Visceral Adiposity Index and Prognostic Nutritional Index in Predicting Atrial Fibrillation after On-Pump Coronary Artery Bypass Operations: a Prospective Study

Abstract Introduction: Rhythm problems are the most observed complications following coronary artery bypass grafting (CABG), the most common being postoperative atrial fibrillation (PoAF), with an incidence reaching 50% of the patients. In this study, we aimed to investigate the predictive importance of prognostic nutritional index (PNI) and visceral adiposity index (VAI) in predicting PoAF, which occurs after CABG accompanied by cardiopulmonary bypass. Methods: Patients who underwent isolated CABG with cardiopulmonary bypass between June 15 and October 15, 2019, were prospectively included in the study. Patients who did not develop in-hospital PoAF were identified as Group 1, and those who did constituted Group 2. Results: PoAF developed in 55 (27.6%) patients (Group 2). The mean age of the 144 patients included in Group 1 and 55 patients in Group 2 were 56.9±8.7 and 64.3±10.2 years, respectively (P<0.001). In multivariate analysis Model 1, age (odds ratio [OR]: 1.084, confidence interval [CI]: 1.010-1.176, P=0.009), chronic obstructive pulmonary disease (OR: 0.798, CI: 0.664-0.928, P=0.048), and PNI (OR: 1.052, CI: 1.015-1.379, P=0.011) were determined as independent predictors for PoAF. In Model 2, age (OR: 1.078, CI: 1.008-1.194, P=0.012), lymphocyte counts (OR: 0.412, CI: 0.374-0.778, P=0.032), and VAI (OR: 1.516, CI: 1.314-2.154, P<0.001) were determined as independent predictors for PoAF. Conclusion: In this study, we determined that low PNI, a simply calculable and cheap parameter, along with high VAI were risk factors for PoAF.

Características diferenciales del bloqueo interauricular avanzado típico y atípico / Differential characteristics of the typical and atypical advanced interatrial block

Resumen Objetivo: Se denomina bloqueo interauricular avanzado (BIA) a la existencia de una onda P ≥ 120 ms y bifásica +/- en las derivaciones inferiores (II-III-VF) del electrocardiograma (ECG) de superficie, el cual constituye un factor predictivo significativo del desarrollo de fibrilación auricular. En fecha reciente se han descrito cuatro patrones de BIA atípicos (BIA-At) con base en la morfología y la duración de la onda P, sin conocer si comparten patogenia y características clínicas similares. Método: Estudio observacional, descriptivo y retrospectivo de pacientes, visitados en el Servicio de Cardiología, en ritmo sinusal y con BIA. Las variables analizadas se obtuvieron de la historia clínica informatizada. El análisis de la onda P se efectuó al aumentar el tamaño del electrocardiograma y mediante calipers electrónicos. El análisis estadístico se realizó con SPSS 19.0, con nivel de significación de p < 0.05. Resultados: Se incluyó a 75 pacientes con media de edad de 74.4 ± 11.7 años, con 62.7% de varones. Se compararon los grupos de pacientes con BIA típico (BIA-T) y BIA-At. El primero se relacionó con la existencia de diabetes mellitus (p = 0.001), enfermedad renal crónica estadio ≥ 3 (p = 0.036), bloqueo auriculoventricular (p = 0.006) y una menor fracción de expulsión ventricular media (p = 0.025); no hubo diferencias respecto de la prevalencia de fibrilación auricular/flúter o accidente cerebrovascular. Sólo la diabetes se acompañó de riesgo de ser un BIA-T (OR: 6.4; p = 0.002; IC 95%: 2.0-21.1). Conclusiones: La diabetes mellitus constituye el único factor de riesgo de que un BIA sea típico. Los pacientes con BIA-T y BIA-At presentan similar prevalencia de fibrilación auricular y accidente cerebrovascular, por lo que son objeto de un mismo tratamiento clínico.

Abstract Objective: It is called advanced interatrial block (IAB) to the existence of a P wave ≥ 120 ms and biphasic ± in the lower leads II-III-VF of the surface electrocardiogram (ECG), which constitutes a significant predictive factor for the development of atrial fibrillation. Recently, four patterns of atypical aIAB (At-IAB) have been described based on the morphology and duration of the P wave, but it's unknown if they share the same pathogenesis and clinical characteristics. Method: An observational, descriptive and retrospective study was performed with patients, visited in cardiology, who have a sinus rhythm and with aIAB. The analyzed variables were obtained from the computerized clinical history. The analysis of the P wave was made by increasing the size of the ECG and by electronic calipers. Statistical analysis was performed with SPSS 19.0; level of significance: p < 0.05. Results: A total of 75 patients with an average age of 74.4 ± 11.7 years and with a 62.7% males, were included. It was compared the group of patients with typical aIAB (T-aIAB) and with At-aIAB. The first one was associated with the existence of diabetes mellitus (p = 0.001), chronic kidney disease stage ≥ 3 (p = 0.036), atrioventricular block (p = 0.006) and a lower mean ventricular ejection fraction (p = 0.025); there were no differences regarding the prevalence of atrial fibrillation/flutter or stroke. Only diabetes was associated with the risk of T-aIAB (odds ratio: 6.4; p = 0.002; 95% confidence interval: 2.0-21.1). Conclusions: Diabetes mellitus is the only risk factor for an aIAB to be typical. Patients with T-aIAB and At-aIAB have a similar prevalence of atrial fibrillation and stroke, so they must follow the same clinical management.

Echocardiographically measured epicardial fat predicts new-onset atrial fibrillation after cardiac surgery

Abstract Objective: The current study aims to investigate the role of echocardiographically measured epicardial adipose tissue (EAT) thickness in the prediction of new-onset atrial fibrillation (AF) following coronary artery bypass grafting (CABG) surgery. Methods: One hundred and twenty-four patients scheduled to undergo isolated on-pump CABG due to coronary artery disease were enrolled to the current study. Patient characteristics, medical history and perioperative variables were prospectively collected. EAT thickness was measured using transthoracic echocardiography (TTE). Any documented episode of new-onset postoperative AF (POAF) until discharge was defined as the study endpoint. Fortyfour participants with POAF served as AF group and 80 patients without AF served as Non-AF group. Results: Two groups were similar in terms of baseline echocardiographic and laboratory findings. In laboratory findings, the groups were similar in terms of the studied parameters, except N-terminal pro-brain natriuretic peptide (NT Pro-BNP), which was higher in AF group than in Non-AF group (P=0.035). The number of left internal mammary artery (LIMA) grafts was not different in both groups. AF group had higher cross-clamp (CC) and cardiopulmonary bypass (CPB) times than Non-AF group (P=0.01 and P<0.001). In multivariate logistic regression analysis, EAT was found an independent predictor for the development of POAF (OR 4.47, 95% CI 3.07-5.87, P=0.001). Conclusion: We have shown that EAT thickness is associated with increased risk of AF development and can be used as a prognostic marker for this purpose.

Fibrilación auricular en cirugía cardíaca / Atrial fibrillation in cardiac surgery

Resumen La fibrilación auricular es la arritmia más frecuente en el periodo posquirúrgico de la cirugía cardíaca. Se relaciona con insuficiencia cardíaca, insuficiencia renal, embolismo sistémico y más días de estancia y mortalidad. La fibrilación auricular en el periodo posquirúrgico de la cirugía cardíaca (FAPCC) suele aparecer en las primeras 48 horas. Los principales mecanismos que producen la aparición y el mantenimiento de la FAPCC son el aumento del tono simpático y la respuesta inflamatoria. Los factores de riesgo adjuntos son la edad avanzada, enfermedad pulmonar obstructiva crónica, enfermedad renal crónica, cirugía valvular, fracción de expulsión del ventrículo izquierdo menor de 40% e interrupción de fármacos bloqueadores β. Existen instrumentos que han demostrado predecir la aparición de FAPCC. El tratamiento profiláctico con bloqueadores β y amiodarona se relaciona con disminución de la aparición de FAPCC. Dada su naturaleza transitoria, se sugiere que el tratamiento inicial de FAPCC sea el control de la frecuencia cardíaca y sólo en caso de que el tratamiento no consiga el retorno al ritmo sinusal está indicada la cardioversión eléctrica. Se desconoce cuál debe ser el seguimiento a largo plazo y sólo se conocen en escasa medida las complicaciones más allá de este periodo. La FAPCC no es una arritmia benigna ni aislada en los pacientes sometidos a operación cardíaca, por lo que la identificación de los factores de riesgo, su prevención y el seguimiento en el ámbito ambulatorio deben formar parte de las unidades dedicadas a la atención y los cuidados de estos pacientes.

Abstract Atrial fibrillation is the most frequent arrhythmia in the postoperative period of cardiac surgery. It is associated with heart failure, renal insufficiency, systemic embolism and increase in days of in-hospital and mortality. Atrial fibrillation in the postoperative period of cardiac surgery (FAPCC) usually appears in the first 48 h after surgery. The main mechanisms involved in the appearance and maintenance of FAPCC are the increase in sympathetic tone and the inflammatory response. The associated risk factors are advanced age, chronic obstructive pulmonary disease, chronic kidney disease, valve surgery, fraction of ejection of the left ventricle less 40% and the withdrawal of beta-blocker drugs. There are instruments that have been shown to predict the appearance of FAPCC. Prophylactic treatment with beta-blockers and amiodarone, is associated with a decrease in the appearance of FAPCC. Given its transient nature, it is suggested that the initial treatment of FAPCC be the heart rate control and only if the treatment does not achieve a return to sinus rhythm, the use of electrical cardioversion is suggested. It is unknown what should be the long-term follow-up and complications beyond this period are little known. FAPCC is not a benign or isolated arrhythmia in patients undergoing cardiac surgery, so the identification of risk factors, their prevention, and follow-up in the outpatient setting, should be part of the units dedicated to the care and care of these patients.

Stroke and transient ischemic attacks related to antiplatelet or warfarin interruption / Acidente vascular cerebral e ataques isquêmicos transitórios relacionados à interrupção de antiplaquetários ou varfarina

ABSTRACT Patients on anticoagulant or antiplatelet therapy are often required to discontinue these medications before and during surgical or invasive procedures. In some cases, the patient stops the treatment without medical supervision. These situations may increase stroke risk. Objective To identify the ischemic stroke and transient ischemic attack (TIA) prevalence related to length of time of discontinuation of antiplatelet or vitamin K antagonist therapy, in a group of inpatients from a specialized neurological hospital in Brazil. Methods Cross-sectional, retrospective and descriptive study of stroke inpatients for three years. Medical reports were reviewed to find study participants, stroke characteristics, risk factors, reasons and time of drug interruption. Results In three years, there were 360 stroke and TIA inpatients, of whom 27 (7.5%) had a history of antiplatelet or vitamin K antagonist interruption correlated with the time of the event (81% ischemic stroke, 19% TIA). The median time between antiplatelet interruption and an ischemic event was five days, and 62% of events occurred within seven days after drug suspension. For vitamin K antagonists, the average time to the ischemic event was 10.4 days (SD = 5.7), and in 67% of patients, the time between drug discontinuation and the event was 7-14 days. The most frequent reason for drug suspension was patient negligence (37%), followed by planned surgery or invasive examination (26%) and side effects, including hemorrhage (18.5%). Conclusion Antiplatelet or vitamin K antagonist suspension has a temporal relationship with the occurrence of stroke and TIA. Since these events are preventable, it is crucial that healthcare professionals convince their patients that drug withdrawal can cause serious consequences.

RESUMO Pacientes em terapia anticoagulante ou antiagregante plaquetária frequentemente são solicitados a descontinuar essas medicações antes e durante procedimentos cirúrgicos ou invasivos. Se o paciente interromper tratamento sem supervisão médica, poderá aumentar de risco de acidente vascular cerebral (AVC). Objetivo Identificar prevalência de AVC isquêmico e ataque isquêmico transitório (AIT) associados à descontinuação de terapia antiplaquetária ou coumarínicos em pacientes internados em hospital especializado em atendimento neurológico no Brasil. Métodos Estudo transversal, retrospectivo de três anos, descritivo dos pacientes hospitalizados por AVC. A revisão de relatórios médicos determinou características do AVC, fatores de risco, motivos e tempo de interrupção medicamentosa. Resultados Em três anos, foram internados 360 pacientes por AVC ou AIT; destes, 27 interromperam temporariamente terapia antiplaquetária ou coumarínicos relacionando ao evento (81% acidente vascular cerebral isquêmico, 19% AIT). A prevalência foi de 7,5%. O tempo médio entre interrupção antiplaquetária e evento foi cinco dias, com 62% deles ocorrendo até sete dias após suspensão medicamentosa. Para coumarínicos, o tempo médio foi 10,4 dias (d.p.= 5,7), em 67% dos casos o tempo entre a descontinuação medicamentosa e o evento foi 7-14 dias. O motivo mais frequente para suspensão do medicamento foi negligência do paciente (37%), seguido por cirurgia planejada ou exame invasivo (26%) e efeitos colaterais, incluindo hemorragia (18,5%). Conclusão Suspensão de terapia de antiplaquetários ou coumarínicos tem relação temporal com ocorrência de AVC e de AIT. Esses eventos são passíveis de serem evitados, sendo imprescindível que profissionais de saúde convençam seus pacientes das consequências graves da retirada do medicamento.

The CHA2DS2-VASc score for predicting atrial fibrillation in patients presenting with ST elevation myocardial infarction: prospective observational study

ABSTRACT BACKGROUND: Atrial fibrillation (AF) is the most common form of supraventricular arrhythmia following ST-elevation myocardial infarction (STEMI). The CHA2DS2-VASc and CHADS2 scores are used to estimate thromboembolic risk in cases of AF. Their usefulness in predicting the development of AF in patients presenting STEMI is unknown. OBJECTIVE: To evaluate the predictive value of the CHADS2 and CHA2DS2-VASc scores in patients with AF following STEMI. DESIGN AND SETTING: This prospective cohort study on 696 patients with STEMI was conducted at a tertiary-level cardiology clinic in a public university hospital. METHODS: Models including clinical and laboratory parameters were constructed to test the predictive value of CHADS2 and CHA2DS2-VASc scores. Patients were divided into two groups: with and without AF. Predictors of AF were determined using multivariate regression analysis. RESULTS: In the patients with AF, CHADS2 and CHA2DS2-VASc scores were significantly higher than in those without AF (for both P < 0.001). Factors associated with AF in multivariate analyses included CHA2DS2-VASc score (odds ratio, OR: 1.48; 95% confidence interval, CI: 1.25-1.75; P < 0.001), peak creatine kinase-myocardial binding (OR: 1.002; 95% CI: 1.00-1.003; P = 0.0024), duration of the coronary intensive care unit stay (OR: 1.69; 95% CI: 1.24-12.30; P = 0.001) and no use of renin-angiotensin system blockers (OR: 2.16; 95% CI: 1.14-4.10; P = 0.0017). Receiver operating characteristic curve analyses showed that CHA2DS2-VASc scores were significant predictors for new-onset AF (C-statistic: 0.698; 95% CI: 0.631-0.765; P < 0.001). CONCLUSION: CHADS2 and CHA2DS2-VASc scores predicted new AF in patients presenting STEMI.

Postoperative atrial fibrillation: evaluation of its economic impact on the costs of cardiac surgery

Abstract Objective: The objective of this study was to calculate the direct costs of postoperative atrial fibrillation (POAF) in a high-complexity cardiovascular hospital. Methods: We performed a cost analysis with a pairwise-matched design. Twenty-two patients with POAF and 22 patients without this complication were included. Pair-matching was performed (1:1) based on the following criteria: identical type of surgery, similar EuroSCORE II values, and absence of any other postoperative complication. Results: The total hospital cost was significantly higher in the POAF group than in the non-POAF group (US$ 10,880 [± 2,688] vs. US$ 8,856 [± 1,782], respectively, for each patient; P=0.005). This difference was attributable to postoperative costs (US$ 3,103 [± 1,552] vs. US$ 1,238 [± 429]; P=0.0001) for patients with or without POAF, respectively. The median postoperative lengths of stay were 9 (range 5-17) and 5 (3-9) days for patients with and without POAF (P=0.032), respectively. Preoperatively, no differences were found in the EuroSCORE II values (median 1.7 vs. 1.6, respectively; P=0.91) or direct costs (US$ 1,127 vs. US$ 1,063, respectively; P=0.56) between POAF and non-POAF groups. Conclusion: POAF generates a high economic burden in the overall costs of cardiac surgery, and our results reveal the differential contribution of each of the evaluated factors. This information, which was previously unavailable in this setting, is essential for the development of more effective prevention strategies.

Pulmonary vein parameters are similar or better predictors than left atrial diameter for paroxysmal atrial fibrillation after cryoablation

Left atrial diameter (LAD) has been considered an independent risk factor for atrial fibrillation (AF) relapse after pulmonary vein isolation (PVI). However, whether LAD or other factors are more predictive of late recurrence in patients with paroxysmal AF remains unclear. We aimed to evaluate the value of pulmonary vein (PV) parameters for predicting AF relapse 1 year after patients underwent cryoablation for paroxysmal AF. Ninety-seven patients with paroxysmal AF who underwent PVI successfully were included. PV parameters were measured through computed tomography scans prior to PVI. A total of 28 patients had recurrence of AF at one-year follow-up. The impact of several variables on recurrence was evaluated in multivariate analyses. LAD and the time from first diagnosis of AF to ablation maintained its significance in predicting the relapse of AF after relevant adjustments in multivariate analysis. When major diameter of right inferior pulmonary vein (RIPV) (net reclassification improvement (NRI) 0.179, CI=0.031-0.326, P<0.05) and cross-sectional area (CSA) of RIPV (NRI: 0.122, CI=0.004-0.240, P<0.05) entered the AF risk model separately, the added predictive capacity was large. The accuracy of the two parameters in predicting recurrence of AF were not inferior (AUC: 0.665 and 0.659, respectively) to echocardiographic LAD (AUC: 0.663). The inclusion of either RIPV major diameter or CSA of RIPV in the model increased the C-index (0.766 and 0.758, respectively). We concluded that major diameter of RIPV had predictive capacity similar to or even better than that of LAD for predicting AF relapse after cryoablation PVI.

Preventive effect of preoperative vitamin d supplementation on postoperative atrial fibrillation

Abstract Objective: To assess the relationship between preoperative vitamin D (vitD) supplementation and the development of postoperative atrial fibrillation (POAF). Methods: The study group consisted of 328 consecutive patients. The ınfluence of preoperative vitD supplementation on POAF was reviewed in 136 patients who underwent coronary artery bypass graft surgery with vitD insufficiency (n=80) and vitD deficiency (n=56). Patients were assigned to receive either oral vitD (50.000 U) (treatment group, n=68) or not (control group, n=68) 48 hours before surgery. Patients were followed up during hospitalisation process with respect to POAF. Results: There was no significant difference between treatment and control groups with regards to age, gender, diabetes mellitus, smoking history, chronic obstructive pulmonary disease, left atrial diameter, and biochemical parameters. Also, there was no significant difference between these groups with regards to mean vitD level on both insufficiency and deficiency patients (24.6±3.7 vs. 24.9±3.9 ng/ml P=0.837, 11.4±4.9 vs. 10.9±5.2 ng/ml P=0.681, respectively). Although the occurrence of POAF was not significantly different among treatment and control groups in patients with vitD insufficiency (31% vs. 33% P=0.538), there was a significant difference between the two groups regarding to POAF in patients with vitD deficiency (18% vs. 29% P=0.02). Conclusion: Although preoperative vitD supplementation was not found to be associated with prevention of POAF in patients with vitD insufficiency, it was found to be strongly associated with prevention of POAF in those with vitD deficiency.

Effect of plasma level of vitamin d on postoperative atrial fibrillation in patients undergoing isolated coronary artery bypass grafting

Abstract Objective: Postoperative atrial fibrillation (PoAF) is a common complication after coronary artery bypass grafting (CABG). The aim of the present study was to evaluate the association between development of PoAF and vitamin D levels in patients undergoing isolated CABG. Methods: This prospective randomized clinical trial was conducted on the patients with isolated CABG. The study was terminated when 50 patients in both PoAF(+) group and PoAF(-) group were reached. Development of AF until discharge period was assessed. Vitamin D level was measured immediately after AF; it was measured on the discharge day for the patients without PoAF. Predictive values of the independent variables were measured for the development of PoAF. Results: The groups were separated as PoAF(-) group (66% male, mean age 58.18±10.98 years) and PoAF(+) group (74% male, mean age 61.94±10.88 years). 25(OH) vitamin D level (OR=0.855, 95% CI: 0.780-0.938, P=0.001) and > 65 years (OR=3.525, 95% CI: 1.310-9.483, P=0.013) were identified as an independent predictor of postoperative AF after CABG surgery in multivariate analysis. The cut-off level for 25(OH) vitamin D level in receiver-operating characteristic curve analysis was determined as 7.65 with sensitivity of 60% and specificity of 64% for predicting PoAF (area under the curve: 0.679, P=0.002). Conclusion: Vitamin D level is considered an independent predictor for development of PoAF. Lower vitamin D levels may be one of the reasons for PoAF.

Hypothyroidism is a risk factor for atrial fibrillation after coronary artery bypass graft

Abstract Introduction: Few reports in the world have shown a differential effect of hypothyroidism in relation to morbidity and mortality following cardiac surgery. Objective: To determine the association between preoperative hypothyroidism, composite and disaggregated outcomes of mortality and complications in patients undergoing first-time isolated myocardial revascularization surgery. Methods: Historical cohort of patients undergoing myocardial revascularization between January 2008 and December 2014, with 626 patients included for evaluation of the composite and disaggregated outcomes of in-hospital mortality and complications (atrial fibrillation, surgical site infection and reoperation due to bleeding). A logistic regression model was used to determine the association between hypothyroidism and the onset of those outcomes. Results: Cohort of 1696 eligible patients for the study, with 1.8 mortality. Median age, female gender and prevalence of arterial hypertension were all significantly higher among hypothyroid patients. No differences were found in other preoperative or intraoperative characteristics. Hypothyroidism was associated with the presence of the composite outcome, RR 1.6 (1.04-2.4) and atrial fibrillation 1.9 (1.05-3.8). No association with mortality, infections or reoperation due to bleeding was found. Conclusion: Hypothyroidism is a disease that affects females predominantly and does not determine the presence of other comorbidities. Hypothyroidism is a risk factor for the onset of postoperative fibrillation in patients undergoing myocardial revascularization surgery. Postoperative care protocols focused on the prevention of these complications in this type of patients must be instituted.

Levels of uric acid and increased diastolic blood pressure: Risk factors for atrial fibrillation in patients older than 60 years / Niveles de ácido úrico y presión arterial diastólica elevada: factores de riesgo de fibrilación atrial en pacientes mayores de 60 años

Summary Objective: To characterize the maximum P-wave duration (Pmax) and P-wave dispersion (PWD) according to blood pressure (BP) and uric acid (UA) levels in geriatric patients. Method: An analytical study was performed in 83 patients aged over 60 years treated at the Family Medical Office 5 of the Aracelio Rodríguez Castellón Polyclinic, in Cienfuegos, Cuba between January and December 2015. The sample was divided into two groups (patients with hyperuricemia and patients with normal UA levels). Results: We found a linear and significant correlation between diastolic BP and Pmax in patients with hyperuricemia (r=0.695; p=0.026), but not in patients with normal UA (r=0.048; p=0.757). A linear and significant correlation was demonstrated between diastolic BP and PWD in patients with hyperuricemia (r=0.657; p=0.039), but not in patients with normal UA (r=0.054; p=0.730). Conclusion: There is correlation between diastolic BP and Pmax plus PWD in elderly patients with hyperuricemia.

Resumen Objetivo: Caracterizar la máxima duración de la onda P (Pmáx) y la dispersión de la onda P (DP) según las cifras de tensión arterial (TA) y los niveles de ácido úrico en pacientes geriátricos. Método: Se realizó un estudio analítico en 83 pacientes mayores de 60 años pertenecientes al Consultorio Médico de la Familia 5 del Policlínico Aracelio Rodríguez Castellón, Cienfuegos, Cuba entre enero y diciembre de 2015. La muestra se dividió en dos grupos (pacientes con hiperuricemia y pacientes con AU normal). Resultados: Existe correlación lineal y significativa entre la tensión arterial diastólica y la Pmáx en los pacientes con hiperuricemia (r=0,695; p=0,026), mas no en los pacientes con AU normal (r=0,048; p=0,757). Se demuestra correlación lineal y significativa entre la tensión diastólica y la DP en los pacientes con hiperuricemia (r=0,657; p=0,039), aunque no en los pacientes con AU normal (r=0,054; p=0,730), respectivamente. Conclusión: Existe correlación entre la Pmáx y la DP y las cifras de tensión arterial diastólica en pacientes geriátricos con hiperuricemia.

Chronic atrial fibrillation ablation with harmonic scalpel during mitral valve surgery

Abstract Objective To evaluate surgical treatment of chronic atrial fibrillation with ultrasound in patients with mitral valve disease, considering preoperative clinical characteristics of patients undergoing surgical procedure and follow-up in the immediate postoperative period, in hospital and up to 60 months after discharge. Methods: We studied 100 patients with chronic atrial fibrillation and mitral valve disease who underwent surgical treatment using ultrasound ablation. Patient data were reviewed by consulting the control reports, including signs and symptoms, underlying disease, functional class, hospital stay, surgical procedure time, ablation time, immediate complications, and complications at discharged and up to 60 months later. Actuarial curve (Kaplan-Meier) was used for the study of permanence without recurrence after 12, 24, 36, 48 and 60 months. Results: 86% of the patients had rheumatic mitral valve disease, 14% had degeneration of the mitral valve, 40% had mitral regurgitation, and 36% had mitral stenosis. Main symptoms included palpitations related to tachycardia by chronic atrial fibrillation (70%), congestive heart failure (70%), and previous episodes of acute pulmonary edema (27%). Early results showed that 94% of the patients undergoing ultrasound ablation reversed the rate of chronic atrial fibrillation, 86% being in sinus rhythm and 8% in atrioventricular block. At hospital discharge, maintenance of sinus rhythm was observed in 86% of patients and there was recurrence of chronic atrial fibrillation in 8% of patients. At follow-up after 60 months, 83.8% of patients maintained the sinus rhythm. Conclusion: Surgical treatment of chronic atrial fibrillation with ultrasound concomitant with mitral valve surgery is feasible and satisfactory, with maintenance of sinus rhythm in most patients (83.8%) after 60 months of follow-up.

Treatment of chronic atrial fibrillation during surgery for rheumatic mitral valve disease

Abstract Introduction: The result of surgical ablation of atrial fibrillation remains controversial, although prospective and randomized studies have shown significant differences in the return to sinus rhythm in patients treated with ablation versus control group. Surgery of the Labyrinth, proposed by Cox and colleagues, is complex and increases the morbidity rate. Therefore, studies are needed to confirm the impact on clinical outcomes and quality of life of these patients. Objective: To analyze the results obtained in the treatment of atrial fibrillation by surgical approach, by Gomes procedure, for mitral valve surgery in patients with rheumatic heart disease associated with chronic atrial fibrillation. Methods: We studied 20 patients with mitral valve dysfunction of rheumatic etiology, evolving with chronic atrial fibrillation, submitted to surgical treatment of valvular dysfunction and atrial fibrillation by Gomes procedure. Results: The mean duration of infusion ranged from 65.8±11.22 and aortic clamping of 40.8±7.87 minutes. Of 20 patients operated, 19 (95%) patients were discharged with normal atrial heart rhythm. One (5%) patient required permanent endocardial pacing. In the postoperative follow-up of six months, 18 (90%) patients continued with regular atrial rhythm, one (5%) patient returned to atrial fibrillation and one (5%) patient continued to require endocardial pacemaker to maintain regular rhythm. Conclusion: Gomes procedure associated with surgical correction of mitral dysfunction simplified the surgical ablation of atrial fibrillation in patients with rheumatic mitral valve disease and persistent atrial fibrillation. The results showed that it is a safe and effective procedure.

Colchicine to Reduce Atrial Fibrillation in the Postoperative Period of Myocardial Revascularization / Colchicina para Redução de Fibrilação Atrial em Pós-Operatório de Revascularização Miocárdica

Abstract Background: The high prevalence of atrial fibrillation (AF) in the postoperative period of myocardial revascularization surgery increases morbidity and mortality. Objective: To assess the efficacy of colchicine to prevent AF in the postoperative period of myocardial revascularization surgery, the impact of AF on hospital length of stay and death, and to identify its risk factors. Methods: Between May 2012 and November 2013, 140 patients submitted to myocardial revascularization surgery were randomized, 69 to the control group and 71 to the colchicine group. Colchicine was used at the dose of 1 mg orally, twice daily, preoperatively, and of 0.5 mg, twice daily, until hospital discharge. A single dose of 1 mg was administered to those admitted 12 hours or less before surgery. Results: The primary endpoint was AF rate in the postoperative period of myocardial revascularization surgery. Colchicine group patients showed no reduction in AF incidence as compared to control group patients (7.04% versus 13.04%, respectively; p = 0.271). There was no statistically significant difference between the groups regarding death from any cause rate (5.6% versus 10.1%; p = 0,363) and hospital length of stay (14.5 ± 11.5 versus 13.3 ± 9.4 days; p = 0.490). However, colchicine group patients had a higher infection rate (26.8% versus 8.7%; p = 0.007). Conclusion: The use of colchicine to prevent AF after myocardial revascularization surgery was not effective in the present study. Brazilian Registry of Clinical Trials number RBR-556dhr.

Resumo Fundamento: A alta prevalência de fibrilação atrial (FA) no pós-operatório de cirurgia de revascularização miocárdica ocasiona maior morbidade e mortalidade. Objetivos: Avaliar a eficácia da colchicina como profilaxia para FA no pós-operatório de cirurgia de revascularização miocárdica, o impacto da FA sobre o tempo de internação hospitalar e óbito e identificar fatores de risco para o seu aparecimento. Métodos: Entre maio de 2012 e novembro de 2013, 140 pacientes submetidos à cirurgia de revascularização miocárdica foram randomizados, 69 no grupo controle e 71 no grupo colchicina. A colchicina foi utilizada na dose de 1 mg via oral, duas vezes ao dia, no pré-operatório, e 0,5 mg, duas vezes ao dia, até a alta hospitalar. Dose única de 1 mg foi administrada aos internados 12 horas ou menos antes da cirurgia. Resultados: O desfecho primário foi a taxa de FA no pós-operatório de cirurgia de revascularização miocárdica. Os pacientes do grupo colchicina não apresentaram redução na incidência de FA em comparação aos do grupo controle (7,0% versus 13,0%, respectivamente; p = 0,271). Não houve diferença estatisticamente significativa entre os grupos em relação à taxa de óbito por qualquer causa (5,6% versus 10,1%; p = 0,363) e ao tempo de internação (14,5 ± 11,5 versus 13,3 ± 9,4 dias; p = 0,490). Porém, o grupo colchicina apresentou maior taxa de infecção (26,8% versus 8,7%; p = 0,007). Conclusões: O uso da colchicina para profilaxia da FA no pós-operatório de revascularização miocárdica não se mostrou eficaz neste estudo. Registro Brasileiro de Ensaios Clínicos número RBR-556dhr.

Predictors of Atrial Fibrillation Recurrence in Hyperthyroid and Euthyroid Patients / Preditores de Recorrência de Fibrilação Atrial em Pacientes com Eutireoidismo e Hipertireoidismo

Background: Atrial fibrillation (AF) is the most common arrhythmia in adults, and is encountered in 10-15% of the patients with hyperthyroidism. Unless euthyroidism is restored, pharmacological or electrical cardioversion is controversial in patients with AF who remain hyperthyroid. Objective: The aim of this study was to assess the efficacy of electrical cardioversion and predictors of AF recurrence in hyperthyroid and euthyroid patients. Methods: The study included 33 hyperthyroid (21 males) and 48 euthyroid (17 males) patients with persistent AF. The patients were sedated with intravenous midazolam before undergoing electrical cardioversion delivered by synchronized biphasic shocks. Rates of AF recurrence were recorded. Results: Mean follow-up was 23.63 ± 3.74 months in the hyperthyroid group and 22.78 ± 3.15 months in the euthyroid group (p = 0.51). AF recurred in 14 (43.8%) and 21 (44.7%) patients in each group, respectively (p = 0.93). Multivariate regression analysis in each group showed that AF duration was the only predictor of AF recurrence, with odds ratios of 1.38 (95% confidence interval [CI] = 1.05 - 1.82, p = 0.02) in the hyperthyroid group and 1.42 (95% CI = 1.05 - 1.91, p= 0.02) in the euthyroid group. Conclusion: Rates of long-term AF recurrence were similar in successfully cardioverted hyperthyroid and euthyroid patients. The only predictor of AF recurrence in both groups was AF duration.

Fundamento: A fibrilação atrial (FA) é a arritmia mais comum em adultos e é encontrada em 10-15% dos pacientes com hipertireoidismo. A menos que haja retorno ao eutireoidismo, a cardioversão farmacológica ou elétrica é controversa em pacientes com FA que permanecem com hipertireoidismo. Objetivo: O objetivo deste estudo foi avaliar a eficácia da cardioversão elétrica e os preditores de recorrência de FA em pacientes com hipertireoidismo e eutireoidismo. Métodos: O estudo incluiu pacientes com FA persistente, dos quais 33 (21 homens) apresentavam hipertireoidismo e 48 (17 homens) eutireoidismo. Os pacientes foram sedados com midazolam endovenoso antes de serem submetidos à cardioversão elétrica com choques sincronizados bifásicos. As taxas de recorrência da FA foram registradas. Resultados: O tempo médio de seguimento foi de 23,63 ± 3,74 meses no grupo com hipertireoidismo e 22,78 ± 3,15 meses no grupo com eutireoidismo (p = 0,51). A FA recorreu em 14 (43,8%) e 21 (44,7%) pacientes em cada grupo, respectivamente (p = 0,93). Uma análise de regressão multivariada em cada grupo mostrou que a duração da FA foi o único preditor de recorrência de FA com odds ratios de 1,38 (intervalo de confiança [IC] 95% = 1,05 - 1,82, p = 0,02) no grupo com hipertireoidismo e 1,42 (IC 95% = 1,05 - 1,91, p = 0,02) no grupo com eutireoidismo. Conclusão: As taxas de recorrência da FA a longo prazo foram semelhantes em pacientes com hipertireoidismo e eutireoidismo submetidos com sucesso à cardioversão. A duração da FA foi o único preditor de recorrência da FA em ambos os grupos.

Atrial Fibrillation and Non-cardiovascular Diseases: A Systematic Review / Fibrilação Atrial e Doenças Não Cardiovasculares: Uma Revisão Sistemática

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with an unfavorable prognosis, increasing the risk of stroke and death. Although traditionally associated with cardiovascular diseases, there is increasing evidence of high incidence of AF in patients with highly prevalent noncardiovascular diseases, such as cancer, sepsis, chronic obstructive pulmonary disease, obstructive sleep apnea and chronic kidney disease. Therefore, considerable number of patients has been affected by these comorbidities, leading to an increased risk of adverse outcomes.The authors performed a systematic review of the literature aiming to better elucidate the interaction between these conditions.Several mechanisms seem to contribute to the concomitant presence of AF and noncardiovascular diseases. Comorbidities, advanced age, autonomic dysfunction, electrolyte disturbance and inflammation are common to these conditions and may predispose to AF.The treatment of AF in these patients represents a clinical challenge, especially in terms of antithrombotic therapy, since the scores for stratification of thromboembolic risk, such as the CHADS2 and CHA2DS2VASc scores, and the scores for hemorrhagic risk, like the HAS-BLED score have limitations when applied in these conditions.The evidence in this area is still scarce and further investigations to elucidate aspects like epidemiology, pathogenesis, prevention and treatment of AF in noncardiovascular diseases are still needed.

A fibrilação atrial (FA) é a arritmia cardíaca mais comum e está associada a um prognóstico desfavorável, aumentando o risco de acidente vascular encefálico e a mortalidade. Apesar de tradicionalmente associada a doenças cardiovasculares, verifica-se atualmente uma elevada incidência de FA em pacientes portadores de doenças não cardiovasculares bastante prevalentes na população geral, como câncer, sepse, doença pulmonar obstrutiva crônica, síndrome da apneia obstrutiva do sono e na doença renal crônica. Assim, cada vez mais um número considerável de doentes é afetado pela concomitância de tais doenças, acarretamento um maior risco de desfechos adversos.Os autores realizaram uma revisão sistemática da literatura buscando elucidar a interação entre essas condições.Existem diversos mecanismos que parecem contribuir para a presença concomitante de FA e doenças não cardiovasculares. Comorbidades em geral, idade avançada, disfunção autonômica, distúrbio eletrolítico e inflamação são comuns a essas doenças e podem predispor à FA.O tratamento de FA nesses pacientes constitui um desafio clínico, especialmente em relação à terapêutica antitrombótica, uma vez que os scores de estratificação de risco tromboembólico como o CHADS2 ou CHADS2DS2VASC, bem como os de risco hemorrágico como o HAS-BLED, apresentam limitações quando aplicados nas doenças em questão.As evidências nesta área ainda são escassas, sendo necessárias investigações futuras para esclarecer aspectos como a epidemiologia, a patogênese, a prevenção e o tratamento da AF nas doenças não cardiovasculares.

Incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting / Incidência de fibrilação atrial no pós-operatório de pacientes submetidos à cirurgia de revascularização do miocárdio com e sem circulação extracorpórea

AbstractObjective:To determine the incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting.Methods:A retrospective study with analysis of 230 medical records between January 2011 and October 2013 was conducted.Results:Fifty-six (24.3%) out of the 230 patients were female. The average age of patients undergoing on-pump coronary artery bypass grafting was 59.91±8.62 years old, and off-pump was 57.16±9.01 years old (P=0.0213). The average EuroSCORE for the on-pump group was 3.37%±3.08% and for the off-pump group was 3.13%±3% (P=0.5468). Eighteen (13.43%) patients who underwent off-pump coronary artery bypass grafting developed postoperative atrial fibrillation, whereas for the onpump group, 19 (19.79%) developed this arrhythmia, with no significant difference between the groups (P=0.1955).Conclusion:Off-pump coronary artery bypass grafting did not reduce the incidence of atrial fibrillation in the postoperative period. Important predictors of risk for the development of this arrhythmia were identified as: patients older than 70 years old and presence of atrial fibrillation in perioperative period in both groups, and non-use of beta-blockers drugs postoperatively in the on-pump group.

ResumoObjetivo:Determinar a incidência de fibrilação atrial no pós -operatório de pacientes submetidos à cirurgia de revascularização do miocárdio com e sem circulação extracorpórea.Métodos:Foi realizado um estudo retrospectivo com análise de 230 prontuários entre janeiro de 2011 e outubro de 2013.Resultados:Do total de 230 pacientes, 56 (24,3%) eram do sexo feminino. A média de idade dos pacientes submetidos à cirurgia de revascularização do miocárdio com circulação extracorpórea foi de 59,91±8,62 anos, e sem circulação extracorpórea, foi de 57,16±9,01 anos (P=0,0213). A média do Euroscore para o grupo com circulação extracorpórea foi de 3,37%±3,08% e para o grupo sem circulação extracorpórea foi de 3,13%±3% (P=0,5468). Entre os pacientes que realizaram a cirurgia de revascularização do miocárdio sem circulação extracorpórea, 18 (13,43%) desenvolveram fibrilação atrial no pós-operatório, enquanto no grupo com circulação extracorpórea, 19 (19,79%) desenvolveram esta arritmia, não havendo diferença significativa entre os grupos (P=0,1955).Conclusão:A cirurgia de revascularização do miocárdio sem circulação extracorpórea não diminuiu a incidência de fibrilação atrial no período pós-operatório. Identificamos como preditores de risco para o desenvolvimento desta arritmia: idade superior a 70 anos e presença de fibrilação atrial no período transoperatório em ambos os grupos estudados, e o não uso de medicamentos betabloqueadores no pós-operatório do grupo com circulação extracorpórea.

Idade avançada e incidência de fibrilação atrial em pós-operatório de troca valvar aórtica / Advanced age and incidence of atrial fibrillation in the postoperative period of aortic valve replacement

Objetivo: Descrever, em idosos, a correlação entre faixa etária e ocorrência de fibrilação atrial após cirurgia por estenose aórtica, além de avaliar a influência da ocorrência de fibrilação atrial na incidência de acidente vascular cerebral, tempo de internação e mortalidade hospitalar. Métodos: Estudo transversal retrospectivo incluindo pacientes com idade > 70 anos submetidos à cirurgia de troca valvar aórtica isolada. Resultados: Foram estudados 348 pacientes com idade média de 76,8±4,6 anos. A incidência de fibrilação atrial no pós-operatório foi 32,8% (n=114), sendo superior nos pacientes > 80 anos (42,9 vs. 28,8% 70-79 anos, P=0,017) e havendo significância estatística limítrofe (P=0,055) para tendência linear na correlação idade e incidência de fibrilação atrial. Verificou-se significativo maior tempo de internação na Unidade de Terapia Intensiva e hospitalar total, porém, não se observou maior taxa de acidente vascular cerebral ou de mortalidade hospitalar decorrente da fibrilação atrial. Conclusão: A incidência de fibrilação atrial no pós-operatório de cirurgia para estenose valvar aórtica em pacientes idosos com > 70 anos foi elevada e linearmente correlacionada ao avanço da idade, especialmente após 80 anos, causando aumento dos tempos de internação total e em Unidade de Terapia Intensiva, sem aumento significativo da morbimortalidade. O conhecimento desses dados é importante para evidenciar a necessidade de medidas profiláticas e de tratamento precoce dessa arritmia nesse subgrupo. .

Objective: This study aims to describe the correlation between age and occurrence of atrial fibrillation after aortic stenosis surgery in the elderly as well as evaluate the influence of atrial fibrillation on the incidence of strokes, hospital length of stay, and hospital mortality. Methods: Cross-sectional retrospective study of > 70 year-old patients who underwent isolated aortic valve replacement. Results: 348 patients were included in the study (mean age 76.8±4.6 years). Overall, post-operative atrial fibrillation was 32.8% (n=114), but it was higher in patients aged 80 years and older (42.9% versus 28.8% in patients aged 70-79 years, P=0.017). There was borderline significance for linear correlation between age and atrial fibrillation (P=0.055). Intensive Care Unit and hospital lengths of stay were significantly increased in atrial fibrillation (P<0.001), but there was no increase in mortality or stroke associated with atrial fibrillation. Conclusion: Post-operative atrial fibrillation incidence in aortic valve replacement is high and correlates with age in patients aged 70 years and older and significantly more pronounced in patients aged 80 years. There was increased length of stay at Intensive Care Unit and hospital, but there was no increase in mortality or stroke. These data are important for planning prophylaxis and early treatment for this subgroup. .

Síndrome do Coração Pós-Feriado Revisto após 34 Anos / Holiday heart syndrome revisited after 34 years

Os efeitos cardiovasculares do álcool são bem conhecidos. No entanto,a maioria das pesquisas tem se concentrado nos efeitos benéficos (o "paradoxo francês") de um consumo moderado ou as consequências danosas, tais como a cardiomiopatia dilatada, associada ao consumo pesado durante um período prolongado. Uma associação entre a ingestão de álcool aguda e o aparecimento de arritmias cardíacas foi relatada pela primeira vez no início dos anos 70.Em 1978, Philip Ettinger descreveu a "síndrome do coração pós-feriado" (HHS) pela primeira vez, como a ocorrência, em pessoas saudáveis e sem doença cardíaca conhecida por causar arritmia, de uma perturbação aguda do ritmo cardíaco, mais frequentemente fibrilação atrial, após o consumo abusivo de bebidas. O nome é derivado do fato de que esses episódios foram inicialmente observados mais frequentemente após finais de semana ou feriados. Desde a descrição original da HHS, 34 anos se passaram e novas pesquisas neste campo aumentaram o volume de conhecimentos relacionados a esta síndrome. Ao longo deste artigo, os autores vão revisar de forma abrangente a maioria dos dados disponíveis sobre a HHS e destacar as questões que permanecem sem solução.

The cardiovascular effects of alcohol are well known. However, most research has focused on the beneficial effects (the "French paradox") of moderate consumption or the harmful consequences, such as dilated cardiomyopathy, associated with heavy consumption over an extended period. An association between the ingestion of acute alcohol and onset of cardiac arrhythmias was first reported in the early 70's. In 1978, Philip Ettinger described "Holiday heart syndrome" (HHS) for the first time, as the occurrence, in healthy people without heart disease known to cause arrhythmia, of an acute cardiac rhythm disturbance, most frequently atrial fibrillation, after binge drinking. The name is derived from the fact that episodes were initially observed more frequently after weekends or public holidays. Since the original description of HHS, 34 years have passed and new research in this field has increased the volume of knowledge related to this syndrome. Throughout this paper the authors will comprehensively review most of the available data concerning HHS and highlight the questions that remain unresolved.