In one of the largest analyses of post-operative atrial fibrillation (POAF) after thoracic aortic aneurysm (TAA) repair, NewYork-Presbyterian/Columbia cardiothoracic surgeons have shown that the long-term survival of surgical patients with POAF in the absence of other surgical complications is equivalent to those without POAF. This novel finding contrasts with previous data and is among the first to distinguish between cases of isolated POAF and cases where patients had concomitant complications.
“TAA repair has become very safe. It is no longer a matter of surviving the surgery. Our program has been focusing on improving relatively minor postoperative issues, such as POAF. If you look at every TAA repair patient and compare those with POAF and those without POAF, the survival looks worse with POAF,” says study author Hiroo Takayama, MD, PhD, Chief of the Adult Cardiac Surgery and Co-Director of the Aortic Program at NewYork-Presbyterian/Columbia. “However, if we exclude the patients who had other complications like stroke and respiratory failure, and then compare patients who had isolated AFib versus patients who had no major complications, their survival was identical.”
Identifying the risks for poor outcomes
Previous research has shown that POAF is associated with negative outcomes, including longer hospital stays and increased mortality. In addition, POAF tends to be accompanied by other post-op complications, such as stroke and renal failure. However, a causal link has not been established.
Dr. Takayama’s team, which included medical students, sought to shed more light on the issue by distinguishing the unique contribution of POAF to adverse outcomes from other post-operative complications.
“Previous papers said that POAF worsens survival, but few really differentiate between patients with concomitant complications or without,” says Dr. Takayama. “Our data suggest that POAF acts as a surrogate of the overall sickness of the patient after the surgery.”
Previous papers said that POAF worsens survival, but few really differentiate between patients with concomitant complications or without. Our data suggest that POAF acts as a surrogate of the overall sickness of the patient after the surgery.
— Dr. Hiroo Takeyama
Dr. Takayama says that TAA repair patients are frequently younger and healthier as the entity has a strong genetic component. “Many of these patients experience isolated POAF,” he says. “Now I feel comfortable telling them that they’re going to have a good long-term outcome.”
Taking aim at AFib
Although the study represents good news for some TAA repair patients, POAF remains a vexing problem among patients undergoing aortic aneurysm repair and other surgeries. Dr. Takayama’s team is focused on preventing this common consequence.
“Even though we now believe POAF doesn't influence the long-term outcome, it is still important since it prolongs patients’ post-op stay,” says Dr. Takayama. “It also causes symptoms. Patients feel palpitations, and they feel nervous about it.”
Dr. Takayama assembled a multidisciplinary task force to try to prevent this common post-operative phenomenon. Based on expert opinion, his surgical patients now receive prophylactic medications, such as beta blockers and the antiarrhythmic medication, amiodarone, to prevent POAF.
“There is some evidence suggesting that blood retained within the pericardium after the surgery may increase the risk of POAF, so we thoroughly drain the blood fluid from the pericardial space after the surgery,” Dr. Takayama adds. “We have been doing this for about a year and a half, and we are now analyzing the data. Hopefully we will see an improvement.”
Even though we now believe POAF doesn't influence the long-term outcome, it is still important since it prolongs patients’ post-op stay. It also causes symptoms. Patients feel palpitations, and they feel nervous about it.
— Dr. Hiroo Takeyama
Results show POAF correlation with postoperative complications
The single-center study looked retrospectively at patients who underwent open thoracic aortic aneurysm repair at NewYork-Presbyterian/Columbia between March 2005 and March 2021. POAF was found to be common – of the 1,454 patients included in the study, 520 (35.8%) were observed to have developed POAF after surgery.
Patients with POAF had a higher rate of postoperative major complications than those without AF (20.2% vs. 12.2%, p<0.001). Ten-year survival was 82.0% in patients with POAF and 87.0% in patients without AF (p=0.008). Among patients without other complications, however, 10-year survival was similar between patients with and without POAF (83.6% vs. 83.8%, p=0.75).
In going against the grain, Dr. Takayama expects the contrarian findings to spark debate. But he welcomes the give-and-take. “Since this is relatively novel and ambitious paper, there were lots of good discussions with our reviewers and even among our coauthors as to how to interpret our data,” Dr. Takayama says. “But I think through our rigorous analysis and biostatistics, we were able to convince the reviewers. Many clinical surgeons likely will welcome our paper.”
NewYork-Presbyterian/Columbia is recognized as a national leader in cardiac research and medicine. “No matter what outcomes you take and examine, our program is among the very best in terms of the quality—and quantity,” says Dr. Takayama. “If we combine the volume of surgeries performed on our campuses together, we’re the largest in this region and one of the biggest in the nation as well. We are very fortunate.”
