Predictors of Postoperative Atrial Fibrillation after Heart Valve Surgery

Document Type : Original Article


Background- Atrial fibrillation (AF) is the most common complication after cardiac surgery and a
major cause of morbidity and increased cost of care. Suitable treatment and prevention of
postoperative AF are important for patients’ improved health and rehabilitation. This study
evaluates the risk factors of paroxysmal AF in patients who underwent valvular heart surgery.
Method- Between April and October 2006, 392 patients who underwent heart valve surgery at our
center were included in this prospective study. All relevant clinical, echocardiographic, and
laboratory data were gathered in all the patients.
Results- Postoperative AF occurred in 52 (13.3%) patients. In the univariate analysis, the presence
of aortic valve disease, mitral valve disease, dyslipidemia, preoperative digoxin consumption,
postoperative adrenergic use, intra-aortic balloon pump (IABP) insertion in post-surgery
intensive care unit, and large left atrium were significantly associated with the occurrence of
postoperative AF (all P<0.05). However, in the stepwise logistic regression model,
dyslipidemia (OR: 2.39, 95% CI: 1.12-5.09, P=0.020), left atrium dimension (OR: 0.12, 95%
CI: 0.76-0.28, P<0.001), IABP (OR: 7.10, 95% CI: 1.98-25.47, P=0.001), preoperative
digoxin use (OR: 2.55, 95% CI: 1.38-4.71, P=0.002), postoperative adrenergic use (OR:3.70,
95% CI: 1.77-7.73, P<0.001), aortic valve replacement (OR:0.38, 95% CI: 0.20-0.69,
P=0.0001), and mitral valve replacement (OR:3.53, 95% CI: 1.75-7.10, P<0.001) remained
independently predictive of postoperative AF.
Conclusions- The result of this study showed that dyslipidemia, left atrium dimension, mitral valve
replacement, aortic valve replacement, IABP, and adrenergic use in ICU and digoxin use
preoperatively were the independent predictors of AF after valvular surgery. Therefore, clinical
data and echocardiography may be useful in preoperative risk stratification of high-risk patients
for the occurrence of postoperative AF(Iranian Heart Journal 2008; 9 (2):10-17).


Hossein Ali Bassiri MD, Khadijeh Ghanbarian MD, Majid Haghjoo MD*

1. Banach M, Goch A, Misztal M, Rysz J, Jaszewski
R, Goch H. Predictors of paroxysmal AF in
patients undergoing aortic valve replacement. J
Thorac cardiovas Surg 2007; 134: 1569-1576.
2. Funk M, Richards S, Desjardins J, Bebon C,
Wilcox H. Incidence, timing, symptoms, and
risk factors for AF after cardiac surgery. Am J
Critical Care 2003; 12: 424-433.
3. Auer J, Weber T, Berent R, Keung C, Lamm G,
Eber B. Risk factors of postoperative AF after
cardiac surgery. J Card Surg 2005; 2: 425-431.
4. David C, Michael J, Anthony C. Interventions for
prevention of postoperative AF and its
complications after cardiac surgery: a metaanalysis.
Eur Heart J 2006; 27: 2846-2857.
5. Kerstein J, Soodan A, Qamar M, Majid M,
Lichstein E, Hollander G, et al. Giving IV and
oral amiodarone perioperatively for the
prevention of postoperative AF in patients
undergoing coronary artery bypass surgery.
Chest 2004; 126: 716-724.
6. Steven J, Vuyisile T, David M, Bernard J, Thoralf
M, Christofer G, et al. AF after surgical
correction of mitral regurgitation in sinus
rhythm. Circulation 2004; 110: 2320-2325.
7. Emile G, Adam S, Chingman D, Rajiva G, Deeb
M, Booling S, et al. Preoperative amiodarone as
prophylaxis against AF after heart surgery.
NEJM 1997; 337: 1785-1791.
8. Fuster V, Wayne A, O'Rourke R(eds.) Atrial
fibrillation. Hurst’s the Heart 2004; Ch 29: 825-
8 .
9. Charles W, Hogue J, Lawrence L, David D, et al
Epidemiology, mechanisms and risks.
American College of Chest Physician
guidelines for the prevention and management
of postoperative AF after cardiac surgery. Chest
2005; 128; 615-645.
10. Joel D, Peter M. Are the American College of
Chest Physicians guidelines for the prevention
and management of AF after cardiac surgery
already obsolete? Chest 2006; 129: 1112-1113.
11. Mathew J, Fontes M, Tudor I, Ramsay J, Duke P,
Mazer D. et al. Investigators of the ischemic
research and education foundation. JAMA
2004; 291: 1720-1729.
12. Creswell L, Schuessler R, Rosenbloon M.
Hazards of postoperative atrial arrhythmias.
Ann Thorac Surg 1993; 56: 539-549.
13. Borzak S, Tisdale J, Amin N, Goldberg D, Frank
D. AF after bypass surgery: does the arrhythmia
or the characteristics of the patients prolong
hospital stay? Chest 1998; 113: 1489-1491.
14. Cagli K, Keles T. Risk factors associated with
development of AF early after coronary artery
bypass grafting. Am J Cardiol 2000; 85: 1259-
15. Quader M, McCarthy P, Gillinov A, Alster J.
Does preoperative AF reduce survival after
coronary artery bypass grafting? Ann Thorac
Surg 2004; 77: 1514-1522.
16. Deliargyris E, Raymond R, Guzzo J. Preoperative
factors predisposing to early postoperative AF
after isolated coronary artery bypass grafting.
Am J Cardiol 2000; 85: 763-4.
17. Jideus L, Blomstorm P, Nilsson L, Stridsberg M.
Tachyarrhythmias and triggering factors for AF
after coronary artery bypass operation. Ann
Thorac Surg 2000; 69: 1064-1069.
18. Kalman J, Muawar M, Howes L, Louis w,
Buxton B, Gutteridge G, et al. AF after
coronary artery bypass operation is associated
with sympathetic activation. Ann Thorac Surg
1995; 60: 1709-1715.
19. Mathew J, Fontes M, Tudor I, Ramsay J, Duck P,
Mazer D, et al. A multicenter risk index for AF
after cardiac surgery. JAMA 2004; 291: 1720-
20. Passman R, Beshai J, Pavri B, Kimmel S.
Predicting post-coronary bypass surgery atrial
arrhythmia from the preoperative ECG. Am
Heart J 2001; 142: 806-810.
21. Skubas N, Brazilia B, Hogue C. AF after
coronary artery bypass graft surgery is
unrelated to cardiac abnormalities detected by
TEE. Anesth Analg 2001; 93: 14-19.
22. Tamis J, Steinberg J. AF independently prolongs
hospital stay after coronary artery bypass
surgery. Clin Cardiol 2000; 23: 155-159.
23. Aranki S, Shaw D, Adams D, Rizzo R, Couper G,
Vandervliet M, et al. Predictors of AF after
coronary artery surgery: Current trends and
impact on hospital resources. Circulation 1996;
94: 390-397.
24. Asher C, Miller D, Grimm R, Cosgrow D.
Analysis of risk factors for development of AF
early after cardiac valvular surgery. Am J
Cardiol 1948; 82: 892-895.
25. Crosby L, Pifalo W, Woll K, Burkholder J. risk
factors for AF after coronary artery bypass
grafting. Am J Cardiol 1990; 66: 1520-1522.
26. Dimmer C, Tavernier R, Gjorgou N, Vannootern
G. Variations of autonomic tone preceding
onset of AF after coronary artery bypass
grafting. Am J Cardiol 1998; 82: 22-25.
27. Fuller J, Adams G, Buxton B. AF after coronary
artery bypass grafting: is it a disorder of the
elderly? J Thorac Cardiovas Surg 1989; 97:
28. Leitch J, Thomson D, Baird D, Harris P. The
importance of age as a predictor of AF and
flutter after coronary artery bypass grafting. J.
Thorac Cardiovasc Surg 1990; 100: 338-342.
29. Mathew J, Parks P, Savino J. AF following
coronary artery bypass graft surgery: predictors,
outcomes, and resource utilization. JAMA
1996; 276: 300-306.
30. Stamou S, Dangas G, Hill P. AF after beating
heart surgery. Am J Cardiol 2000; 86:64-67.
31. Harvank M, Hoffman L, Saal M, Zullo T.
Predictors and impact of AF after isolated
coronary artery bypass grafting. Crit Care Med
2002; 30: 330-337.
32. Almassi G, Schwalter T, Nicolosi A. AF after
cardiac surgery: a major morbid event? Ann
Surg 1997; 226: 501-510.
33. Duceschi V, D’Andreg A, Liccardo B.
Perioperative clinical predictors of AF
occurrence following coronary artery surgery.
Eur J Cardiothorac Surg 1999; 16: 435-439.
34. Frost L, Molgaard H, Christiansen E, Jacobsen C,
Allermand H. Low vagal tone and
supraventricular ectopic activity predict AF and
flutter after coronary artery bypass grafting. Eur
Heart J 1995; 16: 825-831.
35. Azfar G, Archbold R, Helft G, Elizabeth A,
Nicholas P, Peter G. AF after coronary artery
bypass surgery: a model for preoperative risk
stratification. Circulation 2000; 101: 1403-
36. Vikrant S, Nirav J, Syed Abdul-Aziz, Syed M.
Role of postoperative vasopressor use in
occurrence of AF after CABG. Am J Cardiol
2005; 95: 247-249.
37. Halonen J, Hakalat T, Auvinen T, Karjalainen J,
Turpeinen A, Unsaro A. et al. Intravenous
administration of metoprolol is more effective
than oral administration in the prevention of AF
after cardiac surgery. Circulation 2006; 114: 1-
38. Singer D, Albers G, Dalen G, Go A, Halperin J,
Manning W. Antithrombotic therapy in AF.
Chest 2004; 126: 429-456.
39. Villareal R, Hariharan R, Liu B. Postoperative
AF and mortality after coronary artery bypass
surgery. J Am Coll Cardiol 2004; 43: 742-748.
40. Reed G, Singer D, Picard E, DeSanctis R. Stroke
following coronary artery bypass surgery. A
case control estimate of the risk from carotid
bruits. NEJM 1988; 319: 1246-1250.
41. Roach G, Kanchuger M, Mangano C, Newman
M, Nussmeier N, Wolman R, et al. Adverse
cerebral outcomes after coronary bypass
surgery. NEJM 1996; 335: 1857-1863.
42. Bucerius J, Gummert J, Borger M. Walther T.
Predictors of delirium after cardiac surgery:
Effect of beating-heart (off-pump) surgery. J
Thorac Cardiovasc Surg 2004; 127: 57-64.
43. Michael H, Michael D, Morady F, Buckman D,
Lucille R, Hallock R, et al. Effect of
postoperative AF on length of stay after cardiac
surgery (PACS2). Am J Cardiol 2001; 87: 881-
44. Haghioo, M, Bassiri H, Salek M, Sadr Ameli M,
Kargar F, Raissi K, et al. Predictors of
postoperative AF after coronary artery bypass
graft surgery. Indian Pacing Electrophysiology
2008; 8 (2): 94-101.