379

CH
20
A
T
R
I
A
L

F
I
B
R
I
L
L
A
T
I
O
N
Prevention of postoperative AF, if possible, is the preferred
approach; -blocking agents have consistently been shown to
reduce postoperative AF and should be started preoperatively
and continued postoperatively.
144
Amiodarone, ideally in conjunc-
tion with -blockers, seems to be superior to -blockers alone, but
the long half-life of the drug is such that it is best started several
days before cardiac surgery.
145,146
Because many patients go to
cardiac surgery urgently, the optimal use of prophylactic amioda-
rone is limited to elective patients. The drug also has signicant
side effects, including postoperative bradycardia and, occasionally,
postoperative pulmonary damage. Neither digoxin nor calcium
channel antagonists have been shown to prevent postoperative
AF, and they should not be used for this indication.
144
Interestingly,
despite uncertain value in postcardioversion prophylaxis, statin
therapy started preoperatively appears to reduce the risk of post-
operative AF.
147,148
If a patient develops postoperative AF, the risks of anticoagula-
tion with recent surgery must be carefully weighed against poten-
tial benets of thromboembolism prophylaxis. No prospective
trials have evaluated postoperative anticoagulation as part of the
treatment of postoperative AF. Consensus guidelines suggest that
heparin should be limited to patients with postoperative AF who
are deemed to be at higher risk of thromboembolism, particularly
those who have had a prior stroke or TIA. For patients with arrhyth-
mia that has persisted for at least 48 hours, warfarin anticoagula-
tion is recommended, without heparin overlap, with an aim to
continue the drug for approximately 4 weeks after restoration of
sinus rhythm.
149
Naturally, extreme care needs to be taken in adjust-
ing anticoagulation in this patient population, and a signicant
proportion of patients may be deemed to be at a higher than
average risk of bleeding, for whom anticoagulation is considered
inadvisable.
The postcardiac surgery patient may be hemodynamically
unstable; consequently, ventricular rate control in AF is important.
On the other hand, many patients already have a relatively well-
controlled ventricular response because they are on -blocking
agents; the concern for ischemia is relatively low because
those with coronary artery disease will have had coronary
revascularization.
Pericardioversion Anticoagulation
The pericardioversion period represents a special situation in
terms of thromboembolic risk. After restoration of sinus rhythm,
atrial mechanical function may be diminished, and LAA emptying
velocities may be even lower than they were during AF.
137
Several
antiarrhythmic drugs with negative inotropic properties, including
propafenone and sotalol, have been shown to worsen postcardio-
version atrial function; thus they have the potential for promoting
thromboembolism.
138
The return of atrial function generally occurs
within 7 to 14 days after restoration of sinus rhythm, a period of
high thromboembolic risk. Thus, anticoagulation is mandated
during this time, even if a TEE showed no thrombus immediately
prior to cardioversion and even in patients who are deemed
not to need long-term warfarin for AF (i.e., those with lone AF;
Figure 20-2).
139,140
Current data suggest no clinical benet to early
transesophageal-guided cardioversion followed by warfarin over a
strategy of 3 to 4 weeks of warfarin before cardioversion and con-
tinued after cardioversion, although there may be some modest
cost savings.
141-143
Atrial Fibrillation Following
Cardiac Surgery
AF in the postcardiac surgery setting represents a unique situa-
tion. AF develops in 30% to 60% of cases and is more likely to occur
with valvular surgery than with isolated bypass surgery. As with
other types of AF, older age is a major risk factor. AF most often
develops within the rst 72 hours after surgery and may be asymp-
tomatic, or it may be associated with rapid rates and signicant
symptoms. Unlike most other types of AF, postoperative AF tends
to be self-limited and rarely recurs more than 4 weeks after surgery.
The approach to postoperative AF comprises four steps: the rst
is perioperative pharmacologic prophylaxis; if that fails, anticoagu-
lation, electrical or pharmacologic therapy, and/or ventricular rate
control is appropriate. In addition, several intraoperative measures
have been investigated for their effect on prophylaxis of postopera-
tive arrhythmia.
FIGURE 20-2 Algorithm for anticoagulation pericardioversion. AF, atrial fbrillation; CV, cardioversion; INR, International Normalized Ratio; TEE, transesophageal
echocardiography.
AF 48 hr
Cardiovert
Anticoagulate acutely
with heparin if INR
2.0 then cardiovert
Consider aspirin in
presence of structural
heart disease
Continue warfarin/dabigatran
anticoagulation for at
least 1 month depending
on risk factors
Yes
No
Risk factors
present?
AF 48 hr
or unknown
duration
TEE
No thrombus
present
Thrombus
present
Cardiovert, warfarin/dabigatran
for at least 1 month; if
risk factors present, then
anticoagulate for life
Warfarin/dabigatran for 4
weeks after which consider
TEE, or proceed to CV
Warfarin/dabigatran
for 3-4 weeks
Cardiovert
Warfarin/dabigatran for
at least 4 weeks, for life
if risk factors present
Yes
Heparin if
INR 2.0
No
AF
tolerated?