Elsevier

International Journal of Cardiology

Volume 324, 1 February 2021, Pages 38-43
International Journal of Cardiology

Association between cardioplegia and postoperative atrial fibrillation in coronary surgery

https://doi.org/10.1016/j.ijcard.2020.09.065Get rights and content

Highlights

  • Warm cardioplegia may reduce the rate of POAF in CABG patients.

  • Other risk factors for POAF were age, LVEF, IABP, hypercholesterolemia, redo.

  • Cold cardioplegia is associated with worse early outcome.

  • POAF is associated with worse early outcome.

Abstract

Objective

The aim of this multicenter study was to evaluated whether cold or warm cardioplegia are associated with postoperative atrial fibrillation (POAF) and the prognostic role of the latter on early stroke and neurological mortality.

Method

This was a retrospective analysis of prospective collected data from 9 cardiac centers in Italy and the United States including patients undergoing surgery between 2010 and 2018. From the 9 institutional databases, 17,231 patients underwent isolated CABG on-pump, using either warm cardioplegia (n = 7730) or cold cardioplegia (n = 9501); among the latter group blood and crystalloid cardioplegia were used in 691 and 8810 patients, respectively. After matching, two pairs of 4162 patients (overall cohort 8324) were analyzed.

Results

In matched population, the rate of POAF was 18% (1472 cases), 15% (608) in warm group versus 21% (864) in cold group (p < 0.001). Multivariable analysis confirmed that cold cardioplegia was associated with higher rate of POAF, along with age, hypercholesterolemia, LVEF, reoperation, preoperative IABP, previous stroke, cardiopulmonary and cross-clamp. Moreover, cold cardioplegia as well as POAF increased the rate of postoperative stroke as well as early mortality and neurological mortality Propensity-weighted cohort included 11,830 (70%) patients out of 17,231. After adjustment, both cold blood and cold crystalloid cardioplegia negatively influenced POAF, stroke and neurological mortality.

Conclusions

Warm cardioplegia may reduce the rate of POAF in CABG patients with respect to cold cardioplegia, either blood or crystalloid. This has a prognostic impact on postoperative stroke and neurological mortality.

Introduction

The prevalence of postoperative atrial fibrillation (POAF) ranges between 20% and 50%; this wide range is due to differences in definitions of postoperative atrial fibrillation and type of surgery (coronary surgery, valvular, combined coronary and valvular surgery). In fact, POAF occurred in 20–30% of patients undergoing coronary artery bypass grafting (CABG) and in 40–50% after valvular surgery, particularly mitral valve surgery [[1], [2], [3], [4], [5]].

Several risk factors predisposing to atrial fibrillation (AF) have been identified so far: 1) preoperative: age, left ventricular dysfunction, left atrial enlargement, obesity, hypertension, chronic heart failure, chronic pulmonary disease, history of AF; 2) intra- and postoperative: cross-clamp and cardiopulmonary bypass duration, intra-aortic balloon pump, bicaval cannulation, venting via pulmonary vein, inotropic and diuretic use, pericardial fluid [[3], [4], [5], [6], [7], [8], [9]].

There are several evidences that POAF is associated with inflammatory response, and cardiopulmonary bypass (CPB) might contribute to the systemic inflammatory state [[10], [11], [12]]. In addition to CPB, other factors including hypothermia, hemodilution, electrolyte imbalance, pharmacological agents used during surgery have also been implicated in initiating inflammatory responses, being so a possible trigger for POAF [[13], [14], [15]].

The onset of POF has a remarkable impact on the hospital length-of-stay, but it is also linked to severe complication. Indeed, POAF has been repetitively shown to play an important role in the genesis of cerebrovascular events in the postoperative phase.

Hence, the aim of this multicenter study was to evaluated whether cold or warm cardioplegia are associated with POAF and the prognostic role of the latter on early stroke and neurological mortality.

Section snippets

Materials and methods

This was a retrospective analysis of prospective collected data from 9 cardiac centers in Italy and the United States including patients undergoing CABG between 2010 and 2018. All patients consented to surgery. The need for retrospective consent to data collection was waived by local ethical committees. A common dataset, with agreed definitions and variables, was used for this study. Only in-hospital events and outcomes were assessed. Inclusion criteria were isolated, elective, on-pump, with

Results

From the 9 institutional databases, 17,231 patients underwent isolated CABG on-pump, using either warm cardioplegia (n = 7730) or cold cardioplegia (n = 9501); among the latter group blood and crystalloid cardioplegia were used in 691 and 8810 patients, respectively. Three centers used only cold cardioplegia, two centers used only warm cardioplegia, two centers used mainly cold cardioplegia, two centers mainly warm cardioplegia. After matching two pairs of 4162 patients (overall cohort 8324)

Discussion

The overall rate of POAF reported in this multicenter study was 18%, slightly below the range reported in the literature [[1], [2], [3], [4], [5]]; in particular, patients having warm cardioplegia showed an incidence of 15%, very low compared to others [[1], [2], [3], [4], [5]]. Conversely, patients having cold cardioplegia were more prone to develop POAF (21%).

Whether cold or warm cardioplegia can be associated with POAF has not been established yet [17,18]. Franke et al. [18] reported 41% of

Conclusions

Warm cardioplegia may reduce the rate of postoperative atrial fibrillation in CABG patients with respect to cold cardioplegia, either blood or crystalloid. This has a prognostic impact on postoperative stroke and neurological mortality. A further randomized trial is deemed to be necessary to confirm the results of the present study.

Funding

No fund was used for this study.

Disclosures

There are no relationships with industry.

References (44)

  • A. Mezzetti et al.

    Intermittent antegrade warm cardioplegia reduces oxidative stress and improves metabolism of the ischemic-reperfused human myocardium

    J. Thorac. Cardiovasc. Surg.

    (1995)
  • J. Gianetti et al.

    Supplemental nitric oxide and its effect on myocardial injury and function in patients undergoing cardiac surgery with extracorporeal circulation

    J. Thorac. Cardiovasc. Surg.

    (2004)
  • J. Shen et al.

    The persistent problem of new-onset postoperative atrial fibrillation: A single institution experience over two decades

    J. Thorac. Cardiovasc. Surg.

    (2011)
  • R.P. Villareal et al.

    Postoperative atrial fibrillation and mortality after coronary artery bypass surgery

    J. Am. Coll. Cardiol.

    (2004)
  • C.H. Yeh et al.

    Continuous tepid blood cardioplegia can preserve coronary endothelium and ameliorate the occurrence of cardiomyocyte apoptosis

    Chest

    (2003)
  • J.R. López et al.

    Potassium channel openers prevent potassium-induced calcium loading of cardiac cells: Possible implications in cardioplegia

    J. Thorac. Cardiovasc. Surg.

    (1996)
  • S.A. Lubitz et al.

    Long-term outcomes of secondary atrial fibrillation in the community: The Framingham Heart Study

    Circulation

    (2015)
  • J.W. Greenberg et al.

    Postoperative atrial fibrillation following cardiac surgery: A persistent complication. Eur

    J. Cardiothorac. Surg.

    (2017)
  • A. Ahlsson et al.

    Postoperative atrial fibrillation in patients undergoing aortocoronary bypass surgery carries an eightfold risk of future atrial fibrillation and a doubled cardiovascular mortality

    Eur. J. Cardiothorac. Surg.

    (2010)
  • B.A. Steinberg et al.

    Management of postoperative atrial fibrillation and subsequent outcomes in contemporary patients undergoing cardiac surgery: Insights from the Society of Thoracic Surgeons CAPS-Care Atrial Fibrillation Registry

    Clin. Cardiol.

    (2014)
  • D. Dobrev et al.

    Postoperative atrial fibrillation: Mechanisms, manifestations and management

    Nat. Rev. Cardiol.

    (2019)
  • J.P. Mathew et al.

    A multicenter risk index for atrial fibrillation after cardiac surgery

    JAMA

    (2004)
  • Cited by (0)

    View full text