Preventing atrial fibrillation after cardiac surgery: a single-institution cohort study after implementation of a standardized preventative protocol.

BACKGROUND

Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery and leads to increased morbidity and mortality. Prophylaxis strategies have been identified; however, no set preventive algorithm has been established. This study aims to evaluate the efficacy of a POAF-prevention algorithm.

METHODS

The POAF-prevention algorithm was implemented in April of 2023. Algorithm use began in concurrence with initiating placement of active-clearance chest tubes in most patients undergoing cardiac surgery. Postoperatively, patients were admitted to the cardiovascular intensive care unit, and all patients were started on AAI (atrial pacing, atrial sensing, inhibition response to sensing) epicardial pacing, if able, for 24 hours. High-risk patients were started on an amiodarone infusion. A 4-mg intravenous (IV) bolus of magnesium sulfate was given if the patient's postoperative magnesium level was less than 3 mEq/L. On postoperative day (POD) 1, patients were started on or transitioned to amiodarone (400 mg orally twice daily), and metoprolol (12.5 mg orally twice daily) was started if vitals permitted. Daily atorvastatin (80 mg orally) and magnesium oxide (400 mg orally) were also initiated. Hydrocortisone (50 g every 6 hours) could be administered based on the patient's inflammatory profile, vasoplegia, or adrenal response.

RESULTS

We compared the incidence of POAF at the Charleston Area Medical Center 3 months prior to implementing the POAF-prevention algorithm (January-March 2023) and after initiation (April-June 2023). The incidence of POAF decreased from 31.5% of patients in early 2023 to 23% of patients after algorithm introduction. This was a relative risk reduction of 27% and an absolute risk reduction of 8.5%.

CONCLUSIONS

The POAF-prevention algorithm that we developed was effective in reducing the incidence of atrial fibrillation following cardiac surgery in this small, comparative study. Adoption of a similar POAF-prevention algorithm should be considered at other institutions.