intended for educational and informational purposes only.