By Adem Lewis / in , , , , , , , , , , , , , , , , , , , /

it’s my great pleasure to present some of the excerpts regarding post-operative atrial fibrillation and surgical therapy for atrial fibrillation from the 2016 focused update of the CCS guidelines on the management of AF I would like to acknowledge that this was a team effort between dr. Allen skeins and myself and I’m very happy to present this on behalf of both of us so let’s start with some of the clinical considerations that we think about regarding surgical AF ablation procedures of course we think about the overall potential benefits of achieving sinus rhythm the type of surgery mitral valve versus other types of open-heart surgery the extent of the procedure ie a left-sided maze versus a by atrial maze the energy source associated risk and local expertise there has been one randomized trial led by dr. mark Gillan of from the CTS net group of investigators that has been published recently evaluating surgical ablation of atrial fibrillation during mitral valve surgery and in this study 260 patients with persistent atrial fibrillation who required mitral valve surgery were randomized to either surgical ablation or no ablation during mitral valve operation patients were further randomized to pulmonary vein isolation or by atrial maze all patients underwent closure of the left atrial appendage and the primary endpoint of the trial was freedom from atrial fibrillation both at 6 and 12 months assessed by a 3d halter here are the main results looking at freedom from atrial fibrillation in panel a you can see quite nicely that mitral valve surgery coupled with ablation had a significantly higher rate of freedom from atrial fibrillation and on panel B are the data that suggests that there was no difference with respect to the type of ablation ie by a troll maze versus pulmonary vein isolation achieved a very similar outcome what I have not shown you but our data available within the the the full slide deck are the fact that overall mortality morbidity were not different in terms of major efficacy endpoints the trial was not powered for that but from a safety point of view there was a three-fold higher rate of the use of permanent pacemakers and I think this is something that the committee thought about quite long and hard about balancing risk and benefits of sinus rhythm versus the risk of a permanent pacemaker so we suggest that surgical AF ablation procedures should be considered in association with mitral valve a or tick valve or cabbage surgery in patients with atrial fibrillation when the likelihood of success is deemed to be high the additional risk is low and sinus rhythm is expected to achieve substantial symptomatic benefit this is a conditional recommendation with moderate quality evidence now let’s also look at some of the data around surgical left atrial occlusion exclusion if I may for stroke prevention most of this field has been driven by cohort studies there’s a paucity of randomised trials but one very important and Canadian led trial is ongoing called the Leos three study the Leos three study which is being led by dr. Richard Whitlock and dr. Stuart Connolly and we are participating in this study 4700 patients in approximately 80 centers are being randomly allocated to occlusion of the left atrial appendage versus no occlusion on top of usual standard of care and the primary outcome is a Cir standard Mace outcome and this trial is now what half report have recruited so we are looking forward to the the full recruitment and eventual reporting of this these results so the fact that there is no randomized control trial data thus far has led the committee to downgrade the recommendation and we’ve said that in patients with atrial fibrillation we suggest that closure either through excision or obliteration of the left atrial appendage should be considered as part of the surgical ablation procedure of atrial fibrillation associated with mitral a or take or cabbage surgery if this does not increase the risk of surgery this is a conditional recommendation and again based on low quality of evidence what about management of post-operative atrial fibrillation again some important reminders that this occurs in a large proportion of patients the condition is associated with high sympathetic and oxidative stress and inflammation and it’s also associated with increased rates of major cardiovascular outcomes length of stay and costs so new guidelines addressing treatment of post-operative atrial fibrillation and the prophylaxis of post operative atrial fibrillation have been undertaken and really dr. Allen’s gains is to be credited for really leading this section we have made the following recommendation that post-operative atrial fibrillation might be appropriately treated with either a ventricular response rate control strategy or a rhythm control strategy this is based on strong rec this is a strong recommendation based on moderate quality evidence this recommendation places a high value on the randomized control trial data that have investigated rate control as an alternative to rhythm control for atrial fibrillation including one trial that specifically addressed the cardiac post-operative period the choice of strategy should therefore be individualized based on the basis of the degree of symptoms experienced by the patient this time we’ve actually also included some data reviewing the studies limiting inflammation and oxidative stress and they are trials with statins steroids and polyunsaturated fatty acids there is a randomized control trial of nine 922 patients who receive perioperative receive a statin or placebo it showed no reduction the rates of post-operative atrial fibrillation but had a statistically significant increase in the rate of acute kidney injury steroids a systematic review on the use of steroids suggested a beneficial effect on the basis of 14 studies when tested in two definitive studies that randomized over 11,000 patients however no benefit was seen and a potential small signal of harm was noted and polyunsaturated fatty acids to meta-analyses 2600 patients plus one was negative the other one was positive and as a consequence of different trial waiting it was hard for us to evaluate this area precisely the largest randomized trial randomized 1500 patients with no difference in sustained symptomatic or treated episodes of post-operative atrial fibrillation so as sort of key take homes in this area we suggest that patients who have a contraindication to beat a blocker therapy and to amiodarone before or after surgery be considered for prophylactic therapy to prevent post-operative atrial fibrillation with either intravenous magnesium this is a conditional recommendation based on low-quality evidence or colchicine which is also a conditional recommendation based on low-quality evidence or by atrial pacing which is also a conditional recommendation based on low-quality evidence the data on Cole jusen again haven’t had time to review with you in this very short excerpt but the small meta analyses suggests that it may be beneficial but it has to be removed we have to remember that there’s a significant issue around tolerability and discontinuation due to gastrointestinal intolerance with colchicine so finally with respect to anticoagulation for post-operative atrial fibrillation we suggest that consideration be given to anticoagulation therapy if post-operative continuous AF persists for more than 72 hours this consideration will include individualized assessment of the risks of thromboembolic events and the risk of post-operative bleeding it’s been great having a few minutes to spend with you today I hope you will enjoy the overall guidelines and that they will be valuable in making appropriate clinical decisions in patients who are going to surgery or in individuals in whom you are trying to prevent post-operative atrial fibrillation thank you

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