PROTOCOL OF A THESIS FOR PARTIAL FULFILMENT

OF MASTER DEGREE IN CARDIOTHORACIC SURGERY

Title of the Protocol: Perioperative factors causing atrial fibrillation

post CABG surgeries at Ain Shams University Hospitals .

Postgraduate Student: Hazem Mohamed Youssef .

Degree: M.B.B.Ch., Faculty of Medicine, Ain Shams University (2015)

DIRECTOR: Prof. Dr. Mohsen Abdel kerim

Academic Position: Professor
Department : Cardiothoracic Surgery,
Faculty of Medicine Ain Shams University

Co-DIRECTOR: Prof. Dr. Ahmed Helmy Omar

Academic Position: Assistant Professor
Department: Cardiothoracic Surgery,
Faculty of Medicine Ain Shams University

Co-DIRECTOR: Prof. Dr. Tamer Hikal

Academic Position: Lecturer .
Department: Cardiothoracic Surgery,
Faculty of Medicine Ain Shams University

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What is already known on this subject? AND
What does this study add?

Incidence of Atrial Fibrillation post cardiac surgeries is around 10%-65% and usually occurs on
the second or third postoperative day. Postoperative atrial fibrillation is associated with
increased morbidity and mortality and more expensive hospital stays. Prophylactic use of Beta
adrenergic blockers reduces the incidence of postoperative atrial fibrillation and should be
administered before and after cardiac surgery to all patients without contraindication.
Prophylactic amiodarone and atrial overdrive pacing should be considered in patients with high
risk for postoperative atrial fibrillation (for example, patients with previous history of atrial
fibrillation or mitral valve surgery). For patients who developped atrial fibrillation after cardiac
surgery, a strategy of rhythm management or rate management should be considered . For
patients who are hemodynamically unstable or highly symptomatic or who have a
contraindication to anticoagulation, rhythm management with electrical cardioversion,
amiodarone, or both is preferred. Treatment of the remaining patients should focus on rate
control because most will spontaneously revert to sinus rhythm within 6 weeks after discharge.
All patients with atrial fibrillation persisting for more than 24 to 48 hours and without
contraindication should receive anticoagulation.
In this study , we aim to study risk factors that increase risk of atrial fibrillation post CABG
surgeries so as to select patients with high risk factors and put them under observation and
prophylactic management protocol .

1.INTRODUCTION

Atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterized by uncoordinated

atrial activation with subsequent deterioration of mechanical function. Postoperative atrial
fibrillation (POAF) is common after both cardiothoracic and noncardiothoracic surgery. AF has
been reported in up to 5-40% of patients in the early postoperative period following coronary
artery bypass graft (CABG),[1–3] in 37-50% after valve surgery,[4] 64% undergoing mitral valve
replacement plus CABG, 49% undergoing aortic valve replacement (AVR) plus CABG and in 12%
after cardiac transplantation.[5,6] . Patients undergoing CABG alone have a lower incidence of
postoperative atrial fibrillation than patients undergoing valve surgery or combined CABG– valve
operations. POAF after cardiac surgery tends to occur within 2-4 days after the procedure with a
peak incidence on postoperative day 2 .
AF worsens a patient's hemodynamic status and increases the risk of congestive heart failure
(CHF), embolic events and longer ICU stays. AF may also necessitate the use of atrioventricular
nodal blocking and antiarrhythmics, which may increase the need for cardiac pacing. Stroke is a
major complication seen in 2% of CABG patients, 37% of whom had preceding AF. Apart from a
higher risk of stroke (OR 2.02), POAF after CABG was associated with greater in-hospital
mortality (OR 1.7) and worse survival (74% vs. 87%) at long-term follow-up (4 - 5 years).[7]
Many cases can be prevented with appropriate prophylactic therapy. A strategy of rhythm
management for symptomatic patients and rate management for all other patients usually
results in reversion to sinus rhythm within 6 weeks of discharge.

MECHANISMS OF ATRIAL FIBRILLATION AFTER CARDIAC SURGERY

Atrial fibrillation is usually attributed to reentry of multiple wavelets of excitation circulating
throughout the atria. The exact electrophysiologic mechanisms causing atrial fibrillation after
cardiac surgery are incompletely understood.
Slowed atrial conduction also facilitates reentry, and this probably explains the observed

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relation between a prolonged P-wave duration, as measured from a signal-averaged
electrocardiogram, and the increased risk for atrial fibrillation following cardiac surgery(7) .
Atrial incisions, atrial ischemia, and associated cardiac disease contribute not only to abnormal
atrial conduction and refractoriness but also to the increased frequency of triggering events.
Atrial premature beats occur more often in the minutes and hours before onset of atrial
fibrillation(8). Some but not all studies also provide evidence for increased sympathetic
activation preceding atrial fibrillation. The role of atrial ischemia in the development of the
underlying substrate and the triggering of atrial fibrillation after cardiac bypass operations has
been studied(9). Although cardioplegia administered through the coronary circulation effectively
arrests ventricular mechanical and electrical activity, the atrial septum remains significantly
warmer than the ventricle and usually retains electrical activity —a sign of inadequate
myocardial protection . Persistence of atrial electrical activity during bypass is associated with
postoperative atrial arrhythmias(10) .

2. AIM / OBJECTIVES
Analysis of risk factors causing atrial fibrillation post CABG surgeries so as to put preventive
strategies to avoid such problem and thus improve long-term survival and decrease hospital
stay days and financial costs .

Study objectives
Studying risk factors causing early onset AF including :
Preoperative : age , gender, hypertension,Diabetes ,left atrium size, Left ventricle end diastolic
volume , Ejection fraction ,previous congestive heart failure,chronic obstructive pulmonary
disease, right coronary artery disease .
Intaoperative : bypass and cross clamp time, location of venous cannula,type of cardioplegia
solution .
Postoperative : early postop hypoxic or ischemic changes ,early post op. serum electrolytes esp
K+ and Mg .
And their incidence among patients having early onset AF post CABG surgeries .

3. Patients and Methods:

Type of Study: retrospective study,: non randomized

• Study Setting: Ain Shams University hospitals ,cardiothoracic department .
• Study period : from January 2019 to December 2019 .
• Study population :
Inclusion criteria
Any primary native patient who underwent isolated CABG surgery .
Exclusion criteria
o Age more than 70.
o Patients known to have atrial fibrillation either chronic or paroxysmal .
o Patients underwent previous valve surgeries
o Patients with Pacemaker devices.
o More than 7 days postoperative .
o Patients underwent Off pump CABG surgeries .
o Rheumatic valve diseases .

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 o Patients underwent Emergent CABG operations .

Sampling Method:
To be defined by the statistician with statistical method.
Sample Size :
To be defined by the statistician with statistical method.

Ethical Considerations: The study will be presented for approval from the ethical committee of
the department of Cardiothoracic surgery , faculty of medicine, Ain Shams University.

Study Procedures:
Preoperative preparations
o History taking: detailed history will be taken, as regards the age, sex, medical history of
Diabetes,hypertension, chronic obstructive pulmonary disease and peripheral vascular diseases .
o Clinical examination: A complete clinical general and local cardiological examination will be
performed to auscultate any murmurs present or irregular heart rhythms.

Pre-operative measurements
o Laboratory: Complete blood count (CBC), Liver function tests, Prothrombin time and
concentration, INR, Kidney function tests, Fasting blood sugar, Serum electrolytes,
Electrocardiogram (ECG).
o Radiological: Plain chest x-ray , Echocardiography (esp Ejection fraction , Left atrium ,co-existing
rheumatic valvular lesions ).

Intraoperative measurements
Total bypass and cross clamp time , arterial blood gases monitoring , any ischemic ECG changes
and number of DC shocks delivered .

Post-operative measurements
o Ventilation hours , pharmacological cardiac supports (dose , duration of infusion ) , ICU stay .
o Laboratory: arterial blood gases , Serum electrolytes ( Na,K ) ,cardiac enzymes, serial
Electrocardiogram (ECG) every 24 hours .
o Radiological: Plain chest x-ray , Echocardiography.

4.REFERENCES
1- Maisel WH, Rawn JD, Stevenson WG. Atrial fibrillation after cardiac surgery. Ann Intern
Med. 2001;135:1061–1073.

2- Shantsila E, Watson T, Lip GY. Atrial fibrillation post-cardiac surgery: changing

perspectives. Curr Med Res Opin. 2006;22:1437–1441.

3- Villareal RP, Hariharan R, Liu BC, Kar B, Lee VV, Elayda M, et al. Postoperative atrial
fibrillation and mortality after coronary artery bypass surgery. J Am Coll Cardiol. 2004;43:742–
8.

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4-Asher CR, Miller DP, Grimm RA, Cosgrove DM, 3rd, Chung MK. Analysis of risk factors for
development of atrial fibrillation early after cardiac valvular surgery. Am J
Cardiol. 1998;82:892–5.

5- Creswell LL, Schuessler RB, Rosenbloom M, Cox JL. Hazards of postoperative atrial
arrhythmias. Ann Thorac Surg. 1993;56:539–49.

6- Pavri BB, O’Nunain SS, Newell JB, Ruskin JN, William G. Prevalence and prognostic
significance of atrial arrhythmias after orthotopic cardiac transplantation. J Am Coll
Cardiol. 1995;25:1673–80.

7- Blomstrom Lundqvist C. Post CABG atrial fibrillation: What are the incidence, predictors,
treatment, and long-term outcome? In: Raviele A, editor. Venice, Italy: Springer; 2005.

8- Haı¨ssaguerre M, Jaı¨s P, Shah DC, Takahashi A, Hocini M, Quiniou G, et al. Spontaneous

initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J
Med. 1998;339:659-66. [PMID: 9725923] .

9- Frost L, Christiansen EH, Mølgaard H, Jacobsen CJ, Allermand H, Thomsen PE. Premature
atrial beat eliciting atrial fibrillation after coronary artery bypass grafting. J Electrocardiol.
1995;28:297-305. [PMID: 8551172].

10- Sato S, Yamauchi S, Schuessler RB, Boineau JP, Matsunaga Y, Cox JL. The effect of
augmented atrial hypothermia on atrial refractory period, conduction, and atrial
flutter/fibrillation in the canine heart. J Thorac Cardiovasc Surg. 1992; 104:297-306. [PMID:
1495290].

11- Cox JL. A perspective of postoperative atrial fibrillation in cardiac operations [Editorial].
Ann Thorac Surg. 1993;56:405-9. [PMID: 8379709] .

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