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Postoperative atrial fibrillation: mechanisms, manifestations and management

Abstract

Postoperative atrial fibrillation (POAF) complicates 20–40% of cardiac surgical procedures and 10–20% of non-cardiac thoracic operations. Typical features include onset at 2–4 days postoperatively, episodes that are often fleeting and a self-limited time course. Associated adverse consequences of POAF include haemodynamic instability, increased risk of stroke, lengthened hospital and intensive care unit stays and greater costs. Underlying mechanisms are incompletely defined but include intraoperative and postoperative phenomena, such as inflammation, sympathetic activation and cardiac ischaemia, that combine to trigger atrial fibrillation, often in the presence of pre-existing factors, making the atria vulnerable to atrial fibrillation induction and maintenance. A better understanding of the underlying mechanisms might enable the identification of new therapeutic targets. POAF can be prevented by targeting autonomic alterations and inflammation. β-Blocker prophylaxis is the best-established preventive therapy and should be started or continued before cardiac surgery, unless contraindicated. When POAF occurs, rate control usually suffices, and routine rhythm control is unnecessary; rhythm control should be reserved for patients who develop haemodynamic instability or show other indications that rate control alone will be insufficient. In this Review, we summarize the epidemiological and clinical features of POAF, the available pathophysiological evidence from clinical and experimental investigations, the results of prophylactic and therapeutic approaches and the consensus recommendations of various national and international societies.

Key points

  • Atrial fibrillation (AF) is a very common complication after cardiac surgery and also often occurs after non-cardiac thoracic surgery, increasing duration of hospital stay and costs.

  • Postoperative AF episodes are usually transient and follow a typical time course, peaking at 2–4 days after surgery.

  • Underlying mechanisms are specific and complex, including inflammation, myocardial ischaemia and adrenergic activation, in many cases superimposed on an underlying atrial substrate vulnerable to the induction and maintenance of AF.

  • Prophylactic therapy with β-blockers or amiodarone is often indicated to prevent postoperative AF, but if AF nevertheless occurs, control of ventricular rate is usually sufficient because postoperative AF tends to be self-limited.

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Fig. 1: Conceptual model of postoperative atrial fibrillation.
Fig. 2: Time course of the components of a vulnerable substrate for postoperative atrial fibrillation.
Fig. 3: Major components of atrial remodelling in postoperative atrial fibrillation.
Fig. 4: Principles of postoperative atrial fibrillation management in cardiac surgery.

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Acknowledgements

The authors are supported by grants from the German Research Foundation (Do 769/4-1; D.D.), German Center for Cardiovascular Research (D.D.), US NIH (R01-HL131517 and R01-HL136389; D.D.), Canadian Institutes of Health Research (S.N.) and Quebec Heart and Stroke Foundation (S.N.).

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Nature Reviews Cardiology thanks H. Calkins, A. Gillinov and the other anonymous reviewer(s), for their contribution to the peer review of this work.

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Dobrev, D., Aguilar, M., Heijman, J. et al. Postoperative atrial fibrillation: mechanisms, manifestations and management. Nat Rev Cardiol 16, 417–436 (2019). https://doi.org/10.1038/s41569-019-0166-5

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