Risk Factors for the Development of Postoperative Atrial Fibrillation

  • Frederick A. Ehlert
  • Dhiraj D. Narula
  • Jonathan S. Steinberg
Part of the Developments in Cardiovascular Medicine book series (DICM, volume 222)


Atrial fibrillation (AF) is a frequent event following cardiac surgery, occurring in up to 40% of patients [1-5]. The arrhythmia itself is often benign such that its occurrence is sometimes not labeled as a “complication” even so, postoperative AF is associated with an increased length of hospital stay following cardiac surgery. In addition, the sequellae of postoperative AF can be severe and even life-threatening including hemodynamic compromise and thromboemboli. As such, a thorough knowledge of the risk factors associated with the development of the arrhythmia is warranted. Furthermore, it is essential that this understanding include the underlying mechanisms by which these risk factors predispose, and to seek prevention and early treatment of postoperative AF.


Atrial Fibrillation Leave Ventricular Ejection Fraction Coronary Artery Bypass Grafting Cardiopulmonary Bypass Coronary Artery Bypass Surgery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Rubin DA, Neiminski KE, Reed GE, Herman MV. Predictors, prevention, and long-term prognosis of atrial fibrillation after coronary bypass graft operations. J Thorac Cardiovasc Surg 1987; 94:331–5.2.PubMedGoogle Scholar
  2. 2.
    Lauer MS, Eagle KA, Buckley MJ, DeSanctis RW. Atrial fibrillation following coronary artery bypass surgery. Prog in Cardiovasc Diseases 1989;31(5):367–378.CrossRefGoogle Scholar
  3. 3.
    Leitch JW, Thomson D, Baird DK, Harris PJ. The importance of age as a predictor of atrial fibrillation and flutter after coronary artery bypass grafting. J Thorac Cardiovasc Surg 1990;100:338–4.PubMedGoogle Scholar
  4. 4.
    Chee T, Prakash N, Desser K, Benchimol A. Postoperative supraventricular arrhythmias and the role of prophylactic digoxin in cardiac surgery. Am Heart J 1982;104:974–977.CrossRefPubMedGoogle Scholar
  5. 5.
    Davison R, Hartz R, Kaplan K, Parker M, Feiereisel P, Michaelis L. Prophylaxis of supraventricular tachyarrhythmias after coronary artery bypass surgery with oral verapamil: a randomized, double-blinded trial. Ann Thorac Surg 1985;39:336–339.CrossRefPubMedGoogle Scholar
  6. 6.
    Pandozi C, Bianconi L, Villani M, Gentilucci G, Castro A, Altamura G, Jesi AP, Lamberti F, Ammirati F, Santini M. Elecrophysiological characteristics of the human atria after cardioversion of persistent atrial fibrillation. Circulation 1998;98:2860–2865.PubMedGoogle Scholar
  7. 7.
    Wiffels MCEF, Kirchhof CJHJ, Dorland R, Allessie MA. AF begets AF: a study in awake chronically instrumented goats. Circulation 1996;92:1954–1968.Google Scholar
  8. 8.
    Mathew JP, Parks R, Savino JS, Friedman AS, Koch C, Mangano DT, Browner WS. Atrial fibrillation following coronary artery bypass graft surgery: predictors, outcomes, and resource utilization. Multicenter Study of Perioperative Ischemia Research Group. J Am Med Assoc 1996;276:300–6.CrossRefGoogle Scholar
  9. 9.
    Frost L, Molgaard H, Christiansen EH, Jacobsen CJ, Allermand H, Thomsen PE. Low vagal tone and supraventricular ectopic activity predict atrial fibrillation and flutter after coronary artery bypass grafting. Eur Heart J 1995; 16:825–31.PubMedGoogle Scholar
  10. 10.
    Almassi GH, Schowalter T, Nicolosi AC, Aggarwal A, Moritz TE, Henderson WG, Tarazi R, Shroyer AL, Sethi GK, Graver FL, Hammermeister KE. Atrial fibrillation after cardiac surgery: a major morbid event?. Ann Surg 1997;226:501–513.CrossRefPubMedGoogle Scholar
  11. 11.
    Ong JJ, Hsu PC, Lin L, Yu A, Kass RM, Peter CT, Swerdlow CD. Arrhythmias after cardioverter-defibrillator implantation: comparison of epicardial and transvenous systems. Am J Cardiol 1995;75:137–140.CrossRefPubMedGoogle Scholar
  12. 12.
    Aranki SF, Shaw DP, Adams DH, Rizzo RJ, Couper GS, VanderVliet M, Collins JJ Jr, Cohn LH, Burstin HR. Predictors of atrial fibrillation after coronary artery surgery. Current trends and impact on hospital resources. Circulation 1996;94:390–7.PubMedGoogle Scholar
  13. 13.
    Hashimoto K, Ilstrup DM, Schaff HV. Influence of clinical and hemodynamic variables on risk of supraventricular tachycardia after coronary artery bypass. J Thorac Cardiovasc Surg 1991;101:56–65.PubMedGoogle Scholar
  14. 14.
    Stafford PJ, Kolvekar S, Cooper J, Fothergill J, Schlindwein F, deBono DP, Spyt TJ, Garratt CJ. Signal averaged P wave compared with standard electrocardiography or echocardiography for prediction of atrial fibrillation after coronary bypass grafting. Heart 1997;77:417–22.PubMedGoogle Scholar
  15. 15.
    Frost L, Lund B, Pilegaard H, Christiansen EH. Re-evaluation of the role of P-wave duration and morphology as predictors of atrial fibrillation and flutter after coronary artery bypass surgery. Eur Heart J 1996;17:1065–71.PubMedGoogle Scholar
  16. 16.
    Zaman AG, Alamgir F, Richens T, Williams R, Rothman MT, Mills PG. The role of signal averaged P wave duration and serum magnesium as a combined predictor of atrial fibrillation after elective coronary artery bypass surgery. Heart 1997;77:527–31.PubMedGoogle Scholar
  17. 17.
    Mooe T, Gullsby S, Rabben T, Eriksson P. Sleep-disordered breathing: a novel predictor of atrial fibrillation after coronary artery bypass surgery. Coron Art Dis 1996;7:475–8.CrossRefGoogle Scholar
  18. 18.
    Kalman JM, Munawarm, Howes LG, Louis WJ, Buxton BF, Gutteridge G, Tonkin AM. Atrial fibrillation after coronary artery bypass grafting is associated with sympathetic activation. Ann Thorac Surg 1995;60:1709–1715.CrossRefPubMedGoogle Scholar
  19. 19.
    Fuller JA, Adams GG, Buxton B. Atrial fibrillation after coronary artery bypass grafting: is it a disorder of the elderly? J Thorac Cardiovasc Surg 1989;97:821–825.PubMedGoogle Scholar
  20. 20.
    Benjamin EJ, Levy D, Vaziri SM, D’Agostino RB, Belanger AJ, Wolf PA. Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study. JAMA 1994;271:840–844.CrossRefPubMedGoogle Scholar
  21. 21.
    Dimmer C, Jordaens L, Gorgov N, Peene I, Francois K, Van Nooten G, Clement DL. Analysis of the P wave with signal averaging to assess the risk of atrial fibrillation after coronary artery bypass surgery. Cardiol 1998;89:19–24.CrossRefGoogle Scholar
  22. 22.
    Caretta Q, Mercanti CA, DeNardo D, Chiarotti F, Scibilia G, Reale A, Marino B. Ventricular conduction defects and atrial fibrillation after coronary artery bypass grafting, multivariate analysis of preoperative, intraoperative and postoperative variables. Eur J Cardiol 1991; 12:1107–1111.Google Scholar
  23. 23.
    Steinberg JS, Zelenkofske S, Wong SC, Gelernt M, Sciacca R, Menchavez E. Value of the P-wave signal-averaged ECG for predicting atrial fibrillation after cardiac surgery. Circulation 1993;88:2618–22.PubMedGoogle Scholar
  24. 24.
    Creswell LL, Schuessler RB, Rosenbloom M, Cox JL. Hazards of postoperative atrial arrhythmias. Ann Thorac Surg 1993;56:539–49.CrossRefPubMedGoogle Scholar
  25. 25.
    Frost L, Jacobsen CJ, Christiansen EH, Molgaard H, Pilegaard H, Hjortholm K, Thomsen PE. Hemodynamic predictors of atrial fibrillation or flutter after coronary artery bypass grafting. Acta Anaesth Scand 1995;39:690–7.CrossRefPubMedGoogle Scholar
  26. 26.
    Mendes LA, Connelly GP, McKenney PA, Podrid PJ, Cupples LA, Shemin RJ, Ryan TJ, Davidoff R. Right coronary artery stenosis: an independent predictor of atrial fibrillation after coronary artery bypass surgery. J Amer Coll Cardiol 1995;25:198–202.CrossRefGoogle Scholar
  27. 27.
    Pehkonen EJ, Mäkynen PJ, Katajo MJ, Tarkka MR. Atrial fibrillation after blood and crystalloid cardioplegia in CABG patients. Thorac Cardiovasc Surgeon 1995; 43:200–203.CrossRefGoogle Scholar
  28. 28.
    Chew JT, Ong KK. Atrial arrhythmias post coronary bypass grafting. Singapore Med J 1993;34:430–4.PubMedGoogle Scholar
  29. 29.
    Akins CW. Noncardioplegic myocardial preservation for coronary revascularization. J Thorac Cardiovasc Surg 1984;88:174–181.PubMedGoogle Scholar
  30. 30.
    Klein M, Evans SJ, Blumberg S, Cataldo L, Bodenheimer MM. Use of p-wave triggered, p-wave signal-averaged electrocardiogram to predict atrial fibrillation after coronary artery bypass surgery. Am Heart J 1995; 129:895–901.CrossRefPubMedGoogle Scholar
  31. 31.
    Stephenson LW, MacVaugh H, Tomasello DN, Josephson ME. Propranolol for the prevention of postoperative cardiac arrhythmias: A randomized study. Ann Thorac Surg 1980;29:113–116.CrossRefPubMedGoogle Scholar
  32. 32.
    Han J, Moe GK. Nonuniform recovery of excitability in ventricular muscle. Circ Res 1964; 14:44–60.PubMedGoogle Scholar
  33. 33.
    Michelucci A, Padeletti L, Fradella GA. Atrial refractoriness and spontaneous or induced atrial fibrillation. Acta Cardiol 1982;5:333–344.Google Scholar
  34. 34.
    Ali IM, Sanalla AA, Clark V. Beta-blocker effects on postoperative atrial fibrillation. Eur J Cardio-Thor Surg 1997;11:1154–7.CrossRefGoogle Scholar
  35. 35.
    Frost L, Molgaard H, Christiansen EH, Hjortholm K, Paulsen PK, Thomsen PE. Atrial fibrillation and flutter after coronary artery bypass surgery: epidemiology, risk factors and preventive trials. Inter J Cardiol 1992;36:253–61.CrossRefGoogle Scholar
  36. 36.
    Frost L, Molgaard H, Christiansen EH, Jacobsen CJ, Pilegaard H, Thomsen PE. Atrial ectopic activity and atrial fibrillation/flutter after coronary artery bypass surgery. A case-base study controlling for confounding from age, beta-blocker treatment, and time distance from operation. Int J Cardiol 1995;50:153–62.CrossRefPubMedGoogle Scholar
  37. 37.
    Abel RM, Van Gelder HM, Pores IH, Liguori J, Geilchinsky I, Parsonnet V. Continued propranolol administration following coronary bypass surgery. Arch Surg 1983;118:727–731.PubMedGoogle Scholar
  38. 38.
    Silverman NA, Wright R, Levitsky S. Efficacy of low-dose propranolol in preventing postoperative supraventricular tachyarrhythmias. Ann Surg 1982196:194–197.CrossRefPubMedGoogle Scholar
  39. 39.
    Salazar C, Frishman W, Friedman S et al. Betablocker therapy for supraventricular tachyarrhythmias after coronary surgery: a propranolol withdrawal syndrome? Angiology 1979;30:816–819.CrossRefPubMedGoogle Scholar
  40. 40.
    White HD, Antman GM, Glynn MA, et al. Efficacy and safety of timolol for the prevention of supraventricular tachyarrhythmias after coronary artery bypass surgery. Circulartion 1984;70:479–484.Google Scholar
  41. 41.
    Sun LS, Adams DC, Delphin E, Graham J, Meltzer E, Rose EA, Heyer EJ. Sympathetic response during cardiopulmonary bypass: mild versus moderate hypothermia. Crit Care Med 1997;25:1990–3.CrossRefPubMedGoogle Scholar
  42. 42.
    Leier CV, Meacham JA, Schaal SF. Prolonged atrial conduction: A major predisposing factor for the development of atrial flutter. Circulation 1978;57:213–216.PubMedGoogle Scholar
  43. 43.
    Watson RM, Josephson ME. Atrial flutter: I. Electrophysiologic substrates and modes of initiation and termination. Am J Cardiol 1980;45:732–741.CrossRefPubMedGoogle Scholar
  44. 44.
    Buxton AE, Josephson ME. The role of p-wave duration as a predictor of postoperative atrial arrhythmias. Chest 1981;80:68–73.CrossRefPubMedGoogle Scholar
  45. 45.
    Guidera SA, Steinberg JS. The signal-averaged p-wave duration: a rapid and non-invasive marker of risk of atrial fibrillation. J Am Coll Cardiol 1993;21:1645–1651.CrossRefPubMedGoogle Scholar
  46. 46.
    Ehlert FA, Gaur A, Steinberg JS. Correlation of the p-wave signal averaged electrocardiogram to intra-cardiac atrial conduction. Circulation 1996;94:1–70.Google Scholar
  47. 47.
    Hogue CW Jr, Domitrovich PP, Stein PK, Despontis GD, Re L, Schuessler RB, Kleiger RE, Rottman JN. RR interval dynamics before atrial fibrillation in patients after coronary artery bypass graft surgery. Circulation 1998;98:429–434.PubMedGoogle Scholar
  48. 48.
    Hutchinson LA, Steinberg JS. A prospective study of atrial fibrillation after cardiac surgery: multivariate analysis using p wave signal-averaged ECG and clinical variables. Ann Noninv Elec 1996;1:133–140.CrossRefGoogle Scholar
  49. 49.
    Gardin J, Singer D. Atrial infarction: importance, diagnosis and localization. Arch Intern Med 1981;141:1345–1348.CrossRefPubMedGoogle Scholar
  50. 50.
    Lazar E, Goldberger J, Peled H, Sherman M, Frishman W. Atrial infarction: diagnosis and management. Am J Cardiol 1988;116:1058–1061.Google Scholar
  51. 51.
    Rechavia E, Strasberg B, Mager A et al. The incidence of atrial arrhythmias during inferior wall infarction with and without right ventricular involvement. Am Heart J 1992; 124:387–391.CrossRefPubMedGoogle Scholar
  52. 52.
    Salem BI, Chaudhry A, Haikal M, Gowda S, Campbell A, Coordes C, Leidenfrost R. Sustained supraventricular tachyarrhythmias following coronary artery bypass surgery comparing mammary versus saphenous vein grafts. Angiology 1991;42:441–6.CrossRefPubMedGoogle Scholar
  53. 53.
    Subramanian VA, McCabe JC, Geller CM. Minimally invasive direct coronary artery bypass grafting: two-year clinical experience. Ann Thorac Surg 1997;64:1648–55.CrossRefPubMedGoogle Scholar
  54. 54.
    Arom KV, Emery RW, Nicoloff DM, Flavin TF, Emery AM. Minimally invasive direct coronary artery bypass grafting: experimental and clinical experiences. Ann Thorac Surg 1997;63:S48–S52.CrossRefPubMedGoogle Scholar
  55. 55.
    Tamis JE, Vloka ME, Malhotra S, Mindich BP, Steinberg JS. Atrial fibrillation is common after minimally invasive direct coronary artery bypass surgery. J Am Coll Cardiol 1998;31:118A.CrossRefGoogle Scholar
  56. 56.
    Michelson EL, Morganroth J, MacVaugh H. Postoperative arrhythmias after coronary artery and cardiac valvular surgery detected by long term electrocardiographic monitoring. Am Heart J 1979; 97:442–8.CrossRefPubMedGoogle Scholar
  57. 57.
    Rouson IA, Meeran MK, Engelman RM, Brcycr RH, Lemeshou S. Does the type of venous drainage or cardioplegia affect postoperative conduction and atrial arrhythmias? Circulation 1985;72:II-259–II-263.Google Scholar
  58. 58.
    Ormerod OJM, McGregor CGA, Stone DL, Wisbey C, Petch MC. Arrhythmias after coronary bypass surgery. Br Heart J 1984;51:618–621.CrossRefPubMedGoogle Scholar
  59. 59.
    Arom KV, Emery RW, Petersen RJ, Bero JW. Evaluation of 7,000+ patients with two different routes of cardioplegia. Ann Thorac Surg 1997;63:1619–24.CrossRefPubMedGoogle Scholar
  60. 60.
    Smith PK, Buhran WC, Levett JM, Ferguson TB Jr, Holman WL, Cox JL. Supraventricular conduction abnormalities following cardiac operations. A complication of inadequate atrial preservation. J Thorac Cardiovasc Surg 1983;85:105–115.PubMedGoogle Scholar
  61. 61.
    Chen XZ, Newman M, Rosenfeldt FL. Internal cardiac cooling improves atrial preservation: electrophysiological and biochemical assessment. Ann Thorac Surg 1988;46:406–411.CrossRefPubMedGoogle Scholar
  62. 62.
    Tchervenkov CI, Wynands JE, Symes JF, Malcolm ID, Dobell RC. Persistent atrial activity during cardioplegic arrest: A possible factor in the etiology of postoperative supraventricular tachyarrhythmias. Ann of Thorac Surg 1983;36:437–443.CrossRefGoogle Scholar
  63. 63.
    Dewar ML, Rosengarten MD, Blundell PR, Chiu RCJ. Perioperative Holter monitoring and computer analysis of dysarrhythmias and cardiac surgery. Chest 1985;87:593–597.CrossRefPubMedGoogle Scholar
  64. 64.
    Mullen JC, Kahn N, Weisel RD, Christakis GT, Teoh KH, Madonik MM, Mickle DAG, Ivanov J. Atrial activity during cardioplegia and postoperative arrhythmias. J Thoracic Cardiovasc Surg 1987;94:558–565.Google Scholar
  65. 65.
    Yousif H, Davies G, Oakley CM. Peri-operative supraventricular arrhythmias in coronary bypass surgery. Inter J Cardiol 1990;26:313–8.CrossRefGoogle Scholar
  66. 66.
    Scheinman MM, Sullivan RW, Hyatt KN. Magnesium metabolism in patients undergoing cardiopulmonary bypass. Circulation 1969;39(Suppl 1):235–41.Google Scholar
  67. 67.
    Ellis RJ, Mavroudis C, Gardner C, Turley K, Ullyot D, Ebert PA. Relationship between atrioventricular arrhythmias and the concentration of K + ion in cardioplegic solution. J Thorac Cardiovasc Surg 1950;80:517–526.Google Scholar
  68. 68.
    Sharon M, Horowitz LN. Acute myocardial infarction. In Current Managemment of Arrhythmias, Horowitz LN ed. Philadelphia, B.C.Decker Inc, 1991:257–64.Google Scholar
  69. 69.
    Parikka H, Toivonen L, Pellinen T, Verkkala K, Jarvinen A, Nieminen MS. The influence of intravenous magnesium sulphate on the occurrence of atrial fibrillation after coronary artery by-pass operation. Euro Heart J 1993; 14:251–8.Google Scholar
  70. 70.
    Nurozler F, Tokgozoglu L, Pasaoglu I, Boke E, Ersoy U, Bozer AY. Atrial fibrillation after coronary artery bypass surgery: predictors and the role of MgSO4 replacement. J Card Surg 1996; 11:421–7.CrossRefPubMedGoogle Scholar
  71. 71.
    Fanning WJ, Thomas CS, Roach A, Tomichek R, Alford WC, Stoney WS. Prophylaxis of atrial fibrillation with magnesium sulfate after coronary atery bypass grafting. Ann Thorac Surg 1991;52:529–533.CrossRefPubMedGoogle Scholar
  72. 72.
    Crosby LH, Pifalo WB, Woll KR, Burkholder JA. Risk factors for atrial fibrillation after coronary artery bypass grafting. AM J Cardiol 1990;66:1520–1522.CrossRefPubMedGoogle Scholar
  73. 73.
    Page P, Plumb VJ, Okumura K, Waldo AL. A new model of atrial flutter. J Am Coll Cardiol 1986;8:872–875.CrossRefPubMedGoogle Scholar
  74. 74.
    Kumagai K, Khrestian C, Waldo AL. Simultaneous multisite mapping studies during induced atrial fibrillation in the sterile pericarditis model. Insights into the mechanism of its maintenance. Circulation 1995;2:511–521.Google Scholar
  75. 75.
    Massie E, Valle AR. Cardiac arrhythmias complicating total pneumonectomy. Ann Intern Med 1947;26:231–239.PubMedGoogle Scholar
  76. 76.
    Cerney CI. The prophylaxis of cardiac arrhythmias complicating pulmonary surgery. J Thorac Surg 1957;34:105–110.PubMedGoogle Scholar

Copyright information

© Kluwer Academic Publishers 2000

Authors and Affiliations

  • Frederick A. Ehlert
    • 1
  • Dhiraj D. Narula
    • 1
  • Jonathan S. Steinberg
    • 1
  1. 1.St. Luke’s-Roosevelt Hospital Center and Columbia University College of Physicians and SurgeonsNew York

Personalised recommendations