Operative interventions and incidence of AF
Operative interventions to reduce the incidence of AF.
Ventral cardiac denervation has not been convincingly shown to affect the incidence of postoperative AF in patients undergoing CABG.
(Grade D recommendation based on individual level 3b studies)
Posterior pericardiotomy has been shown to reduce the incidence of AF in a single randomised controlled trial but this finding requires confirmation in further clinical trials prior to use in routine clinical practise.
(Grade B recommendation based on an individual level 1b study)
Several search strategies were employed to search for intra-operative interventions that might reduce the incidence of AF. However, only four papers were found that documented any intra-operative intervention to reduce the incidence of post-operative AF [65—68]. These include three papers investigating aortic fat pad removal, and one paper performing a posterior pericardiotomy in order to reduce the incidence of AF. Thus, this search was not published in the ICVTS.
Melo et al.  performed a ventral cardiac denervation in 207 patients undergoing low risk coronary arterial surgery. The fat pads that surround the superior vena cava, the aorta and the anterior and right lateral aspects of the main pulmonary artery were excised prior to cardiopulmonary bypass. This took on average 5min (_2 min). A total of 219 patients were identified to act as non-randomised controls. Of the patients who had ventral cardiac denervation, 15 developed AF (7%, 95% CI 4—12%) compared with 56 in the control group (27%, 95% CI 18—35%), which was a significant finding ( p < 0.01). This prospective cohort study was limited by a lack of telemetry post-operatively, a 20% incidence of patients undergoing off-pump surgery, 20% non-use of b-blockers, and its non-randomised design (level 3b study).
Davis and Jacobs  hypothesised that removal of the aortic fat pad and its extension to the pulmonary artery may, in fact, increase the incidence of AF. They conducted a pilot study and subsequent cohort study in 320 patients, with the treatment group protected from the standard procedures of aortic fat pad disruption. They found that there was no difference between the groups in the incidence of AF and concluded that the aortic fat pad did not impact the incidence of AF (level 3b study).
Alex and Guvendik  carried out a cohort study where 70 consecutive patients undergoing CABG but also having ventral cardiac denervation were compared with 70 consecutive patients who did not have this additional procedure. Denervation took around 5 min to complete. The AF rate was 34% in control patients compared with 29% in those patients who had ventral cardiac denervation, which was a nonsignificant finding ( p = 0.03).
Farsak et al.  studied the impact of a posterior pericardiotomy, with a 4 cm incision made posterior to the left phrenic nerve. An RCT was performed in 150 patients undergoing CABG. Seven of the 75 patients receiving a posterior pericardiotomy (9.3%) went into AF, compared with 24 of 75 controls (32%). In addition, the incidence of early and late pericardial effusion was significantly lower in the pericardiotomy group. Of note, patients receiving b-blockers were excluded from this study (level 1b study).
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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