Professional Documents
Culture Documents
CARDIOVASCULAR
Anticoagulation Indicated?
Andras Kollar, MD, PhD, Scott D. Lick, MD, Kathleen N. Vasquez, PA, and
Vincent R. Conti, MD
Division of Cardiothoracic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, Texas
Background. Atrial fibrillation (AF) is considered as a intraoperative and 4 having postoperative stroke. Of the
risk factor for stroke after coronary artery bypass grafting 6 patients with AF before neurologic event, three strokes
operations. occurred within 1 week after spontaneous conversion to
Methods. A retrospective search in our hospitals med- normal sinus rhythm. One patient with preoperative and
ical record database was done to identify patients with also with intraoperative AF who underwent emergency
postoperative strokes who underwent coronary artery coronary artery bypass grafting woke up with stroke. In
bypass grafting operations from January 1, 1993, until the remaining two cases, the AF or atrial flutter episodes
December 31, 2004. All cases were individually reviewed, lasted less than 6 hours each before the neurologic event.
and the temporal relationship between neurologic event More aggressive anticoagulation as suggested in the
and postoperative episodes of AF was determined. Dur- published guidelines could not have prevented strokes
ing the study period it was our consistent policy to use in any of these 6 patients.
only Coumadin anticoagulation limited to patients who Conclusions. This retrospective analysis does not sup-
had persistent AF or were to be discharged in AF. port the use of aggressive anticoagulation, particularly
Results. Of the 2,964 coronary artery bypass grafting full intravenous heparinization as a bridging therapy to
operations, 576 patients (19.4%) had AF and 32 patients decrease the already low incidence of postoperative
(1.1%) suffered stroke. Seventeen stroke patients main- strokes after routine coronary artery bypass grafting
tained normal sinus rhythm during their hospital stay. surgery.
Of the remaining 15 patients, 9 presented with neuro- (Ann Thorac Surg 2006;82:51523)
logic deficit before the first episode of AF, with 5 having 2006 by The Society of Thoracic Surgeons
strokes could have been prevented by a more aggres- tal (side-to-side or end-to-side) vein and internal thoracic
sive anticoagulation protocol. artery anastomoses. All patients received two right ven-
tricular and two right atrial temporary pacing wires, and
atrial or atrioventricular sequential pacing was instituted
Material and Methods as deemed appropriate.
CARDIOVASCULAR
Table 1. Preoperative History and Clinical Data occurred 12 hours to 3 days after the stroke. Of the
remaining 5 patients, one (no. 7) developed intraopera-
Variable n
tive AF, which was electrically terminated, then atrially
Medical history paced for 24 hours. On postoperative day 3 he had
Hypertension 24 another episode of AF that converted to sinus rhythm
CARDIOVASCULAR
Diabetes mellitus 23 within 6 hours, but he suffered a stroke the same evening.
Myocardial infarction 16 Transesophageal echocardiography showed a small atrial
Recent MI 2 septal defect with bidirectional shunt suggesting para-
Congestive heart failure 4 doxical embolism. One patient (no. 22) developed atrial
Chronic atrial fibrillation 1 flutter on day 2 (successfully rapid paced into sinus
Acute atrial fibrillation (post MI) 1 rhythm) and had a first recurrence of flutter with similar
COPD 3
conversion again on postoperative day 8 and a stroke the
same day. One patient (no. 24) had four short episodes
Smoking 15
(30 minutes to 6 hours) of AF and was discharged in sinus
History of stroke/TIA 13
rhythm on postoperative day 7. He was readmitted in
Carotid bruit 5
normal sinus rhythm with symptoms of stroke and short-
Preoperative medications
ness of breath and was confirmed to have a pulmonary
Aspirin 22
embolism and a patent foramen ovale with a right-to-left
Coumadin 0 shunt. One patient (no. 25) had three short episodes (30
-blocker 26 minutes to 4 hours) of AF and was discharged home in
Ca antagonist 9 sinus rhythm on postoperative day 6. This patient had
ACE inhibitor 14 documented normal sinus rhythm on return clinic visits
Digoxin 5 (postoperative day 17 and postoperative day 31) and also
Diuretic 10 at readmission to the hospital with a massive stroke and
right internal carotid artery occlusion (postoperative day
ACE angiotensin-converting enzyme; COPD chronic obstructive
pulmonary disease; MI myocardial infarction; TIA transient 35 after CABG). The last patient (no. 27) again had three
ischemic attack. short episodes (30 minutes to 4 hours) of AF until
postoperative day 4. This patients postoperative recov-
ery was slower than usual, but he had no neurologic
neurologically intact after extubation and presented with deficit until he had a sudden respiratory arrest on post-
sudden hemiparesis, focal deficit, or signs of encephalop- operative day 13. His cardiac recovery was complete (no
athy between postoperative days 2 and 35. Four patients more AF episodes), but he suffered bilateral anoxic brain
with focal neurologic deficit and no evidence of infarct damage and subsequently died.
recovered completely (TIA), and all other surviving pa- In our series no patient with neurologic event after
tients were discharged in improved neurologic condition
after a median postoperative length of stay of 14 days
(range, 6 to 90 days). Table 2. Intraoperative and Perioperative Data
From the available clinical data and study reports, each
Variable n
case was retrospectively reconstructed, and the likely
source or cause of stroke was determined (Tables 3, 4). Of Elective CABG 28
the 12 patients with intraoperative strokes, 6 remained in Emergency CABG 4
normal sinus rhythm and 5 patients had subsequent AF Number of grafts (n/patient) 3.4 (26)
without additional neurologic sequel. One patient required Cardiopulmonary bypass time (min) 128.6 (70216)
emergency CABG for acute myocardial infarction and had Aortic cross-clamp time (min) 91.6 (46166)
preoperative AF after temporizing percutaneous translumi- Systemic hypothermia
nal coronary angioplasty for which he was fully anticoagu- Moderate (2832C) 29
lated with heparin. He suffered an intraoperative stroke, Deep (1820C) 3
and a TEE on postoperative day 3 confirmed left atrial Intraoperative arrhythmia (AF) 2
appendage thrombus (intraoperative TEE was not available Intraoperative antiarrhythmic drug 0
at that time). Post-bypass pacemaker
Of the 20 patients with postoperative strokes, 11 had no
Atrial pacing 16
episodes of AF or atrial flutter (Table 3). Suspected causes
AV sequential pacing 5
were vertebral artery disease (5 patients), carotid artery
Normal sinus rhythm 11
disease (2 patients), aortic arch atheromas (2 patients),
Inotropic support 24 hours 4
and unexplained (2 patients).
Ventilator support 24 hours 5
The remaining 9 patients, then, are of greatest interest
for this analysis: they had postoperative strokes or TIA Reoperation for bleeding 1
(days 2 to 8) and AF or atrial flutter (Table 4). In 4 patients Perioperative MI 1
(2 had strokes on postoperative day 2 and 2 on postop- AF atrial fibrillation; AV atrioventricular; CABG coronary
erative day 3) the first episodes of atrial fibrillation artery bypass grafting; MI myocardial infarction
CARDIOVASCULAR
518
ATRIAL FIBRILLATION AND STROKE AFTER CABG
KOLLAR ET AL
Table 3. Detailed Clinical Data on Stroke Patients Without Postoperative Atrial Fibrillation
Case Carotid HX of CVA/ Postoperative Clinical Postoperative
No. Cardiac Status Bruit TIA Carotid Duplex Stroke Picture Likely Source AF Occurence Comment
2 Stable No Recent TIA Bilateral 40% Intraoperative Mental change Unexplained No ...
4 Unstable IABP No No Intraoperative Hemiparesis Aortic atherosclerosis No ...
5 Stable No No POD 4 Focal TIA Vertebral artery No ...
athersclerosis
9 Stable No No POD 3 Hemiparesis L carotid disease No ...
13 Stable Recent MI No No Intraoperative Hemiparesis LV thrombus No POD 4 autopsy
15 Stable Yes Recent TIAs Bilateral 15% POD 3 Mental change Unexplained No Patient refused
TEE study
16 Stable No No POD 2 Hemiparesis Aortic atherosclerosis No ...
18 Stable Yes No Bilateral 50%70% Intraoperative Mental change Carotid disease No ...
19 Stable Yes Recent TIA L, 65% R, 15% POD 3 Mental change Carotid disease No ...
20 Stable No No ... Intraoperative Mental change Unexplained No ...
21 Stable No No ... POD 4 Focal TIA Unexplained No ...
23 Stable No Remote ... Intraoperative Hemiparesis Unexplained No ...
26 Stable No No ... POD 12 Hemiparesis Vertebral artery No Readmission with
occlusion stroke
28 Stable No Remote Bilateral 16%49% POD 4 Focal TIA Aortic atherosclerosis No ...
29 Stable No No ... POD 18 Hemiparesis Unexplained No Readmission with
stroke
30 Stable No No ... POD 31 Focal TIA Vertebral artery No Readmission with
occlusion stroke
31 Stable No No ... POD 8 Focal TIA Unexplained No Readmission with
TIA and SOB
(confirmed PE)
AF atrial fibrillation; CVA cerebrovascular accident; HX history; IABP intra aortic balloon pump; L left; LV left ventricular; MI myocardial infarction; PE
pulmonary embolism; POD postoperative day; R right; SOB shortness of breath; TEE transesophageal echocardiography; TIA transient ischemic attack.
AF atrial fibrillation; CVA cerebrovascular accident; HX history; L left; LAA left atrial appendage; LCO low cardiac output; NSR normal sinus rhythm; PE
POD postoperative day; R right; TIA transient ischemic attack.
KOLLAR ET AL
pulmonary embolism;
519
CARDIOVASCULAR
520 KOLLAR ET AL Ann Thorac Surg
ATRIAL FIBRILLATION AND STROKE AFTER CABG 2006;82:51523
postoperative AF had a long enough AF episode to rhythm control is a successful strategy to prevent strokes.
warrant aggressive anticoagulation suggested by the In the AFFIRM study [26] performed in the United States
ACC/AHA guidelines. and in another study [27] from the Netherlands, medical
patients with chronic AF were randomized into rate
control plus anticoagulation versus rhythm control plus
CARDIOVASCULAR
agement. Additional variables were preoperative stroke though the effectiveness of anticoagulation and its effect
or TIA (21 cases), significant valvular disease (18 cases), on neurologic outcomes was not analyzed. The authors
and history of preoperative AF (5 cases), and 8 of the conclude that sicker patients develop AF more often and
above AF 19 cases suffered a stroke in spite of anticoag- they also have a higher incidence of other postoperative
ulation. Similarly no information was given on other complications, which, however, did not seem to apply to
CARDIOVASCULAR
potential intraoperative risk factors, such as left atrial patients with only one episode of postoperative AF.
vent placement, that might be relevant in surgical The Northern New England Cardiovascular Disease
patients. Group analyzed more than 11,000 CABG patients data
A recent analysis from the Texas Heart Institute Car- from 1996 to 2001 [30] and found AF was a positive
diovascular Research Database [7] compared 994 CABG predictor for stroke (odds ratio, 1.82). Interestingly, how-
patients with postoperative AF and 5,481 patients without ever, prolonged cardiopulmonary bypass time (longer
arrhythmia. Atrial fibrillation was found to be an inde- than 114 minutes; odds ratio, 2.36) and prolonged inotro-
pendent predictor of long-term mortality at 5 years pic agent use (odds ratio, 2.59), which had previously
(adjusted odds ratio, 1.5). It was also associated with been established as predisposing factors for AF, were
greater in-hospital mortality (odds ratio, 1.7), with more stronger predictors for stroke than AF by itself. In spite of
perioperative strokes (odds ratio, 2.02), and with pro- their large database, a temporal relationship could only
longed hospital stay (14 versus 10 days). However, pa- be determined in less than one third of the stroke
tients who developed AF were older, more often hyper- patients, but even those cases were unconfirmed. This
tensive, had chronic obstructive pulmonary disease, same group also analyzed the etiologic mechanism of
noncoronary vascular disease, congestive heart failure, stroke in 388 patients operated on from 1992 to 2000 [31,
and more severe underlying coronary artery disease, all and reported that almost two thirds of all cerebrovascular
of which are strong predictors for stroke without surgery. events occurred within 2 days of the operation and 38%
They were also likely to have had an intraaortic balloon were classified as nonembolic. In these patients even
pump placed and longer cardiopulmonary bypass time. early anticoagulation with intravenous heparin could not
Although the authors performed a case-matched suba- have prevented stroke.
nalysis to strengthen their argument, the adequacy of the Our 12-year surgical experience is limited compared
adjustment was limited and therefore the reported asso- with large institutional or pooled data and includes
ciations may not be truly independent, as pointed out in slightly more than 2,900 CABG cases with 19.4% AF
the editorial comment [29]. Also no temporal relationship incidence, and a stroke incidence of 1.1% (32 patients).
between AF and stroke was reported in this series. We have not performed a detailed retrospective risk
The Multicenter Study of Perioperative Ischemia Re- factor analysis, but according to the Society of Thoracic
search Group and investigators of the Ischemia Research Surgeons database yearly reports, our overall risk profile
and Education Foundation have recently published their is comparable to the national database population. Our
prospective study performed in 70 hospitals on 4 conti- telemetry monitoring system, however, includes simul-
nents [8]. This study included more than 5,000 patients taneous continuous monitoring of atrial electrograms
undergoing CABG operations with or without valve and surface electrocardiograms, enabling us to identify
surgery on cardiopulmonary bypass. Patients with post- the exact nature and onset of postoperative arrhythmias
operative AF were significantly older (67.8 years versus more precisely, particularly supraventricular arrhyth-
61.8 years), and a significantly larger number had history mias, and to reliably detect all episodes of AF. Therefore,
of AF (14.6% versus 6.0%), valvular disease (27.8% versus we believe that our recorded AF incidence is accurate,
14.9%), congestive heart failure (40.1% versus 32.0%), with atrial arrhythmias rarely if ever missed during
chronic obstructive pulmonary disease (14.0% versus hospitalization. Moreover, the prompt identification of
8.6%), and prior neurologic event (13.0% versus 9.3%). the nature of the arrhythmia allowed us to establish a
The overall incidence of postoperative AF was 32.3%, temporal relationship between these episodes and the
with 43% of patients having more than one episode and neurologic complication in every case.
22% having more than two episodes. The overall stroke According to our initial analysis the overall incidence
rate for patients without AF was 1.2%, whereas it was of stroke in patients with AF was higher (2.6%), than in
0.93% in patients with one episode of AF and 1.4% in patients who maintained normal sinus rhythm (0.7%)
patients with more than one episode of AF. The incidence during their hospital stay. However, of the 15 patients
of composite neurologic outcomes (stroke, encephalopa- who had both stroke and AF, 9 patients had their neuro-
thy, and stroke score changes postoperatively) was sig- logic event before the first episode of arrhythmia, with 6
nificantly higher for patients with more than one episode having intraoperative stroke. Of the 6 patients who
of AF as compared with patients with normal sinus experienced atrial arrhythmia before stroke (1.0% true
rhythm, but not for patients with only one episode of AF. incidence of stroke in AF patients), 1 was an emergency
Patients with more than one episode of AF had an overall case with preoperative myocardial infarction and AF
higher mortality (4.7% versus 2.1%) than patients without episodes who developed left atrial appendage thrombus
AF, and composite complication outcome was also sig- in spite of heparin anticoagulation and suffered an intra-
nificantly higher (22.6% versus 15.4%, respectively). In operative stroke (case 6). Three (nos. 24, 25, and 27)
this study, 56.2% of all patients with AF were started on strokes occurred more than 1 week after the patients
intravenous heparin, and 17.6% received Coumadin, al- were successfully converted and stayed in normal sinus
522 KOLLAR ET AL Ann Thorac Surg
ATRIAL FIBRILLATION AND STROKE AFTER CABG 2006;82:51523
rhythm (no indication for anticoagulation). The last 2 2. Mathew JP, Parks R, Savino JS, et al. Atrial fibrillation
patients (nos. 7 and 22) had preoperative history of TIA following coronary artery bypass graft surgery: predictors,
outcomes, and resource utilization. MultiCenter Study of
without significant carotid disease; both of these patients
Perioperative Ischemia Research Group. JAMA 1996;276:
had two to three short episodes (6 hours duration) of 300 6.
AF or atrial flutter with successful conversion each time
CARDIOVASCULAR
the incidence of postoperative atrial fibrillation in humans. 26. Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate
J Am Coll Cardiol 2004;43:994 1000. control and rhythm control in patients with atrial fibrillation.
20. Sparks PB, Jayaprakash S, Mond HG, Vohra JK, Grigg LE, N Engl J Med 2002;347:182533.
Kalman JM. Left atrial mechanical function after brief dura- 27. Van Gelder IC, Hagens VE, Bosker HA, et al. A comparison
tion atrial fibrillation. J Am Coll Cardiol 1999;33:3429. of rate control and rhythm control in patients with recurrent
persistent atrial fibrillation. N Engl J Med 2002;347:1834 40.
CARDIOVASCULAR
21. Stoddard MF, Dawkins PR, Prince CR, Ammash NM. Left
atrial appendage thrombus is not uncommon in patients 28. Lahtinen J, Biancari F, Salmela E, et al. Postoperative atrial
with acute atrial fibrillation and a recent embolic event: a fibrillation is a major cause of stroke after on-pump coronary
transesophageal echocardiographic study. J Am Coll Cardiol artery bypass surgery. Ann Thorac Surg 2004;77:1241 4.
1995;25:4529. 29. Levy D, Kannel WB. Postoperative atrial fibrillation and
mortality: do the risks merit changes in clinical practice?
22. Beyth RJ, Milligan PE, Gage BF. Risk factors for bleeding in
J Am Coll Cardiol 2004;43:749 51.
patients taking coumarins. Curr Hematol Rep 2002;1:419.
30. Likosky DS, Leavitt BJ, Marrin CA, et al. Intra- and postop-
23. Gage BF, van Walraven C, Pearce L, et al. Selecting patients
erative predictors of stroke after coronary artery bypass
with atrial fibrillation for anticoagulation: stroke risk strati- grafting. Ann Thorac Surg 2003;76:428 35.
fication in patients taking aspirin. Circulation 2004;110:2287 31. Likosky DS, Marrin CA, Caplan LR, et al. Determination of
92. etiologic mechanisms of strokes secondary to coronary ar-
24. Rockson SG, Albers GW. Comparing the guidelines: antico- tery bypass graft surgery. Stroke 2003;34:2830 4.
agulation therapy to optimize stroke prevention in patients 32. Fanikos J, Tsilimingras K, Kucher N, Rosen AB, Hieblinger
with atrial fibrillation. J Am Coll Cardiol 2004;43:929 35. MD, Goldhaber SZ. Comparison of efficacy, safety, and cost
25. Wang TJ, Massaro JM, Levy D, et al. A risk score for of low-molecular-weight heparin with continuous-infusion
predicting stroke or death in individuals with new-onset unfractionated heparin for initiation of anticoagulation after
atrial fibrillation in the community: the Framingham Heart mechanical prosthetic valve implantation. Am J Cardiol
Study. JAMA 2003;290:1049 56. 2004;93:24750.
The Society of Thoracic Surgeons (STS) is pleased to E-mail senators and representatives about upcoming
announce a new member benefitthe STS Policy Action medical liability reform legislation
Center, a website that allows STS members to participate Track congressional campaigns in ones districtand
in change in Washington, DC. This easy, interactive, become involved
hassle-free site allows members to: Research the proposed policies that help or hurt
ones practice
Personally contact legislators with ones input on key Take action on behalf of cardiothoracic surgery
issues relevant to cardiothoracic surgery
Write and send an editorial opinion to ones local media This website is now available at www.sts.org/takeaction.
2006 by The Society of Thoracic Surgeons Ann Thorac Surg 2006;82:523 0003-4975/06/$32.00
Published by Elsevier Inc