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(Chest. 2005;128:28S-35S.)
© 2005 American College of Chest Physicians

Intraoperative Interventions*

American College of Chest Physicians Guidelines for the Prevention and Management of Postoperative Atrial Fibrillation After Cardiac Surgery

Lawrence L. Creswell, MD; John C. Alexander, Jr., MD, FCCP; T. Bruce Ferguson, Jr., MD; Alan Lisbon, MD, FCCP and Lee A. Fleisher, MD

* From the Division of Cardiothoracic Surgery (Dr. Creswell), University of Mississippi Medical Center, Jackson, MS; Hackensack University Medical Center (Dr. Alexander), Hackensack, NJ; the Division of Cardiothoracic Surgery (Dr. Ferguson), Louisiana State University School of Medicine, New Orleans, LA; the Department of Anesthesia and Critical Care Medicine (Dr. Lisbon), Beth Israel-Deaconess Medical Center, Boston, MA; and the Department of Anesthesia (Dr. Fleisher), University of Pennsylvania Health System, Philadelphia, PA.

Correspondence to: Lawrence L. Creswell, MD, Division of Cardiothoracic Surgery, Washington University School of Medicine, 11155 Dunn Rd, Suite 204N, St. Louis, MO 63136; e-mail: creswelll{at}msnotes.wustl.edu

A comprehensive evidence review was conducted of the medical literature regarding the relationship between intraoperative interventions and the incidence of postoperative atrial arrhythmias, including, most commonly, atrial fibrillation (AF). Fifteen randomized, controlled studies and one large-scale concurrent cohort study were identified that reported on the following issues: systemic temperature during surgery (one report); "beating heart" surgery vs conventional bypass surgery (three reports); type of myocardial protection (five reports); the use of adjunctive posterior pericardiotomy (one report); the use of thoracic epidural anesthesia (TEA) [two reports]; the use of glucose-insulin-potassium (GIK) solutions (two reports); and the use of heparin-coated circuits for cardiopulmonary bypass (CPB) [two reports]. Based on a systematic review of the reported data and an analysis of the quality of the reported data, we recommend the following: (1) that mild hypothermia, rather than moderate hypothermia, may be effective in reducing the frequency of postoperative AF; (2) the use of posterior pericardiotomy may be a useful adjunct to reduce the frequency of postoperative AF; and (3) the use of heparin-coated CPB circuits is associated with less postoperative AF. Because of conflicting or inadequate data, we cannot conclude that the frequency of postoperative AF is affected by (1) the use of beating-heart techniques, (2) the type of myocardial protection strategy used, (3) the use of TEA, or (4) the use of GIK solutions perioperatively.

Key Words: arrhythmia • atrial fibrillation • heart surgery






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