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Eur J Cardiothorac Surg 2002;21:159
© 2002 Elsevier Science NL

Letter to the Editor

Postoperative atrial fibrillation after coronary surgery and prolonged intensive care unit stay: a coin with two sides

Cardiac Surgery Division, Civic Hospital, 25125 Brescia, Italy

Received 27 August 2001; accepted 14 October 2001.

* Corresponding author. Tel.: +39-30-3995-637/8; fax: +39-30-3995-004
e-mail: ptotaro{at}yahoo.com

Key Words: Coronary artery diseases • Myocardial revascularization • Atrial fibrillation

We read with interest the paper entitled ‘Atrial fibrillation after coronary artery bypass grafting: does the type of procedure influence the early postoperative incidence?’ by Siebert and colleagues, published in the April issue of the European Journal of Cardio-thoracic Surgery [1]. We would congratulate the authors for addressing such interesting issues, related to the most frequent complication after coronary surgery, with a linear and clear exposition. We have, however, some comments regarding the conclusions reached by Siebert and colleagues. Despite several studies have been published in order to elucidate potential risk factors, as well as potential prophylactic treatment, for early postoperative atrial fibrillation (AF), it has become clear that the onset of post-operative AF is multi-factorial phenomenon caused by the conjunction of particular triggering factors with a predisposed substrate [2]. A clear distinction should be made therefore when analysing potential risk factors in between potential predisposing substrate and potential triggering factors. In their paper, evaluating the type of surgical procedures as potential triggering factor for post-operative AF, Siebert and colleagues stated that AF is a common post-operative complication which cause a prolonged ICU stays. The correlation between postoperative AF and ICU stay, despite previously stressed by other authors [3], is, nonetheless, in our opinion, questionable, especially in the terms which have been proposed by Siebert and colleagues. The fact that the duration of ICU stay was higher in the group of patients who experienced AF, if compared to the patients with uneventful outcome, is indeed a coin which can be observed by two different sides. If we look at the reversed side of the coin in fact, the prolonged duration of the ICU stay can itself be a trigger situation for postoperative AF, instead that the consequence of postoperative AF. In low risk patients undergoing isolated CABG procedure with uneventful early postoperative outcome and early discharge from ICU, postoperative AF is, indeed, a frequent but usually self-limiting situation, well tolerated and most of the time easily converted to synus rhythm by mean of pharmacological treatment. Such a patients can be conventionally treated in the ward and usually they do not require to go back in ICU. Conversely in patients with unfavourable early postoperative outcome and/or high preoperative risk the AF can occurs during ICU stays and, in such a case, it could be triggered by the prolonged ICU stay or by some of the conditions frequently associated to the prolonged ICU stay (that is: persistent inotropic support, sepsis, prolonged mechanical ventilation), as recently shown by the experience of Mayr and colleagues [4]. In such a circumstance AF further impair the postoperative recovery, and it is usually hardly converted to SR, despite intensive pharmacological treatment. In conclusion we do believe that postoperative AF can assume different appearances, with extremely different clinical impact on the postoperative outcome, that should be, therefore, differentiated when talking about causes and effects of postoperative AF. Prolonged ICU stay is, moreover, rarely related only to the onset of post-operative AF in patients with otherwise uneventful outcome.

References

1. Siebert J., Anisimowicz L., Lango R., Rogowski J., Pawlaczyk R., Brzezinski M., Beta S., Narkiewicz M. Atrial fibrillation after coronary artery bypass graft: does the type of procedure influence the early postoperative incidence?. Eur J Cardiothorac Surg 2001;19:455-459.[Abstract/Free Full Text]
2. Jidéus L., Blomström P., Nilsson L., Stridsberg M., Hansell P., Blomström-Lundqvist C. Tachyarrhythmias and triggering factors for atrial fibrillation after coronary artery bypass operations. Ann Thorac Surg 2000;69:1064-1069.[Abstract/Free Full Text]
3. Almassi G.H., Schowalter T., Nicolosi A.C., Aggarwal A., Moritz T.E., Henderson W.G., Tarazi R., Shroyer A.L., Sethi G.K., Grover F.L., Hammermeister K.E. Atrial fibrillation after cardiac surgery: a major morbid event?. Ann Surg 1997;226(4):501-511.[Medline]
4. Mayr A., Knotzer H., Pajk W., Luckner G., Ritsch N., Dunser M., Ulmer H., Schobersberger W., Hasibeder W. Risk factors associated with new onset tachyarrhythmias after cardiac surgery — a retrospective analysis. Acta Anaesthesiol Scand 2001;45(5):543-549.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Pasquale Totaro Roberto Lorusso Gaetano Minzioni Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Totaro, P. Articles by Minzioni, G. Search for Related Content PubMed PubMed Citation Articles by Totaro, P. Articles by Minzioni, G. Related Collections Electrophysiology - arrhythmias