Post-operative Atrial Fibrillation after Non-cardiac Thoracic Surgery

Recommendations from a Review and Analysis of Strategies for Prediction, Prevention and Management of Post-operative Atrial Fibrillation after Non-cardiac Thoracic Surgery.


Background:

Atrial fibrillation (AF) is the most commonly sustained arrhythmia after non-cardiac thoracic surgery, occurring between 12%-44% of pulmonary and esophageal resections, and is associated with a significant increase in post-operative morbidity, length of stay (LOS), intensive care unit (ICU) admission and mortality ([i],[ii]). Patients who develop postoperative atrial fibrillation (POAF) often experience an increased LOS of 2 to 14 days ([iii]). If sustained, it can increase the patient’s risk of thromboembolic events ([iv]). As an independent risk factor of stroke in the 30 days following development of new sustained AF ([v]), anticoagulation is critical ([vi]). AF is associated with increased mortality risk after esophagectomy (mortality increase from 4.8 to 8.1%, p=0.04) ([vii]) and decreased long-term survival after lobectomy (HR 3.75; 95% CI 1.44 to 9.08) (1). AF is both common and impactful, efforts to effectively and optimally predict, prevent and manage POAF is critical to improving quality of thoracic surgical care.

Our review and analysis aimed to provide a practical, feasible and clinically applicable strategy for the prediction, prevention and management of POAF in patients undergoing non-cardiac thoracic surgery. Below are the recommendations developed from our review and analysis, as well as an algorithm to guide individualized evidence-based management of POAF.

Recommendation

  1. Multiple existing predictive models are capable of identifying patients at increased risk for POAF; however clinical application of these risk models first requires external validation, followed by ongoing evaluation and improvement over time.
  2. Prophylactic therapy with beta-blocker agents, amiodarone, calcium-channel blockers (CCB) and magnesium may be considered to reduce the risk of POAF; however, providing prophylaxis to all patients is not recommended because the exposure of all patients to the risk of adverse events outweighs the benefit experienced by only a few patients in preventing POAF. The approach of implementing prophylaxis only in high-risk patients only to reduce incidence and severity of POAF is promising yet unproven, and requires further study to evaluate safety and effectiveness.
  3. For patients with new onset POAF who develop acute hemodynamic instability, immediate synchronized electrocardioversion is recommended and consideration of echocardiogram.
  4. Hemodynamically stable patients with POAF should receive incremental dosing of rate control therapy with continuous cardiac monitoring until a heart rate of <110 BPM is achieved. If the patient has known decompensated heart failure or ejection fraction <35%, consider the least negatively inotropic agent, namely amiodarone. If no decompensated heart failure, initial trial of low trial dose of beta-blocker (e.g. 2 mg metoprolol IV push) should be given followed by repeat dosing if beneficial effect witnessed (e.g. lowering HR) and no adverse events (e.g. hypotension, bronchospasm, bradycardia) until desired effect; or if no effect observed on heart rate or blood pressure, consider CCB (e.g. 5 mg diltiazem IV push), with repeat dosing if beneficial effect and no adverse events to achieve rate control.
  5. To augment effect of either beta-blocker or CCB, consider digoxin to further augment effectiveness of rate control and minimize adverse events.
  6. Early assessment and correction of underlying POAF triggers may help facilitate early return to sinus rhythm (such as pneumothorax, pneumonia, pulmonary embolism, infection, bleeding or electrolyte abnormalities).
  7. Cardioversion should be reserved for patients who cannot tolerate rate control agents or who, after 48h, continue to have POAF despite rate control.
  8. The choice of antiarrhythmic agent should be selected in accordance with the patient’s comorbidities and the agents side effect profile.
  9. Further formal evaluations of standardized protocols to predict, prevent and manage POAF are warranted to evaluate impact on incidence, duration and severity of POAF.
  10. Antithrombotic therapy to reduce the risk of stroke in patients with persistent AF should be considered if POAF persists >48h, and should be individualized based on patient’s risk factors for thromboembolic event (congestive heart failure, hypertension, diabetes, previous thromboembolic event, peripheral vascular disease) and post-operative bleeding risk.

Abbreviations: POAF, post-operative atrial fibrillation; CCB, calcium channel blocker; BPM, beats per minute.

Abbreviations: IV, intravenous; O2, oxygen; ECG, electrocardiogram; CBC, complete blood count; LOC, level of consciousness; HR, heart rate; HF, heart failure; EF, ejection fraction, CHF, congestive heart failure; HTN, hypertension; DM, diabetes mellitus; TIA, transient ischemic attack, CXR, chest x-ray; TEE, trans-esophageal echocardiogram; LMWH, low molecular weight heparin; ASA, acetylsalicylic acid.

References

[i] Imperatori, A., Mariscalco, G., Riganti, G., et al. (2012b). Atrial fibrillation after pulmonary lobectomy for lung cancer affects long-term survival in a prospective single-center study. Journal of Cardiothoracic Surgery, 7, 4. https://doi.org/10.1186 /1749-8090-7-4

[ii] Amar D, Zhang H, Shi W, et al. Brain natriuretic peptide and risk of atrial fibrillation after thoracic surgery. The Journal of Thoracic and Cardiovascular Surgery. 2012 Nov 1;144(5):1249–53.

[iii] Polanczyk, C.A., Goldman, L., Marcantonio, E.R., et al. Supraventricular arrhythmia in patients having non cardiac surgery: clinical correlates and effect on length of stay. The Annals of Internal Medicine. 1998; 129: 279–285

[iv] Investigators, T. A. F. F. I. of R. M. (AFFIRM). (2002). A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation. New England Journal of Medicine, 347(23), 1825–1833. https://doi.org/10.1056/NEJMoa021328

[v]  Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. The Lancet. 2008 May 31;371(9627):1839–47.

[vi]  Camm, A.J., Lip G.Y.H, De Caterina R., et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation An update of the 2010 ESC Guidelines for the management of atrial fibrillation Developed with the special contribution of the European Heart Rhythm Association. Europace. 2012 Oct 1;14(10):1385–413.

[vii] Rao, V. P., Addae-Boateng, E., Barua, A., et al. (2012). Age and neo-adjuvant chemotherapy increase the risk of atrial fibrillation following oesophagectomy. European Journal of Cardio-Thoracic Surgery, 42(3), 438–443. https://doi.org/10.1093/ejcts /ezs085


Authors:
H Smith, MD ; C, Yeung, MD2; S Gowing, MD2; MM Sadek, MD, FRCPC3; DE Maziak, MD, FRCSC2; S Gilbert, MD, FRCSC2; FM Shamji MD, FRCSC2; PJ Villeneuve, MD, FRCSC2; RS Sundaresan MD FRCSC2, AJE Seely MD, PhD, FRCSC
[1] Division of General Surgery, The Ottawa Hospital, University of Ottawa
[2] Division of Thoracic Surgery, The Ottawa Hospital, University of Ottawa
[3] Division of Cardiology, The Ottawa Hospital, University of Ottawa

Correspondence to:
Heather Smith
Department of Surgery, Division of General Surgery, The Ottawa Hospital
501 Smyth Rd, Ottawa, ON K1H 8L6
Email: hesmith@toh.ca
Telephone: (613) 789-5555

Author’s Contribution:
(II) Administrative support: HS
(III) Provision of study materials or patients: NA
(IV) Collection and assembly of data: HS, AS, MS, FS, DM, SS, AS
(V) Data analysis and interpretation: HS, AS, MS, FS, DM, SS, AS
(VI) Manuscript writing: All authors
(VII) Final approval of manuscript: All authors


Recommendation for Thoracic Surgery Perioperative VTE Prophylaxis.


Background:

It is now widely accepted that the true incidence of post-op VTE following lung and esophageal resection is largely under-reported. A large range of incidence has been reported, with variations mainly related to different detection methods, type and duration of prophylaxis, and the subclinical nature of a significant proportion of VTE occurrence. Thoracic surgery poses an increased risk of postop VTE given the high prevalence of oncologic surgery, the protracted post-operative recovery, and the direct manipulation of the lung and pulmonary vascular anatomy.

CATS Recommendations

CATS members continue to be involved in research evaluating the optimal method and duration for post-thoracic surgery VTE prophylaxis. The committee recognizes however the paucity of high-level evidence in this field. As higher level evidence emerges, CATS hopes that a unified approach to postop VTE prophylaxis can serve as a starting point to adopt new guidelines for in-hospital and post discharge care.

  1. Post Thoracic surgery in-hospital prophylaxis = LMWH or LDUH +/- mechanical compression
  2. No recommendation for extended prophylaxis = use at surgeon’s discretion
  3. Symptomatic postop VTE = Thrombosis referral + therapeutic anticoagulation

Summary of the Evidence

  • Most data is based on retrospective single-institution cohort studies.
    • Results are challenged by the retrospective nature of the studies, dependence on symptomatic diagnosis and not asymptomatic screening, and lack of recognition of de novo PE without DVT
    • Estimates of postop incidence: 5-15.2%
  • More recent research has evaluated prevalence of post-lung resection VTE using screening strategies in a prospective fashion
    • Prospective screening studies
      • CTPA 7-15 days postop = prevalence of 14%
      • B/L Doppler U/S + CTPA @ 30-days postop = prevalence 12.1%
    • 23% of VTE occur post-discharge & Post-pneumonectomy peak incidence à >7 days postop
    • Cohort of 2,373 cancer patients identified that 40% of VTE occurred >21 days post discharge
  • Canadian Delphi Survey including CATS members (Journal Thorac Dis. 2017 Jan; 9(1)80-87)
    • Strong agreement in identifying risk factors for VTE, and which of those factors may potentially influence the decision for extended post-hospital discharge prophylaxis.
    • Limited agreement on the type of prophylaxis (pharmacological, mechanical and/or both), as well as the initiation and duration of thromboprophylaxis—indicating high degree of variability
    • The only reliable factor of agreement was the use of LMWH in hospital

ACCP 9th Edition Guidelines for Thoracic Surgery

  • Moderate risk for VTE + not high bleeding risk à LDUH or LMWH (Grade 2B), or MCS (Grade 2c)
  • High risk for VTE + not high bleeding risk à LDUH or LMWH (Grade 1B) + MCS (Grade 2C)
  • High risk for Major bleeding à MCS with optimally applied IPC (Grade 2C)
  • No recommendation for extended post-discharge prophylaxis.

Follow-up and Surveillance Recommendations for Patients Treated Curatively for Lung Cancer.


Background:

Despite advances in the care of patients with NSCLC, the overall 5-year survival for patients treated with curative intent remains poor. The rationale for surveillance following the treatment of lung cancer is the detection of recurrent disease or a new primary lung cancer, no randomized data exist to support specific recommendations for surveillance modality and interval. Most recommendations are based on expert consensus and cohort studies, and the effect of surveillance on survival continues to be debated. Data extrapolated from screening trials does demonstrate a survival benefit to the detection of early stage cancers and most guideline-setting groups recommend a surveillance strategy involving regular clinical examinations and imaging. 1-8, 10-16

Recommendations

  • Surveillance for early recurrence or new primaries in patients treated with curative intent for NSCLC:
    • Low dose CT chest +/- contrast q6mo in years 1 and 2 1-5,9,17,18
    • Low dose CT chest +/- contrast q12mo years thereafter1-5,9,17,18
  • CT dose (i.e. Low dose vs Minimal dose) and the use of contrast is controversial. There are no data to suggest one dose over another. Extrapolation of data from the National Lung Cancer Screening Trial would suggest Low dose CT provides good sensitivity for the detection of early stage cancers.4,5,6
  • Surveillance for early recurrence or new primaries in patients treated with curative intent for SCLC:
  • Surveillance recommendations for surveillance post curative intent treatment of SCLC are based on expert consensus and parallel those for NSCLC.
  • Contrast enhanced CT chest may provide superior assessment of mediastinal nodal involvement18

References

  1. Calman L, Beaver K, Hind D, Lorigan P, Roberts C, Lloyd-Jones M. Survival benefits from follow-up of patients with lung cancer: a systematic review and meta-analysis. J Thorac Oncol. 2011;6(12):1993-2004.
  2. Sugimura H, Yang P. Long-term survivorship in lung cancer: a review. Chest.2006;129(4):1088-97
  3. Srikantharajah D, Ghuman A, Nagendran M, Maruthappu M. Is computed tomography follow-up of patients after lobectomy for non-small cell lung cancer of benefit in terms of survival? Interact Cardiovasc Thorac Surg. 2012;15(5):893-8.
  4. Hanna WC, Paul NS, Darling GE, Moshonov H, Allison F, Waddell TK, et al. Minimal-dose computed tomography is superior to chest x-ray for the follow-up and treatment of patients with resected lung cancer. J Thorac Cardiovasc Surg. 2014;147(1):30-5.
  5. National Lung Screening Trial Research Team, Church TR, Black WC, Aberle DR, Berg CD, Clingan KL, et al. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med. 2013;368(21):1980-91.
  6. Crabtree TD, Puri V, Chen SB, et al. Does the method of radiologic surveillance affect survival after resection of stage I non-small cell lung cancer? J Thorac Cardiovasc Surg 2015;149:45-52, 53 e41-43.
  7. Aberle DR, DeMello S, Berg CD, Black WC, Brewer B, Church TR, et al. Results of the two incidence screenings in the National Lung Screening Trial. N Engl J Med. 2013;369(10):920-31.
  8. Erb CT, Su KW, Soulos PR, et al. Surveillance practice patterns after curative intent therapy for stage I non-small-cell lung cancer in the medicare population. Lung Cancer 2016;99:200-207. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27565940.
  9. Colt HG, Murgu SD, Korst RJ, et al. Follow-up and surveillance of the patient with lung cancer after curative-intent therapy: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e437S-454S. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23649451.
  10. Lou F, Huang J, Sima CS, et al. Patterns of recurrence and second primary lung cancer in early-stage lung cancer survivors followed with routine computed tomography surveillance. J Thorac Cardiovasc Surg 2013;145:75-81; discussion 81-72. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23127371.
  11. Srikantharajah D, Ghuman A, Nagendran M, Maruthappu M. Is computed tomography follow-up of patients after lobectomy for non-small cell lung cancer of benefit in terms of survival? Interact Cardiovasc Thorac Surg 2012;15:893-898. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22859511.
  12. Dane B, Grechushkin V, Plank A, et al. PET/CT vs. non-contrast CT alone for surveillance 1-year post lobectomy for stage I non-small-cell lung cancer. Am J Nucl Med Mol Imaging
  13. Nakamura R, Kurishima K, Kobayashi N, et al. Postoperative follow-up for patients with non-small cell lung cancer. Onkologie. 2010;33(1-2):14-18
  14. Johnson BE. Second lung cancers in patients after treatment for an initial lung cancer. J Natl Cancer Inst 1998; 90: 1335–1345.
  15. Demicheli R, Fornili M, Ambrogi F et al. Recurrence dynamics for non-small-cell lung cancer: effect of surgery on the development of metastases. J Thorac Oncol 2012; 7: 723–730.
  16. Toba H, Sakiyama S, Otsuka H et al. 18F-fluorodeoxyglucose positron emission tomography/computed tomography is useful in postoperative follow-up of asymptomatic non-small cell lung cancer patients. Interact Cardiovasc Thorac Surg 2012; 15: 859–864
  17. Vansteenkiste, et al. 2nd ESMO Consensus Conference on Lung Cancer: early-stage non-small-cell lung cancer consensus on diagnosis, treatment and follow-up. Annals of Oncology 25: 1462–1474, 2014
  18. Ung YC, Souter LH, Darling G, Dobranowski J, Donohue L, Leighl N, et al. Follow-up and surveillance of curatively treated lung cancer patients. Toronto (ON): Cancer Care Ontario; 2014 Aug 29. Program in Evidence-Based Care Evidence-Based Series No.: 26-3.