Bi-atrial pacing for prophylaxis against AF
Bi-atrial pacing for prophylaxis against AF.
Biatrial pacing significantly reduces the incidence of AF in patients undergoing cardiac
surgery. Care must be taken in the placement of the wires in order to minimise avoidable complications.
(Grade A recommendation based on level 1b studies)
A pacing strategy of 80—90 beats/min is recommended for 3—5 days with the increased rate if the native rate increases above 80 beats/min.
(GradeBrecommendationbasedonindividual level 1b studies)
Right atrial pacing is not recommended as a strategy to reduce the incidence of AF for patients undergoing cardiac surgery.
(Grade A recommendation based on level 1b studies)
Evidence was sought for whether atrial pacing reduces the incidence of post-operative AF in patients undergoing cardiac surgery. This search is fully documented in the ICVTS (Ronald and Dunning ) together with a summary of all identified papers. Four hundred and fifty eight papers were identified using the presented search strategy. From these, 16 papers represented the best evidence on this topic.
We identified 13 RCTs recruiting between 21 and 230 patients. These varied markedly both in their placement of atrial pacing wires, pacing strategies and also in their definitions of AF. Eleven studies looked at biatrial pacing. Six found a significant benefit and five found no significant benefit. Eight studies used right atrial pacing. Two studies reported a significant benefit but six found no benefit. Ten of the 13 completed RCTs were identified in the meta-analysis by Crystal et al.  but we repeated the meta-analysis in order to update these data. We found that there was a significant benefit shown for biatrial pacing (OR 0.51, 95% CI 0.36—0.72) but combining the right atrial studies showed no significant benefit (OR 0.71, 95% CI 0.45—1.15).
While there is a clear benefit in the use of biatrial pacing, several papers reported technical difficulties, with loss of sensing, diaphragmatic pacing and LV pacing, which led to a number of patients being withdrawn from their respective studies. Thus, if biatrial pacing is contemplated, much care must be used when placing the wires. In addition, many different pacing strategies were used, but most paced at a rate of 80—90 beats/min with higher rates if the native rhythm went above 80 beats/min. Finally, the number of days of pacing varied among the studies. As the incidence of AF generally peaked around day 2 in these studies, 3—5 days of pacing seem necessary for full protection from AF.
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Autorisatiedatum en geldigheid
Laatst beoordeeld : 26-11-2010
Laatst geautoriseerd : 26-11-2010
Revisiedatum uiterlijk november 2015
Deze richtlijn is mede gebaseerd op de EACTS-guidelines on the prevention and management of de novo atrial fibrillation after cardiac and thoracic surgery.
Notitie specifiek met betrekking op de Nederlandse situatie:
Lees ipv Warfarine: Coumarine-derivaten
Deze notitie vormt een integraal onderdeel van de Engelstalige tekst van de hierbij behorende richtlijn.
Doel en doelgroep
This guideline covers the prophylaxis and treatment of de novo AF in adults undergoing cardiac and thoracic surgery. It includes recommendations for intra-operative strategies to
minimise the incidence of AF, the pharmacological treatment of AF and recommendations for anticoagulation of these patients. In addition, monitoring and ward management
of these patients are also addressed. It excludes recommendations for the surgical management of patients coming to surgery with chronic AF, and recommendations for
patients in chronic AF not undergoing cardiothoracic surgery.
- Joel Dunning (James Cook University Hospital, Middlesbrough, UK)
- Tom Treasure (Guy’s Hospital, London, UK)
- Michael Versteegh (Leiden University Medical Center, The Netherlands)
- Samer A.M. Nashef (Papworth Hospital, Cambridge, UK)
on behalf of the EACTS Audit and Guidelines Committee
The EACTS Audit andGuidelineCommittee is grateful to thefollowing authors for assisting with the literature reviewprocess by publishing Best Evidence Topics for the ICVTS:
Muneer Amanullah, Ali Behranwala, Phil Botha, Mohammed Hanif, Noman Khasati, Graham Morritt, Darbhamulla Nagarajan, Mohammed Nouraei, Brian Nyawo, Savvas Omorphos, Anish Patel, Brian Prendergast, Shahzad Raja, Jagan Rao, Andrew Ronald, Anthony Rostron, Aliu Sanni, Vivek Shrivastava.
This guideline comprises several novel aspects in the methodology employed in the derivation of this document. Many guidelines are based on a single systematic review and
multiple clinical questions are then answered on the basis of the papers found from this one review. In contrast, we felt that it was important to perform a full literature review for
every single question addressed in order to maximise the robustness of the guideline. We used a structured systematic review protocol named ‘Best Evidence Topics’ to construct each review, where the search strategy, results of the search and a full appraisal of all papers are published in a structured format. The details of this protocol are described in the Interactive Cardiovascular and Thoracic Surgery (ICVTS) . Guidelines often fall short of expectations due to a failure to consult those clinicians who are most likely to
use them. For this guideline, every literature review has already been published in full in the ICVTS. Every topic was published online and clinicians were able to post comments
on the topic over a 2-month period. These comments were then published together with the full paper in the ICVTS and are now available to all readers in full text online at www.icvts.org.
These guidelines assess individual studies according to recommendations developed and refined over time  and previously used in the specialty . Briefly, level 1 papers are
randomised controlled trials, level 2 papers are cohort studies, level 3 papers are case-controlled studies or small cohort studies and level 4 studies are experimental papers.
The ‘b’ suffix implies that the study is an original article at this level and the ‘a’ suffix implies that the paper is a systematic review or meta-analysis of papers at that level (further details are available from the website of the Oxford Centre for Evidence based Medicine: http://www.cebm.net/levels_of_evidence.asp 2001).
Systematic literature review was up to the end of 2005. Once recommendations are made, they are graded according to the quality of papers used to come to our conclusion:
- Grade A evidence: based on multiple level 1a or level 1b papers
- Grade B evidence: based on multiple level 2a/2b papers or individual level 1a/1b papers
- Grade C evidence: based on multiple level 3a/3b papers or individual level 2a/2b papers
- Grade D evidence: based on individual level 3a/3b papers or level 4 papers
- Grade E evidence: based on expert consensus in the absence of acceptable papers