Does preoperative atrial fibrillation increase the risk for mortality and morbidity after coronary artery bypass grafting?
Preoperative atrial fibrillation has been associated with less favorable outcomes in patients undergoing coronary artery bypass grafting. However, it was never investigated in a large cohort of patients using a national database. This study aims to (1) identify the effect of atrial fibrillation on operative mortality and morbidity in patients undergoing isolated coronary artery bypass grafting and (2) identify the potential effect of atrial fibrillation on patients with decreased left ventricular ejection fraction (<or=40%).
The Society of Thoracic Surgeons National Adult Cardiac Surgery Database was used for patients with coronary artery disease undergoing isolated coronary artery bypass grafting (n = 281,567). The association between atrial fibrillation and outcomes was estimated within 3 categories of low (ejection fraction, <40%), moderate (ejection fraction, 40%-55%), or normal (ejection fraction, >55%) systolic function.
Patients with atrial fibrillation were found to be older and have a higher incidence of comorbidities. A higher incidence of all major complications and mortality after surgical intervention was documented. An interaction between atrial fibrillation and an ejection fraction of greater than 40% for mortality, stroke, prolonged ventilation, and prolonged length of stay was identified.
Our findings suggest that preoperative atrial fibrillation is associated with an increased risk for perioperative mortality and morbidity in patients undergoing coronary artery bypass grafting. The negative effect of atrial fibrillation might be more significant in patients undergoing coronary artery bypass grafting with an ejection fraction of greater than 40%. Both the EuroSCORE and, until recently, the Society of Thoracic Surgeons risk calculator do not include atrial fibrillation as a potential risk modifier; however, based on this study, it should be identified as a variable to be investigated and incorporated into future risk calculators.
Available from: Walter F. Stafford
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ABSTRACT: It has been known for some time that slow kinetics will distort the shape of a reversible reaction boundary. Here we present a tutorial on direct boundary fitting of sedimentation velocity data for a monomer-dimer system that exhibits kinetic effects. Previous analysis of a monomer-dimer system suggested that rapid reaction behavior will persist until the relaxation time of the system exceeds 100 s (reviewed in Kegeles and Cann, 1978). Utilizing a kinetic integrator feature in Sedanal (Stafford and Sherwood, 2004), we can now fit for the k(off) values and measure the uncertainty at the 95% confidence interval. For the monomer-dimer system the range of well determined k(off) values is limited to 0.005 to 10(-5) s(-1) corresponding to relaxation times (at a loading concentration of the Kd) of approximately 70 to approximately 33,000 s. For shorter relaxation times the system is fast and only the equilibrium constant K but not k(off) can be uniquely determined. For longer relaxation times the system is irreversibly slow, and assuming the system was at initial equilibrium before the start of the run, only the equilibrium constant K but not k(off) can be uniquely determined.
Methods in enzymology 02/2009; 455:419-46. DOI:10.1016/S0076-6879(08)04215-8 · 2.09 Impact Factor
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ABSTRACT: Although chronic atrial fibrillation (AF) is thought to negatively affect survival after aortic valve replacement (AVR), evidence is limited and intraoperative methods to restore sinus rhythm are not widely adopted. This study investigated long-term outcome in valve prosthesis patients with or without AF.
Between 1994 and 2006, 420 patients with the same mechanical prosthesis were prospectively entered into a database; 90 had chronic AF preoperatively. Medical therapy was used to attempt to restore sinus rhythm postoperatively, but none had intraoperative ablation. All were anticoagulated with warfarin and monitored serially in National Health Service (United Kingdom) clinics. Survival and adverse events were determined by detailed review.
Mean follow-up was 79.5 months (range, 18 months to 13.5 years); 12 were lost to follow-up. Procedures included 225 AVRs with or without coronary bypass (AVR with CABG), 151 mitral valve replacements (MVR) with CABG, and 32 double-valve replacements (DVR). Preoperative AF patients remained in the same rhythm 6 months postoperatively. Prosthesis-related events were infrequent. For chronic AF patients, mortality at 10 years was greater after AVR (64.3% vs 19.2% p < 0.001), AVR with CABG (83.3% vs 21.3% p < 0.001), and DVR (80.0% vs 17.6% p < 0.001). Survival after isolated MVR or MVR with CABG (p > 0.05) was similar. Most MVR with CABG patients in sinus rhythm had acute ischemic mitral regurgitation. Greater age (p = 0.001) and preoperative AF (p = 0.02) were risk factors for death.
Chronic AF negatively affects survival after AVR with or without CABG and DVR with a mechanical prosthesis. Prospective randomized evaluation of AF ablation is suggested for these patients.
The Annals of thoracic surgery 03/2010; 89(3):738-44. DOI:10.1016/j.athoracsur.2009.12.023 · 3.85 Impact Factor
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ABSTRACT: The impact of pre-existing atrial fibrillation on the long-term outcome in patients after off-pump coronary revascularisation is not well known. This study aims to determine the independent effects of preoperative atrial fibrillation on the early and late outcomes of off-pump coronary artery bypass surgery.
A total of 513 patients undergoing isolated coronary artery bypass surgery using off-pump approach between 2000 and 2005 were studied. Twenty-six of them (5.1%) had preoperative atrial fibrillation (15 had paroxysmal atrial fibrillation and 11 had persistent or permanent atrial fibrillation) and the other 487 patients were in normal sinus rhythm. Early and late outcomes were compared retrospectively between patients with preoperative atrial fibrillation and patients in sinus rhythm. The median follow-up period for the entire study population was 3.3 + or - 2.7 years.
The baseline characteristics of the patients with preoperative atrial fibrillation were generally similar to those of patients in sinus rhythm. However, the patients with atrial fibrillation had a significantly lower left ventricular ejection fraction compared with those in sinus rhythm (50 + or - 15 vs 56 + or - 12%, p=0.03). The mean age of the atrial fibrillation group was almost 3 years more than that of the sinus rhythm group. Operative mortality was similar in patients with atrial fibrillation (3.8%) and those in sinus rhythm (1.0%). Ten patients developed cerebral infarction within 7 days after surgery, including one patient (3.8%) from the atrial fibrillation group and nine patients (1.8%) from the sinus rhythm group. Long-term survival was significantly decreased in the atrial fibrillation group (5-year survival: 70 + or - 9.6% vs 87 + or - 1.8%; p=0.0018). Freedom from cerebral complications was also significantly decreased in the atrial fibrillation group (5-year survival: 85 + or - 8.3% vs 95 + or - 1.2%; p=0.0009), but there were no differences in cardiac death and major cardiac adverse events. On Cox proportional hazards regression analysis, preoperative atrial fibrillation was a significant adverse predictor for survival (hazard ratio=3.0, 95% confidence intervals (CIs) 1.3-6.9; p=0.009) and independent predictor of late cerebral infarction (hazard ratio=6.2, 95% CIs 2.0-19.3; p=0.0002).
Uncorrected preoperative atrial fibrillation is strongly associated with poor long-term survival and increased late cerebral complications after off-pump coronary artery bypass surgery. Concomitant atrial fibrillation surgery should be considered to improve the long-term results of surgical revascularisation.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 03/2010; 38(3):366-72. DOI:10.1016/j.ejcts.2010.01.062 · 3.30 Impact Factor
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