Association between cardioplegia and postoperative atrial fibrillation in coronary surgery
Graphical abstract
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.
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