Postoperative atrial fibrillation: mechanisms, manifestations and management

• Published in: Nature reviews cardiology 2019-07, Vol.16 (7), p.417-436
• Main Authors: Dobrev, Dobromir, Aguilar, Martin, Heijman, Jordi, Guichard, Jean-Baptiste, Nattel, Stanley
• Format: Article
• Language: English
• Subjects: 692/4019/592/75/29/1309; 692/700/459/1748; 692/700/565/545; Adrenergic beta blockers; Adrenergic beta-Antagonists - therapeutic use; Amiodarone; Amiodarone - therapeutic use; Animals; Anti-Arrhythmia Agents - therapeutic use; Atrial fibrillation; Atrial Fibrillation - epidemiology; Atrial Fibrillation - etiology; Atrial Fibrillation - physiopathology; Atrial Fibrillation - prevention & control; Calcium Channel Blockers - therapeutic use; Cardiac arrhythmia; Cardiac Imaging; Cardiac Pacing, Artificial; Cardiac Surgery; Cardiac Surgical Procedures - adverse effects; Cardiology; Care and treatment; Diagnosis; Dosage and administration; Heart; Heart Atria; Heart Rate; Heart surgery; Humans; Inflammation; Medicine; Medicine & Public Health; Medicine, Preventive; Methods; Myocardial Ischemia - complications; Postoperative Complications - epidemiology; Postoperative Complications - etiology; Postoperative Complications - physiopathology; Postoperative Complications - prevention & control; Practice Guidelines as Topic; Preventive health services; Review Article; Risk factors; Sotalol - therapeutic use; Surgery; Thoracic surgery
• ISSN: 1759-5002; 1759-5010
• DOI: 10.1038/s41569-019-0166-5

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. Postoperative atrial fibrillation complicates 20–40% of cardiac surgical procedures. In this Review, the authors summarize the epidemiological and clinical features of postoperative atrial fibrillation, the available pathophysiological evidence and the recommended prophylactic and therapeutic approaches. 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 mainten