Advertisement

2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. Executive summary

Open ArchivePublished:June 28, 2014DOI:https://doi.org/10.1016/j.jtcvs.2014.06.037

      CTSNet classification

      Preamble

      Our mission was to develop evidence-based guidelines for the prevention and treatment of perioperative/postoperative atrial fibrillation and flutter (POAF) for thoracic surgical procedures. Sixteen experts were invited by the American Association for Thoracic Surgery (AATS) leadership: 7 cardiologists and electrophysiology specialists, 3 intensivists/anesthesiologists, 1 clinical pharmacist, joined by 5 thoracic and cardiac surgeons who represented AATS (see Online Data Supplement 1 for the list of members and Online Data Supplement 2 for the conflict of interest declaration online). Members were tasked with making recommendations based on a review of the literature, with grading the quality of the evidence supporting the recommendations, and with assessing the risk-benefit profile for each recommendation (Table 1). Members were specifically asked to assess the applicability of the available evidence to patients undergoing thoracic surgery (detailed methodology can be found online). All recommendations were subjected to a vote. Acceptance for the final document required greater than 75% approval of each of the recommendations. Subsequently, the recommendations were posted for public comments from AATS members (via REDCap), and then peer reviewed by outside experts selected by AATS Council.
      Table 1Size of treatment effect and level of evidence for its impact
      Schema used to guide the grading of available published evidence and the expected effect of the interventions for their impact on patient outcomes (the arrow indicates the direction of increased effect size). COR, Class of recommendation.
      The following recommendations are based on the best available evidence from thoracic surgery. When evidence specific to thoracic surgery was not available, we extrapolated from the cardiac surgical literature. In the absence of direct evidence, we present the best expert opinion based on cardiology/cardiac electrophysiology experience and best practices.
      For the development of the guidelines, we followed the recommendations of The Institute of Medicine (IOM) 2011 Clinical Practice Guidelines We Can Trust: Standards for Developing Trustworthy Clinical Practice Guidelines; www.iom.edu/cpgstandards.
      Institute of Medicine
      Clinical Practice Guidelines We Can Trust.
      Efforts were made to minimize repetition of existing guidelines
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      • Onaitis M.
      • D'Amico T.
      • Zhao Y.
      • O'Brien S.
      • Harpole D.
      Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database.
      ; rather we focused on new information and advances in diagnosis and therapy, and present these current guidelines within the framework of the new IOM recommendations. In order to meet these standards, most societies (American Heart Association and AATS included) initiated the revision
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      of existing guidelines.

      AATS Member Survey

      Our survey of the AATS members (results presented in Online Data Supplement 3) indicated the need for a guideline update and identified opportunities for improvement in the areas of prevention, standards for postoperative electrocardiography (ECG) monitoring and the use of novel oral anticoagulants. When asked how the AATS could help members improve their practices, 29% of respondents recommended “initiating studies,” whereas 58% recommended that the AATS “issue guidelines” and promote uniform practices.

      Target Audience and Patient Population

      These guidelines are intended for all noncardiac intrathoracic surgeries and esophagectomies, as well as for patients whose risk factors and comorbidities place them at intermediate to high risk for POAF independent of the procedure. In assessing the patient's risk for POAF, it must be noted that the risks posed by the procedure and by patient factors/comorbidities will likely be additive, if not synergistic. Therefore, these factors should be evaluated in combination during the preoperative assessment.
      The target audience includes not only thoracic surgeons and anesthesiologists but all providers who participate in the care of thoracic surgical patients.
      The following novel information is included in this 2014 document: (1) standardized definitions for atrial fibrillation (AF) and (2) recommendations for: (a) ECG monitoring, (b) postdischarge management, (c) use of the new-class of novel oral anticoagulants (NOAC); and (d) obtaining cardiology consultation. In addition, flow diagrams summarize the strategies for acute and chronic management. Specific drug recommendations and dosing tables are also included.

      Epidemiology and Mechanisms of POAF

      AF, the most common sustained arrhythmia after pulmonary and esophageal surgery, is a major, potentially preventable, adverse outcome. It is associated with longer intensive care unit and hospital stays,
      • Onaitis M.
      • D'Amico T.
      • Zhao Y.
      • O'Brien S.
      • Harpole D.
      Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database.
      • Vaporciyan A.A.
      • Correa A.M.
      • Rice D.C.
      • Roth J.A.
      • Smythe W.R.
      • Swisher S.G.
      • et al.
      Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients.
      • Roselli E.E.
      • Murthy S.C.
      • Rice T.W.
      • Houghtaling P.L.
      Atrial fibrillation complicating lung cancer resection.
      • Henri C.
      • Giraldeau G.
      • Dorais M.
      • Cloutier A.-S.
      • Girard F.
      • Noiseux N.
      • et al.
      Atrial fibrillation after pulmonary transplantation: incidence, impact on mortality, treatment effectiveness, and risk factors.
      • Nielsen T.D.
      • Bahnson T.
      • Davis R.D.
      Atrial fibrillation after pulmonary transplant.
      increased morbidity, including strokes/new central neurologic events (incidence of 1.3%-1.7%
      • Onaitis M.
      • D'Amico T.
      • Zhao Y.
      • O'Brien S.
      • Harpole D.
      Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database.
      • Biancari F.
      • Mahar M.A.A.
      Meta-analysis of randomized trials on the efficacy of posterior pericardiotomy in preventing atrial fibrillation after coronary artery bypass surgery.
      ); and mortality (up to 5.6%-7.5% [RR, 1.7-3.4]
      • Onaitis M.
      • D'Amico T.
      • Zhao Y.
      • O'Brien S.
      • Harpole D.
      Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database.
      • Roselli E.E.
      • Murthy S.C.
      • Rice T.W.
      • Houghtaling P.L.
      Atrial fibrillation complicating lung cancer resection.
      • Henri C.
      • Giraldeau G.
      • Dorais M.
      • Cloutier A.-S.
      • Girard F.
      • Noiseux N.
      • et al.
      Atrial fibrillation after pulmonary transplantation: incidence, impact on mortality, treatment effectiveness, and risk factors.
      • Nielsen T.D.
      • Bahnson T.
      • Davis R.D.
      Atrial fibrillation after pulmonary transplant.
      ), as well as higher resource utilization.
      • Roselli E.E.
      • Murthy S.C.
      • Rice T.W.
      • Houghtaling P.L.
      Atrial fibrillation complicating lung cancer resection.
      • Irshad K.
      • Feldman L.S.
      • Chu V.F.
      • Dorval J.-F.
      • Baslaim G.
      • Morin J.E.
      Causes of increased length of hospitalization on a general thoracic surgery service: a prospective observational study.
      The incidence of POAF varies widely based on the intensity of surgical stress (Table 2, A
      • Onaitis M.
      • D'Amico T.
      • Zhao Y.
      • O'Brien S.
      • Harpole D.
      Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database.
      • Vaporciyan A.A.
      • Correa A.M.
      • Rice D.C.
      • Roth J.A.
      • Smythe W.R.
      • Swisher S.G.
      • et al.
      Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients.
      • Roselli E.E.
      • Murthy S.C.
      • Rice T.W.
      • Houghtaling P.L.
      Atrial fibrillation complicating lung cancer resection.
      • Henri C.
      • Giraldeau G.
      • Dorais M.
      • Cloutier A.-S.
      • Girard F.
      • Noiseux N.
      • et al.
      Atrial fibrillation after pulmonary transplantation: incidence, impact on mortality, treatment effectiveness, and risk factors.
      • Nielsen T.D.
      • Bahnson T.
      • Davis R.D.
      Atrial fibrillation after pulmonary transplant.
      • Van Gelder I.C.
      • Groenveld H.F.
      • Crijns H.J.
      • Tuininga Y.S.
      • Tijssen J.G.
      • Alings A.M.
      • et al.
      RACE II Investigators
      Lenient versus strict rate control in patients with atrial fibrillation.
      • De Decker K.
      • Jorens P.G.
      • Van Schil P.
      Cardiac complications after noncardiac thoracic surgery: an evidence-based current review.
      • Passman R.S.
      • Gingold D.S.
      • Amar D.
      • Lloyd-Jones D.
      • Bennett C.L.
      • Zhang H.
      • et al.
      Prediction rule for atrial fibrillation after major noncardiac thoracic surgery.
      • Park B.J.
      • Zhang H.
      • Rusch V.W.
      • Amar D.
      Video-assisted thoracic surgery does not reduce the incidence of postoperative atrial fibrillation after pulmonary lobectomy.
      • Ciszewski P.
      • Tyczka J.
      • Nadolski J.
      • Roszak M.
      • Dyszkiewicz W.
      Lower preoperative fluctuation of heart rate variability is an independent risk factor for postoperative atrial fibrillation in patients undergoing major pulmonary resection.
      • Krowka M.J.
      • Pairolero P.C.
      • Trastek V.F.
      • Payne W.S.
      • Bernatz P.E.
      Cardiac dysrhythmia following pneumonectomy. Clinical correlates and prognostic significance.
      • Hardy J.
      Risk factors for atrial fibrillation following extrapleural pneumonectomy, the effect of prophylactic beta blockade.
      • Lee G.
      • Wu H.
      • Kalman J.M.
      • Esmore D.
      • Williams T.
      • Snell G.
      • et al.
      Atrial fibrillation following lung transplantation: double but not single lung transplant is associated with long-term freedom from paroxysmal atrial fibrillation.
      • Tisdale J.E.
      • Wroblewski H.A.
      • Wall D.S.
      • Rieger K.M.
      • Hammoud Z.T.
      • Young J.V.
      • et al.
      A randomized, controlled study of amiodarone for prevention of atrial fibrillation after transthoracic esophagectomy.
      ) and patient characteristics (Table 2, B
      • Onaitis M.
      • D'Amico T.
      • Zhao Y.
      • O'Brien S.
      • Harpole D.
      Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database.
      • Vaporciyan A.A.
      • Correa A.M.
      • Rice D.C.
      • Roth J.A.
      • Smythe W.R.
      • Swisher S.G.
      • et al.
      Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients.
      • Roselli E.E.
      • Murthy S.C.
      • Rice T.W.
      • Houghtaling P.L.
      Atrial fibrillation complicating lung cancer resection.
      • Passman R.S.
      • Gingold D.S.
      • Amar D.
      • Lloyd-Jones D.
      • Bennett C.L.
      • Zhang H.
      • et al.
      Prediction rule for atrial fibrillation after major noncardiac thoracic surgery.
      • Rao V.P.
      • Addae-Boateng E.
      • Barua A.
      • Martin-Ucar A.E.
      • Duffy J.P.
      Age and neo-adjuvant chemotherapy increase the risk of atrial fibrillation following oesophagectomy.
      • Ivanovic J.
      • Maziak D.E.
      • Ramzan S.
      • McGuire A.L.
      • Villeneuve P.J.
      • Gilbert S.
      • et al.
      Incidence, severity and perioperative risk factors for atrial fibrillation following pulmonary resection.
      • Polanczyk C.A.
      • Goldman L.
      Supraventricular arrhythmia in patients having noncardiac surgery: clinical correlates and effect on length of stay.
      ). Some of the risk factors for AF, such as hypertension, obesity, and smoking, are modifiable, whereas others, such as older age, Caucasian ancestry, and male sex are not. POAF peaks on postoperative days 2 to 4, and 90% to 98% of new-onset POAF resolves within 4 to 6 weeks.
      Table 2, ARisk stratification of thoracic surgical procedures for their risk of POAF
      Type of proceduresRisk of POAF by surgical procedures
      Low-risk procedures (<5% incidence)Intermediate risk procedures (5%-15% incidence)High-risk procedures (>15% incidence)
      Intrathoracic/airway procedures
       Minor proceduresFlexible bronchoscopy with and without biopsy

      Photodynamic therapy

      Tracheal stenting

      Placement of thoracostomy tube or PleurX catheter (CareFusion Corporation, San Diego, Calif)

      Pleuroscopy, pleurodesis, decortication
       Procedures with moderate stressTracheostomy

      Rigid bronchoscopy

      Mediastinoscopy

      Thoracoscopic wedge resection
      • Vaporciyan A.A.
      • Correa A.M.
      • Rice D.C.
      • Roth J.A.
      • Smythe W.R.
      • Swisher S.G.
      • et al.
      Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients.
      • Roselli E.E.
      • Murthy S.C.
      • Rice T.W.
      • Houghtaling P.L.
      Atrial fibrillation complicating lung cancer resection.


      Bronchoscopic laser surgery
      Thoracoscopic sympathectomy
       Major proceduresSegmentectomy
      • Vaporciyan A.A.
      • Correa A.M.
      • Rice D.C.
      • Roth J.A.
      • Smythe W.R.
      • Swisher S.G.
      • et al.
      Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients.
      • Roselli E.E.
      • Murthy S.C.
      • Rice T.W.
      • Houghtaling P.L.
      Atrial fibrillation complicating lung cancer resection.
      Resection of anterior mediastinal mass

      Thoracoscopic lobectomy

      Open thoracotomy for lobectomy
      • Onaitis M.
      • D'Amico T.
      • Zhao Y.
      • O'Brien S.
      • Harpole D.
      Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database.
      • Vaporciyan A.A.
      • Correa A.M.
      • Rice D.C.
      • Roth J.A.
      • Smythe W.R.
      • Swisher S.G.
      • et al.
      Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients.
      • Roselli E.E.
      • Murthy S.C.
      • Rice T.W.
      • Houghtaling P.L.
      Atrial fibrillation complicating lung cancer resection.
      • De Decker K.
      • Jorens P.G.
      • Van Schil P.
      Cardiac complications after noncardiac thoracic surgery: an evidence-based current review.
      • Passman R.S.
      • Gingold D.S.
      • Amar D.
      • Lloyd-Jones D.
      • Bennett C.L.
      • Zhang H.
      • et al.
      Prediction rule for atrial fibrillation after major noncardiac thoracic surgery.
      • Park B.J.
      • Zhang H.
      • Rusch V.W.
      • Amar D.
      Video-assisted thoracic surgery does not reduce the incidence of postoperative atrial fibrillation after pulmonary lobectomy.
      • Ciszewski P.
      • Tyczka J.
      • Nadolski J.
      • Roszak M.
      • Dyszkiewicz W.
      Lower preoperative fluctuation of heart rate variability is an independent risk factor for postoperative atrial fibrillation in patients undergoing major pulmonary resection.


      Tracheal resection and reconstruction/carinal resection

      Pneumonectomy
      • Vaporciyan A.A.
      • Correa A.M.
      • Rice D.C.
      • Roth J.A.
      • Smythe W.R.
      • Swisher S.G.
      • et al.
      Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients.
      • Roselli E.E.
      • Murthy S.C.
      • Rice T.W.
      • Houghtaling P.L.
      Atrial fibrillation complicating lung cancer resection.
      • De Decker K.
      • Jorens P.G.
      • Van Schil P.
      Cardiac complications after noncardiac thoracic surgery: an evidence-based current review.
      • Passman R.S.
      • Gingold D.S.
      • Amar D.
      • Lloyd-Jones D.
      • Bennett C.L.
      • Zhang H.
      • et al.
      Prediction rule for atrial fibrillation after major noncardiac thoracic surgery.
      • Ciszewski P.
      • Tyczka J.
      • Nadolski J.
      • Roszak M.
      • Dyszkiewicz W.
      Lower preoperative fluctuation of heart rate variability is an independent risk factor for postoperative atrial fibrillation in patients undergoing major pulmonary resection.
      • Krowka M.J.
      • Pairolero P.C.
      • Trastek V.F.
      • Payne W.S.
      • Bernatz P.E.
      Cardiac dysrhythmia following pneumonectomy. Clinical correlates and prognostic significance.
      • Hardy J.
      Risk factors for atrial fibrillation following extrapleural pneumonectomy, the effect of prophylactic beta blockade.


      Pleurectomy
      • Van Gelder I.C.
      • Groenveld H.F.
      • Crijns H.J.
      • Tuininga Y.S.
      • Tijssen J.G.
      • Alings A.M.
      • et al.
      RACE II Investigators
      Lenient versus strict rate control in patients with atrial fibrillation.


      Volume reduction/bullectomy

      Bronchopleural fistula repair

      Clagett window

      Lung transplantation
      • Henri C.
      • Giraldeau G.
      • Dorais M.
      • Cloutier A.-S.
      • Girard F.
      • Noiseux N.
      • et al.
      Atrial fibrillation after pulmonary transplantation: incidence, impact on mortality, treatment effectiveness, and risk factors.
      • Nielsen T.D.
      • Bahnson T.
      • Davis R.D.
      Atrial fibrillation after pulmonary transplant.
      • Lee G.
      • Wu H.
      • Kalman J.M.
      • Esmore D.
      • Williams T.
      • Snell G.
      • et al.
      Atrial fibrillation following lung transplantation: double but not single lung transplant is associated with long-term freedom from paroxysmal atrial fibrillation.
      Esophageal proceduresEsophagoscopy/PEG/esophageal dilation and/or stentingLaparoscopic Nissen fundoplication/myotomy

      Zenker diverticulectomy
      Esophagectomy
      • Vaporciyan A.A.
      • Correa A.M.
      • Rice D.C.
      • Roth J.A.
      • Smythe W.R.
      • Swisher S.G.
      • et al.
      Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients.
      • Passman R.S.
      • Gingold D.S.
      • Amar D.
      • Lloyd-Jones D.
      • Bennett C.L.
      • Zhang H.
      • et al.
      Prediction rule for atrial fibrillation after major noncardiac thoracic surgery.
      • Tisdale J.E.
      • Wroblewski H.A.
      • Wall D.S.
      • Rieger K.M.
      • Hammoud Z.T.
      • Young J.V.
      • et al.
      A randomized, controlled study of amiodarone for prevention of atrial fibrillation after transthoracic esophagectomy.
      Other proceduresPericardial window
      Thoracic surgical procedures were divided into low (<5%), moderate (5%-15%) and high (>15%) risk groups based on their expected incidence of POAF in order to facilitate the preoperative risk stratification of patients. POAF, Postoperative atrial fibrillation; PEG, percutaneous endoscopic gastrostomy.
      Table 2, BKnown patient risk factors for and comorbidities that increase the risk of POAF
      Risk factors and comorbiditiesThoracic surgery references
      Modifiable risk factors
       Hypertension
      • Onaitis M.
      • D'Amico T.
      • Zhao Y.
      • O'Brien S.
      • Harpole D.
      Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database.
      • Passman R.S.
      • Gingold D.S.
      • Amar D.
      • Lloyd-Jones D.
      • Bennett C.L.
      • Zhang H.
      • et al.
      Prediction rule for atrial fibrillation after major noncardiac thoracic surgery.
      • Rao V.P.
      • Addae-Boateng E.
      • Barua A.
      • Martin-Ucar A.E.
      • Duffy J.P.
      Age and neo-adjuvant chemotherapy increase the risk of atrial fibrillation following oesophagectomy.
       MI
      • Ivanovic J.
      • Maziak D.E.
      • Ramzan S.
      • McGuire A.L.
      • Villeneuve P.J.
      • Gilbert S.
      • et al.
      Incidence, severity and perioperative risk factors for atrial fibrillation following pulmonary resection.
       VHD
       Heart failure
      • Vaporciyan A.A.
      • Correa A.M.
      • Rice D.C.
      • Roth J.A.
      • Smythe W.R.
      • Swisher S.G.
      • et al.
      Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients.
      • Roselli E.E.
      • Murthy S.C.
      • Rice T.W.
      • Houghtaling P.L.
      Atrial fibrillation complicating lung cancer resection.
      • Polanczyk C.A.
      • Goldman L.
      Supraventricular arrhythmia in patients having noncardiac surgery: clinical correlates and effect on length of stay.
       Obesity
      • Onaitis M.
      • D'Amico T.
      • Zhao Y.
      • O'Brien S.
      • Harpole D.
      Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database.
       Obstructive sleep apnea
       Smoking
       Exercise
       Alcohol use
       Hyperthyroidism
       Increased pulse pressure
       Mitral regurgitation
       LVH
       Increased LV wall thickness
      Nonmodifiable risk factors
       Increasing age
      • Onaitis M.
      • D'Amico T.
      • Zhao Y.
      • O'Brien S.
      • Harpole D.
      Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database.
      • Vaporciyan A.A.
      • Correa A.M.
      • Rice D.C.
      • Roth J.A.
      • Smythe W.R.
      • Swisher S.G.
      • et al.
      Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients.
      • Roselli E.E.
      • Murthy S.C.
      • Rice T.W.
      • Houghtaling P.L.
      Atrial fibrillation complicating lung cancer resection.
      • Passman R.S.
      • Gingold D.S.
      • Amar D.
      • Lloyd-Jones D.
      • Bennett C.L.
      • Zhang H.
      • et al.
      Prediction rule for atrial fibrillation after major noncardiac thoracic surgery.
      • Ivanovic J.
      • Maziak D.E.
      • Ramzan S.
      • McGuire A.L.
      • Villeneuve P.J.
      • Gilbert S.
      • et al.
      Incidence, severity and perioperative risk factors for atrial fibrillation following pulmonary resection.
      • Polanczyk C.A.
      • Goldman L.
      Supraventricular arrhythmia in patients having noncardiac surgery: clinical correlates and effect on length of stay.
       African American (protective factor)
      • Onaitis M.
      • D'Amico T.
      • Zhao Y.
      • O'Brien S.
      • Harpole D.
      Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database.
       Family history
       Genetic variants
       Male sex
      • Onaitis M.
      • D'Amico T.
      • Zhao Y.
      • O'Brien S.
      • Harpole D.
      Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database.
      • Vaporciyan A.A.
      • Correa A.M.
      • Rice D.C.
      • Roth J.A.
      • Smythe W.R.
      • Swisher S.G.
      • et al.
      Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients.
      • Passman R.S.
      • Gingold D.S.
      • Amar D.
      • Lloyd-Jones D.
      • Bennett C.L.
      • Zhang H.
      • et al.
      Prediction rule for atrial fibrillation after major noncardiac thoracic surgery.
      • Polanczyk C.A.
      • Goldman L.
      Supraventricular arrhythmia in patients having noncardiac surgery: clinical correlates and effect on length of stay.
       History of arrhythmias
      • Vaporciyan A.A.
      • Correa A.M.
      • Rice D.C.
      • Roth J.A.
      • Smythe W.R.
      • Swisher S.G.
      • et al.
      Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients.
      • Roselli E.E.
      • Murthy S.C.
      • Rice T.W.
      • Houghtaling P.L.
      Atrial fibrillation complicating lung cancer resection.
      Derived from the 2014 American Heart Association Atrial Fibrillation Guidelines and relevant literature for thoracic surgery. Patient risk factors and comorbidities that were shown to increase the risk of atrial fibrillation (AF) are listed. Much of this information was extracted from the general population, thoracic surgery–specific references are listed when available. These risk factors/comorbidities should be assessed in conjunction with the procedure-related risks of AF in order to determine the true risk of POAF. MI, Myocardial infarction; VHD, valvular heart disease; LV, left ventricle; LVH, left ventricular hypertrophy.
      The mechanisms of POAF are complex and require both a vulnerable atrial substrate and a trigger to initiate AF (Table 3). In the presence of a vulnerable substrate, additional electrophysiologic abnormalities (drivers) will sustain AF. As POAF is mostly limited to the first 4 to 6 weeks of the postoperative period, it is likely that inflammation related to surgery and healing contributes to POAF.
      Table 3Probable mechanisms contributing to POAF
      Clinically meaningful AF requires the presence of both a trigger and a vulnerable atrial substrate
      Atrial substrate changes that facilitate AF
       Sympathetic or parasympathetic stimulation
       Atrial dilation or acute atrial stretch
       Pericarditis
       Fibrosis
       Inhomogeneous dispersion of conduction abnormalities
       Short wavelength (conduction velocity × ERP)
       Other (like inflammation and oxidative stress)
      In addition, a driver(s) is thought to be needed to sustain AF in the vulnerable substrate
       Rapidly firing ectopic focus (atrial or other)
       Reentrant circuit(s) of short cycle length (ordered reentry)
       Potential role, if any, of multiple reentrant wavelets (random reentry)
      AF, Atrial fibrillation; ERP, effective refractory period.

      Recommendations

      Recommend the Use of the Following Definitions for the Diagnosis of POAF

      • Class I
      • 1.1.
        Electrophysiologic definition/diagnosis: ECG recordings (1 or more ECG leads) that demonstrate the presence of characteristic ECG features of AF (Table 4) lasting at least for 30 seconds or for the duration of the ECG recording (if shorter than 30 seconds)
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cleveland J.C.
        • Cigarroa J.E.
        • et al.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        • Anderson J.L.
        • Halperin J.L.
        • Albert N.M.
        • Bozkurt B.
        • Brindis R.G.
        • Curtis L.H.
        • et al.
        Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        (level of evidence [LOE] C).
        Table 4Recommended definitions for the diagnosis of POAF
        DefinitionsCOR
        Electrophysiologic definition/diagnosisECG recordings (1 or more ECG leads) with ECG features of AF lasting at least for 30 seconds or for the duration of the ECG recording (if <30 seconds) (LOE C)I
        Clinical definition/diagnosisClinically significant POAF: intra- and postoperative AF requiring treatment, or anticoagulation, and/or extending the duration of hospitalization (LOE C)I
        These measures should be included in the clinical documentation and reported in the clinical trials/studies. POAF, Postoperative atrial fibrillation; ECG, electrocardiography; COR, class of recommendation; LOE, level of evidence; AF, atrial fibrillation.
      • 1.2.
        Clinical definition/diagnosis: clinically significant POAF is AF in the (intra- and) postoperative setting that requires treatment with rate or rhythm control agents, or requires anticoagulation, and/or extends the duration of hospitalization (LOE C). Clinical symptoms may include hypotension, dizziness, decreased urinary output, fatigue, and so on.
      • We recommend that both electrophysiologically documented AF and clinically diagnosed AF be included in the clinical documentation and reported in clinical trials/studies.

      Physiologic (ECG) Monitoring of Patients at Risk for POAF

      Recommendations for the ECG monitoring of the patients at risk for POAF are presented in Table 5.
      • Class I
      • 2.1.
        Patients should be monitored with continuous ECG telemetry postoperatively for 48 to 72 hours (or less if their hospitalization is shorter) if:
        • 2.1.1.
          They are undergoing procedures that pose intermediate (5%-15% expected incidence of AF) or high (>15%) risk (Table 2, A) for the development of postoperative AF or have significant additional risk factors (CHA2DS2-VASc ≥2) for stroke (LOE C).
        • 2.1.2.
          They have a history of preexisting or periodic recurrent AF before their surgery. These patients should also receive ECG monitoring in the immediate preoperative period if procedures (eg, epidural catheter or other regional anesthesia blocks) are performed (LOE C).
      • Class IIa
      • 2.2.
        Not using routine ECG telemetry is reasonable for patients who undergo low-risk (<5% expected incidence of AF) procedures, and have neither a previous history of AF nor significant risk for stroke (based on CHA2DS2-VASc score), and have no relevant comorbidities (such as heart failure or previous stroke) (LOE C).
        • Class I
        • 2.2.1.
          If patients exhibit clinical signs of possible AF while not monitored with telemetry, ECG recordings to diagnose POAF and ongoing telemetry to monitor the period of AF should be immediately implemented (LOE C).
      Table 5Recommendations for physiologic (ECG) monitoring
      Recommendations for monitoringCOR
      Patients should be monitored with continuous ECG telemetry postoperatively for 48-72 h (or less if their hospitalization is shorter) if:
      • they are undergoing procedures that pose high (>15% expected incidence of AF) or intermediate (5%-15%) risk for POAF or
      • they have significant additional risk factors (CHA2DS2-VASc >2) for stroke (LOE C)
      • they have a history of preexisting or periodic recurrent AF before their surgery
      • These patients should also receive ECG monitoring in the immediate preoperative period if procedures (epidural catheter, regional anesthesia blocks, and so forth) are performed (LOE C)
      I
      Not using routine ECG telemetry is reasonable for patients who
      • undergo low risk surgery (<5% expected incidence of AF) and
      • had no previous history of AF, or
      • have no significant risk for stroke and
      • have no relevant comorbidities (eg, heart failure or previous stroke) (LOE C)
      IIa
      • If patients exhibit clinical signs of possible AF while not monitored with ECG telemetry, ECG recordings to diagnose POAF and continuous telemetry to monitor the period of AF should be immediately implemented (LOE C)
      I
      ECG, Electrocardiography; COR, class of recommendation; AF, atrial fibrillation; POAF, postoperative atrial fibrillation; LOE, level of evidence.

      Rate Control and Antiarrhythmic Drugs, Mechanism of Action, Side Effects and Limitations

      A detailed description of the drugs used for the management of rate (Table 6) or rhythm control (Table 7
      • Neumar W.
      • Otto C.W.
      • Link M.S.
      • Kronick S.L.
      • Shuster M.
      • Callaway C.W.
      • et al.
      Part 8: Adult advanced cardiovascular life support 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
      ), their mechanism of action, side effects, and limitations are further discussed in the online document. Dosing information is also presented in Table 6, Table 7.
      • Class IIa
      • 3.1.
        To optimize the efficacy and safety of amiodarone, it is reasonable to exercise caution when selecting its doses or intravenous versus oral route, because cases of acute respiratory distress syndrome (ARDS) have been reported following pneumonectomy with cumulative intravenous doses more than 2150 mg
        • Van Mieghem W.
        • Coolen L.
        • Malysse I.
        • Lacquet L.M.
        • Deneffe G.J.
        • Demedts M.G.
        Amiodarone and the development of ARDS after lung surgery.
        (LOE C).
      Table 6Commonly used rate control agents
      DrugRecommended dosesSignificant limitations and known side effects
      Diltiazem0.25 mg/kg IV loading dose over 2 min, then 5-15 mg/h IV continuous infusionHypotension

      Bradycardia

      Heart failure exacerbation
      Digoxin0.25 mg IV repeated every 2-4 h to a maximum dose of 1.5 mg over 24 hNausea, vomiting, anorexia

      Confusion

      AV block

      Ventricular arrhythmias

      Accumulates in acute kidney injury/chronic kidney disease
      Esmolol500 μg/kg IV bolus over 1 min, then 50-300 μg/kg/min IV continuous infusionBradycardia

      Hypotension

      Bronchospasm

      Heart failure exacerbation
      Metoprolol2.5-5.0 mg IV bolus over 2 min; maximum 3 dosesBradycardia

      Hypotension

      Bronchospasm

      Heart failure exacerbation
      Amiodarone150-300 mg IV over 1 h, followed by 10-50 mg/h IV continuous infusion over 24 hBradycardia

      QT interval prolongation

      Pulmonary toxicity has not been demonstrated at this dose
      Detailed information in section 3 of the online version of the guidelines and in references
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      ,
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      . IV, Intravenous; AV, atrioventricular.
      Table 7Commonly used antiarrhythmic agents
      DrugRecommended dosesSignificant limitations and known side effectsRef
      ProcainamideConversion to sinus rhythm: 20-50 mg/min IV continuous infusion until AF terminated, hypotension occurs, or QRS duration prolonged by 50%, or cumulative total dose of 15 mg/kg reached

      Alternative dose: 100 mg IV every 5 min until AF terminated or other conditions as listed above are met

      If available orally, could be used for maintenance
      Hypotension

      QT interval prolongation

      Torsades de pointes

      Contraindicated in patients with heart failure with reduced left ventricular ejection fraction

      Contraindicated in patients with pretreatment QTc interval >470 ms (men) or 480 ms (women)
      • Neumar W.
      • Otto C.W.
      • Link M.S.
      • Kronick S.L.
      • Shuster M.
      • Callaway C.W.
      • et al.
      Part 8: Adult advanced cardiovascular life support 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
      FlecainideConversion to sinus rhythm: 200-300 mg single oral dose

      Maintenance of sinus rhythm: 50-150 mg orally once every 12 h
      Dizziness

      Blurred vision

      Sinus bradycardia

      AV block

      Contraindicated in patients with heart failure with reduced left ventricular ejection fraction

      Contraindicated in patients with coronary artery disease/structural heart disease
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      PropafenoneConversion to sinus rhythm: 450-600 mg single oral dose

      Maintenance of sinus rhythm: 150-300 mg orally every 8 h (immediate release); 225-425 mg orally every 12 h (extended release)
      Dizziness

      Blurred vision

      Sinus bradycardia

      AV block

      Contraindicated in patients with heart failure with reduced left ventricular ejection fraction

      Contraindicated in patients with coronary artery disease/structural heart disease
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      AmiodaroneProphylaxis: 300 mg IV bolus, then 600 mg orally twice daily for 3-5 d

      Treatment: 150 mg IV over 10 min; then 1 mg/min IV continuous infusion for 6 h; the 0.5 mg/min IV continuous infusion for 18 h or change to oral administration at 100-400 mg daily
      Bradycardia

      QT interval prolongation

      Pulmonary toxicity has not been demonstrated at this dose

      Bradycardia

      Hypotension

      QT interval prolongation

      Pulmonary toxicity has occurred at cumulative IV doses >2150 mg in patients undergoing pneumonectomy
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      • Riber L.P.
      • Christensen T.D.
      • Jensen H.K.
      • Hoejsgaard A.
      • Pilegaard H.K.
      Amiodarone significantly decreases atrial fibrillation in patients undergoing surgery for lung cancer.
      DofetilideNot ideal for conversion to sinus rhythm in the postoperative setting; may take 2-3 d to convert to normal sinus rhythm, which would require commitment to anticoagulation

      Maintenance of sinus rhythm: calculated CrCl 20-40 mL/min: 125 μg orally once every 12 h

      Calculated CrCl 40-60 mL/min: 250 μg orally once every 12 h

      Calculated CrCl >60 mL/min: 500 μg orally every 12 h
      QT interval prolongation

      Torsades de pointes

      Risk of torsades de pointes is greater in patients with heart failure

      Dose adjustment is important in patients with acute kidney injury or chronic kidney disease

      Contraindicated in patients with calculated CrCl <20 mL/min

      Contraindicated in patients with pretreatment QTc interval >470 ms (men) or 480 ms (women)

      Monitor ECGs 2 h after doses, telemetry for at least 3 d
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      IbutilideConversion to sinus rhythm:

      Weight ≥60 kg: 1 mg IV administered over 10 min

      Weight <60 kg: 0.01 mg/kg IV administered over 10 min

      If the AF does not terminate within 10 min of completion of the first infusion, a second dose of equal strength may be administered IV over 10 min

      Not indicated for maintenance of sinus rhythm
      QT interval prolongation

      Torsades de pointes

      Risk of torsades de pointes greater in patients with heart failure

      Nonsustained ventricular tachycardia

      Sinus pauses after AF conversion

      Contraindicated in patients with pretreatment QTc interval >470 ms (men) or 480 ms (women)
      Corvert prescribing information 2006; Pfizer, Inc
      SotalolMaintenance of sinus rhythm: 40-160 mg orally every 12 h

      Dosing interval should be adjusted in patients with acute kidney injury or chronic kidney disease:

      If the calculated CrCl is 30-59 mL/min: administer every 24 h

      If the calculated CrCl is 10-29 mL/min: administer every 36-48 h
      Sinus bradycardia

      AV block

      QT interval prolongation

      Torsades de pointes

      Heart failure exacerbation

      Risk of torsades de pointes greater in patients with heart failure

      Bronchospasm

      Dose adjustment is important in patients with acute kidney injury or chronic kidney disease

      Use with extreme caution in patients with calculated CrCl <10 mL/min and in patients undergoing hemodialysis

      Contraindicated in patients with pretreatment QTc interval >470 ms (men) or 480 ms (women)
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • Calkins H.
      • Cleveland J.C.
      • Cigarroa J.E.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      IV, Intravenous; AF, atrial fibrillation; AV, atrioventricular; CrCl, creatinine clearance; ECG, electrocardiography.

      Prevention Strategies and Their Efficacy

      Recent evidence suggest that some prevention strategies (avoiding β-blockade withdrawal for those chronically on those medications, correction of serum magnesium when abnormal) maybe effective for all patients for reducing the incidence of POAF. By surveying the AATS membership, we also found that many of these strategies are currently underused (Figure 1).
      • 4.1.
        Recommended prevention strategies for all patients Class I
        • 4.1.1.
          Patients taking β-blockers before thoracic surgery should continue them in the postoperative period to avoid β-blockade withdrawal
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          • Nattel S.
          • Rangno R.E.
          • Van Loon G.
          Mechanism of propranolol withdrawal phenomena.
          • Jakobsen C.-J.
          • Bille S.
          • Ahlburg P.
          • Rybro L.
          • Hjortholm K.
          • Bay Andresen E.
          Perioperative metoprolol reduces the frequency of atrial fibrillation after thoracotomy for lung resection.
          • Bayliff C.D.
          • Massel D.R.
          • Inculet R.I.
          • Malthaner R.A.
          • Quinton S.D.
          • Powell F.S.
          • et al.
          Propranolol for the prevention of postoperative arrhythmias in general thoracic surgery.
          • Burgess D.C.
          • Kilborn M.J.
          • Keech A.C.
          Interventions for prevention of post-operative atrial fibrillation and its complications after cardiac surgery: a meta-analysis.
          • Rena O.
          • Papalia E.
          • Oliaro A.
          • Casadio C.
          • Ruffini E.
          • Filosso P.L.
          • et al.
          Supraventricular arrhythmias after resection surgery of the lung.
          (LOE A).
        • Class IIb
        • 4.1.2.
          Intravenous magnesium supplementation may be considered to prevent postoperative AF when serum magnesium level is low or it is suspected that total body magnesium is depleted
          • Rena O.
          • Papalia E.
          • Oliaro A.
          • Casadio C.
          • Ruffini E.
          • Filosso P.L.
          • et al.
          Supraventricular arrhythmias after resection surgery of the lung.
          • Terzi A.
          • Furlan G.
          • Chiavacci P.
          • Dal Corso B.
          • Luzzani A.
          • Dalla Volta S.
          Prevention of atrial tachyarrhythmias after non-cardiac thoracic surgery by infusion of magnesium sulfate.
          • Rostron A.
          • Sanni A.
          • Dunning J.
          Does magnesium prophylaxis reduce the incidence of atrial fibrillation following coronary bypass surgery?.
          (LOE C).
        • Class III
        • 4.1.3.
          Digoxin should not be used for prophylaxis against AF
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          • Anderson J.L.
          • Halperin J.L.
          • Albert N.M.
          • Bozkurt B.
          • Brindis R.G.
          • Curtis L.H.
          • et al.
          Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
          • Ritchie A.J.
          • Tolan M.
          • Whiteside M.
          • McGuigan J.A.
          • Gibbons J.R.
          Prophylactic digitalization fails to control dysrhythmia in thoracic esophageal operations.
          • Kaiser A.
          • Zünd G.
          • Weder W.
          • Largiadèr F.
          Preventive digitalis therapy in open thoracotomy.
          • Amar D.
          • Roistacher N.
          • Burt M.E.
          • Rusch V.W.
          • Bains M.S.
          • Leung D.H.
          • et al.
          Effects of diltiazem versus digoxin on dysrhythmias and cardiac function after pneumonectomy.
          (LOE A).
        • 4.1.4.
          Catheter or surgical pulmonary vein isolation (at the time of surgery) is not recommended for prevention of POAF for patients who have no previous history of AF
          • See V.Y.
          • Roberts-Thomson K.C.
          • Stevenson W.G.
          • Camp P.C.
          • Koplan B.A.
          Atrial arrhythmias after lung transplantation: epidemiology, mechanisms at electrophysiology study, and outcomes.
          (LOE C).
        • 4.1.5.
          Complete or partial pulmonary vein isolation at the time of (even bilateral) lung surgery should not be considered for prevention of POAF, as it is unlikely to be effective
          • See V.Y.
          • Roberts-Thomson K.C.
          • Stevenson W.G.
          • Camp P.C.
          • Koplan B.A.
          Atrial arrhythmias after lung transplantation: epidemiology, mechanisms at electrophysiology study, and outcomes.
          • Mason D.P.
          • Marsh D.H.
          • Alster J.M.
          • Murthy S.C.
          • McNeill A.M.
          • Budev M.M.
          • et al.
          Atrial fibrillation after lung transplantation: timing, risk factors, and treatment.
          • Dizon J.M.
          • Chen K.
          • Bacchetta M.
          • Argenziano M.
          • Mancini D.
          • Biviano A.
          • et al.
          A comparison of atrial arrhythmias after heart or double-lung transplantation at a single center: insights into the mechanism of post-operative atrial fibrillation.
          (LOE B).
        • For those patients at increased risk for the development of POAF, preventive administration of medications (diltiazem or amiodarone) may be reasonable. However, these strategies may not be useful for all thoracic surgical patients.
      • 4.2.
        Recommended prevention strategies for intermediate to high-risk patients
        • Class IIa
        • 4.2.1.
          It is reasonable to administer diltiazem to those patients with preserved cardiac function who are not taking β-blockers preoperatively in order to prevent POAF
          • Amar D.
          • Roistacher N.
          • Rusch V.W.
          • Leung D.H.Y.
          • Ginsburg I.
          • Zhang H.
          • et al.
          Effects of diltiazem prophylaxis on the incidence and clinical outcome of atrial arrhythmias after thoracic surgery.
          • Wijeysundera D.N.
          • Beattie W.S.
          • Rao V.
          • Karski J.
          Calcium antagonists reduce cardiovascular complications after cardiac surgery: a meta-analysis.
          (LOE B).
        • 4.2.2.
          It is reasonable to consider the postoperative administration of amiodarone to reduce the incidence of POAF for intermediate- and high-risk patients undergoing pulmonary resection
          • Riber L.P.
          • Christensen T.D.
          • Jensen H.K.
          • Hoejsgaard A.
          • Pilegaard H.K.
          Amiodarone significantly decreases atrial fibrillation in patients undergoing surgery for lung cancer.
          • Khalil M.A.
          • Al-Agaty A.E.
          • Ali W.G.
          • Abdel Azeem M.S.
          A comparative study between amiodarone and magnesium sulfate as antiarrhythmic agents for prophylaxis against atrial fibrillation following lobectomy.
          • Tisdale J.E.
          • Wroblewski H.A.
          • Wall D.S.
          • Rieger K.M.
          • Hammoud Z.T.
          • Young J.V.
          • et al.
          A randomized trial evaluating amiodarone for prevention of atrial fibrillation after pulmonary resection.
          (LOE A).
        • Class IIb
        • 4.2.3.
          Postoperative administration of intravenous amiodarone may be considered to prevent POAF in patients undergoing esophagectomy
          • Tisdale J.E.
          • Wroblewski H.A.
          • Wall D.S.
          • Rieger K.M.
          • Hammoud Z.T.
          • Young J.V.
          • et al.
          A randomized, controlled study of amiodarone for prevention of atrial fibrillation after transthoracic esophagectomy.
          (LOE B).
        • 4.2.4.
          Atorvastatin may be considered to prevent POAF for statin-naive patients scheduled for intermediate- and high-risk thoracic surgical procedures
          • Amar D.
          • Zhang H.
          • Heerdt P.M.
          • Park B.
          • Fleisher M.
          • Thaler H.T.
          Statin use is associated with a reduction in atrial fibrillation after noncardiac thoracic surgery independent of C-reactive protein.
          • Fauchier L.
          • Pierre B.
          • de Labriolle A.
          • Grimard C.
          • Zannad N.
          • Babuty D.
          Antiarrhythmic effect of statin therapy and atrial fibrillation a meta-analysis of randomized controlled trials.
          • Chopra V.
          • Wesorick D.H.
          • Sussman J.B.
          • Greene T.
          • Rogers M.
          • Froehlich J.B.
          • et al.
          Effect of perioperative statins on death, myocardial infarction, atrial fibrillation, and length of stay: a systematic review and meta-analysis.
          (LOE C).
      • 4.3.
        Recommended prevention strategies for the highest-risk patients
        • Class IIb
        • 4.3.1.
          Left atrial appendage excision may be considered at the time of extensive left lung surgery for patients with preexisting AF who are considered too high a risk for anticoagulation in the perioperative period
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          • Anderson J.L.
          • Halperin J.L.
          • Albert N.M.
          • Bozkurt B.
          • Brindis R.G.
          • Curtis L.H.
          • et al.
          Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
          • Johnson W.D.
          • Ganjoo A.K.
          • Stone C.D.
          • Srivyas R.C.
          • Howard M.
          The left atrial appendage: our most lethal human attachment! Surgical implications.
          (LOE C).
      Figure thumbnail gr1
      Figure 1Prevention strategies and their efficacy for postoperative atrial fibrillation (POAF). LOE, Level of evidence; PVI, pulmonary vein isolation; i.v., intravenous; LVEF, left ventricular ejection fraction; AF, atrial fibrillation.

      Treatment Strategies for AF and Their Efficacy

      The management of patients presenting with POAF requires different strategies depending on their hemodynamic stability. Although some interventions are likely to benefit all patients (see section 5.1), hemodynamically unstable patients will require urgent efforts for the restitution of sinus rhythm (section 5.2). However, for stable patients with POAF, the emphasis shifts to rate control strategies (see details in section 5.3).
      • 5.1.
        Management strategies recommended for all patients with new-onset POAF (Figure 2)
        • Class I
        • 5.1.1.
          Reduce or stop catecholaminergic inotropic agents if hemodynamics allow (LOE C).
        • 5.1.2.
          Optimize fluid balance and maintain normal electrolyte levels (LOE C).
        • 5.1.3.
          Evaluate the presence of and treat all possible correctable triggering factors. These may include bleeding, pulmonary embolism, pneumothorax, pericardial processes, airway issues, myocardial ischemia, or infection/sepsis (LOE C).
        • Class IIb
        • 5.1.4.
          Cardiology consultation may be useful for those patients (LOE C) who:
          • 5.1.4.1.
            Develop recurrent or refractory POAF.
          • 5.1.4.2.
            Develop a hemodynamically unstable condition.
          • 5.1.4.3.
            Are at high risk for stroke based on CHA2DS2-VASc score and will likely require longer-term anticoagulation.
          • 5.1.4.4.
            Require a second-line antiarrhythmic medication for stabilization.
          • 5.1.4.5.
            Also develop acute kidney injury.
        Figure thumbnail gr2
        Figure 2Management algorithm for postoperative atrial fibrillation (POAF). AF, Atrial fibrillation; MI, myocardial infarction; HF, heart failure; WPW, Wolff-Parkinson-White syndrome; DC, direct current; i.v./IV, intravenous; HR, heart rate; LV, left ventricular; COPD, chronic obstructive pulmonary disease; LA/LAA, left atrial/left atrial appendage; TEE, transesophageal echocardiography.
      • 5.2.
        Recommendations for the management of the hemodynamically unstable patient with new-onset POAF (Figure 3)
        • Class I
        • 5.2.1.
          Emergency R-wave synchronized direct current (DC) electrical cardioversion is recommended for hemodynamically unstable patients and for patients with evidence of acute myocardial ischemia or infarction. Signs of hemodynamic instability include: severe symptomatic hypotension, shock, or pulmonary edema
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          • Polanczyk C.A.
          • Goldman L.
          Supraventricular arrhythmia in patients having noncardiac surgery: clinical correlates and effect on length of stay.
          • Fernando H.C.
          • Jaklitsch M.T.
          • Walsh G.L.
          • Tisdale J.E.
          • Bridges C.D.
          • Mitchell J.D.
          • et al.
          The Society of Thoracic Surgeons practice guideline on the prophylaxis and management of atrial fibrillation associated with general thoracic surgery: executive summary.
          (LOE C).
          • 5.2.1.1.
            For unstable patients with new-onset POAF of less than 48-hours duration, emergency DC cardioversion is indicated and is acceptable before initiation of anticoagulation
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            (LOE C).
          • 5.2.1.2.
            For unstable patients who undergo cardioversion more than 48 hours after the onset of AF, and who do not have an excessive bleeding risk or other contraindication, anticoagulation should be initiated as soon as possible and continued for at least 4 weeks
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • Fuster V.
            • Rydén L.E.
            • Cannom D.S.
            • Crijns H.J.
            • Curtis A.B.
            • Ellenbogen K.A.
            • et al.
            2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
            (LOE C).
        • Class IIa
        • 5.2.2.
          If initial DC cardioversion is unsuccessful or hemodynamically unstable AF recurs, the following steps can be useful:
          • 5.2.2.1.
            Initiate rate and possible rhythm control therapy with intravenous esmolol, diltiazem, digoxin, or amiodarone while preparing for repeat DC cardioversion (LOE C).
          • 5.2.2.2.
            Repeat DC cardioversion (more likely to be successful after initiating a rhythm control agent) (LOE C).
        Figure thumbnail gr3
        Figure 3Management of the hemodynamically unstable patient with new-onset postoperative atrial fibrillation (POAF). AF, Atrial fibrillation; MI, myocardial infarction; HF, heart failure; DC, direct current; i.v., intravenous; TEE, transesophageal echocardiography.
      • 5.3.
        Recommendations for the management of the hemodynamically stable patient with new-onset AF (Figure 4, Figure 5)
        Figure thumbnail gr4
        Figure 4Management of the hemodynamically stable patient with new-onset postoperative atrial fibrillation (POAF) of less than 48 hours duration. WPW, Wolff-Parkinson-White syndrome; HR, heart rate; i.v., intravenous; HF, heart failure; LV, left ventricular; COPD, chronic obstructive pulmonary disease; AF, atrial fibrillation; DC, direct current; TEE, transesophageal echocardiography.
        Figure thumbnail gr5
        Figure 5Management of the hemodynamically stable patient with new-onset postoperative atrial fibrillation (POAF) of more than 48 hours duration. WPW, Wolff-Parkinson-White syndrome; HR, heart rate; i.v., intravenous; HF, heart failure; LV, left ventricular; COPD, chronic obstructive pulmonary disease; TEE, transesophageal echocardiography; LA/LAA, left atrial/left atrial appendage; DC, direct current; AF, atrial fibrillation.
      • Primary treatment goal is rate control with rhythm control as a secondary option.
        • Class IIa
        • 5.3.1.
          It is reasonable to manage stable, well-tolerated new-onset POAF with a rate control strategy
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          • Rena O.
          • Papalia E.
          • Oliaro A.
          • Casadio C.
          • Ruffini E.
          • Filosso P.L.
          • et al.
          Supraventricular arrhythmias after resection surgery of the lung.
          • Bobbio A.
          • Caporale D.
          • Internullo E.
          • Ampollini L.
          • Bettati S.
          • Rossini E.
          • et al.
          Postoperative outcome of patients undergoing lung resection presenting with new-onset atrial fibrillation managed by amiodarone or diltiazem.
          • Lee J.K.
          • Klein G.J.
          • Krahn A.D.
          • Yee R.
          • Zarnke K.
          • Simpson C.
          • et al.
          Rate-control versus conversion strategy in postoperative atrial fibrillation: a prospective, randomized pilot study.
          • Soucier R.
          • Silverman D.
          • Abordo M.
          • Jaagosild P.
          • Abiose A.
          • Madhusoodanan K.P.
          • et al.
          Propafenone versus ibutilide for post operative atrial fibrillation following cardiac surgery: neither strategy improves outcomes compared to rate control alone (the PIPAF study).
          (LOE C).
        • 5.3.2.
          Rhythm control with antiarrhythmic drugs and/or DC cardioversion can be useful for patients with hemodynamically stable new-onset POAF who have recurrent or refractory POAF, continued symptoms, intolerance to rate control medications, or ventricular rates that cannot be adequately controlled
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          • Lee J.K.
          • Klein G.J.
          • Krahn A.D.
          • Yee R.
          • Zarnke K.
          • Simpson C.
          • et al.
          Rate-control versus conversion strategy in postoperative atrial fibrillation: a prospective, randomized pilot study.
          • Soucier R.
          • Silverman D.
          • Abordo M.
          • Jaagosild P.
          • Abiose A.
          • Madhusoodanan K.P.
          • et al.
          Propafenone versus ibutilide for post operative atrial fibrillation following cardiac surgery: neither strategy improves outcomes compared to rate control alone (the PIPAF study).
          (LOE C).
        • 5.3.3.
          A rhythm control approach with pharmacologic or DC cardioversion is reasonable for patients with new-onset POAF nearing 48 hours in duration, who are at high risk for bleeding, in order to avoid anticoagulation that would be otherwise indicated for AF persisting longer than 48 hours (LOE C).
      • 5.4.
        Medical management of patients with new-onset POAF (Figure 4, Figure 5)
        • 5.4.1.
          Rate control recommendations
          • Class I
          • 5.4.1.1.
            Intravenous administration of β-blockers (eg, esmolol or metoprolol) or non–dihydropyridine calcium channel blockers (diltiazem or verapamil) is recommended to achieve rate control (heart rate ≤110 bpm) for patients who develop POAF with rapid ventricular response
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • Van Gelder I.C.
            • Groenveld H.F.
            • Crijns H.J.
            • Tuininga Y.S.
            • Tijssen J.G.
            • Alings A.M.
            • et al.
            RACE II Investigators
            Lenient versus strict rate control in patients with atrial fibrillation.
            • Bobbio A.
            • Caporale D.
            • Internullo E.
            • Ampollini L.
            • Bettati S.
            • Rossini E.
            • et al.
            Postoperative outcome of patients undergoing lung resection presenting with new-onset atrial fibrillation managed by amiodarone or diltiazem.
            (LOE B).
            • 5.4.1.1.1.
              Caution should be used with patients with hypotension, left ventricular (LV) dysfunction, or heart failure
              • January C.T.
              • Wann L.S.
              • Alpert J.S.
              • Calkins H.
              • Cleveland J.C.
              • Cigarroa J.E.
              • et al.
              2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
              • Van Gelder I.C.
              • Groenveld H.F.
              • Crijns H.J.
              • Tuininga Y.S.
              • Tijssen J.G.
              • Alings A.M.
              • et al.
              RACE II Investigators
              Lenient versus strict rate control in patients with atrial fibrillation.
              • Anderson J.L.
              • Halperin J.L.
              • Albert N.M.
              • Bozkurt B.
              • Brindis R.G.
              • Curtis L.H.
              • et al.
              Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
              • Bobbio A.
              • Caporale D.
              • Internullo E.
              • Ampollini L.
              • Bettati S.
              • Rossini E.
              • et al.
              Postoperative outcome of patients undergoing lung resection presenting with new-onset atrial fibrillation managed by amiodarone or diltiazem.
              (LOE B).
          • Class IIa
          • 5.4.1.2.
            Combination use of atrioventricular (AV) nodal blocking agents, such as β-blockers (eg, esmolol or metoprolol), non–dihydropyridine calcium channel antagonists (eg, diltiazem or verapamil), or digoxin, can be useful to control heart rates when a single agent fails to control rates of POAF. The choice should be individualized and doses modified to avoid bradycardia
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • Anderson J.L.
            • Halperin J.L.
            • Albert N.M.
            • Bozkurt B.
            • Brindis R.G.
            • Curtis L.H.
            • et al.
            Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
            (LOE B).
          • 5.4.1.3.
            For patients with hypotension, heart failure, or LV dysfunction, or when other measures are unsuccessful or contraindicated, intravenous amiodarone can be useful for control of heart rate. Amiodarone could result in conversion to sinus rhythm, and if it is initiated after 48 hours of AF, both transesophageal echocardiography (TEE) when possible, to rule out left atrial (LA)/left atrial appendage (LAA) thrombus, and full anticoagulation should be considered
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • Anderson J.L.
            • Halperin J.L.
            • Albert N.M.
            • Bozkurt B.
            • Brindis R.G.
            • Curtis L.H.
            • et al.
            Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
            • Rena O.
            • Papalia E.
            • Oliaro A.
            • Casadio C.
            • Ruffini E.
            • Filosso P.L.
            • et al.
            Supraventricular arrhythmias after resection surgery of the lung.
            • Bobbio A.
            • Caporale D.
            • Internullo E.
            • Ampollini L.
            • Bettati S.
            • Rossini E.
            • et al.
            Postoperative outcome of patients undergoing lung resection presenting with new-onset atrial fibrillation managed by amiodarone or diltiazem.
            • Lee J.K.
            • Klein G.J.
            • Krahn A.D.
            • Yee R.
            • Zarnke K.
            • Simpson C.
            • et al.
            Rate-control versus conversion strategy in postoperative atrial fibrillation: a prospective, randomized pilot study.
            • Soucier R.
            • Silverman D.
            • Abordo M.
            • Jaagosild P.
            • Abiose A.
            • Madhusoodanan K.P.
            • et al.
            Propafenone versus ibutilide for post operative atrial fibrillation following cardiac surgery: neither strategy improves outcomes compared to rate control alone (the PIPAF study).
            • Ciriaco P.
            • Mazzone P.
            • Canneto B.
            • Zannini P.
            Supraventricular arrhythmia following lung resection for non-small cell lung cancer and its treatment with amiodarone.
            (LOE B).
          • Class IIb
          • 5.4.1.4.
            For patients with heart failure, LV dysfunction or hypotension, intravenous digoxin may be considered for rate control of POAF
            • Anderson J.L.
            • Halperin J.L.
            • Albert N.M.
            • Bozkurt B.
            • Brindis R.G.
            • Curtis L.H.
            • et al.
            Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
            • Rena O.
            • Papalia E.
            • Oliaro A.
            • Casadio C.
            • Ruffini E.
            • Filosso P.L.
            • et al.
            Supraventricular arrhythmias after resection surgery of the lung.
            • Tisdale J.E.
            • Padhi I.D.
            • Goldberg A.D.
            • Silverman N.A.
            • Webb C.R.
            • Higgins R.S.
            • et al.
            A randomized, double-blind comparison of intravenous diltiazem and digoxin for atrial fibrillation after coronary artery bypass surgery.
            (LOE B).
          • Class III
          • 5.4.1.5.
            For patients with ventricular preexcitation (ie, Wolff-Parkinson-White syndrome) and POAF, use of AV nodal blocking agents, such as β-blockers (eg, esmolol or metoprolol), intravenous amiodarone, non–dihydropyridine calcium channel antagonists (eg, diltiazem or verapamil), or digoxin, should be avoided
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • Anderson J.L.
            • Halperin J.L.
            • Albert N.M.
            • Bozkurt B.
            • Brindis R.G.
            • Curtis L.H.
            • et al.
            Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
            (LOE C).
        • 5.4.2.
          Recommendations for the use of antiarrhythmic drugs (Figure 6, A and B)
          • Class IIa
          • 5.4.2.1.
            Restoration of sinus rhythm with pharmacologic cardioversion is reasonable in patients with symptomatic, hemodynamically stable POAF
            • Strasberg B.
            • Arditti A.
            • Sclarovsky S.
            • Lewin R.F.
            • Buimovici B.
            • Agmon J.
            Efficacy of intravenous amiodarone in the management of paroxysmal or new atrial fibrillation with fast ventricular response.
            • Faniel R.
            • Schoenfeld P.
            Efficacy of i.v. amiodarone in converting rapid atrial fibrillation and flutter to sinus rhythm in intensive care patients.
            • Kumar A.
            Intravenous amiodarone for therapy of atrial fibrillation and flutter in critically ill patients with severely depressed left ventricular function.
            (LOE C).
            • 5.4.2.1.1.
              Intravenous amiodarone can be useful for pharmacologic cardioversion of POAF
              • Henri C.
              • Giraldeau G.
              • Dorais M.
              • Cloutier A.-S.
              • Girard F.
              • Noiseux N.
              • et al.
              Atrial fibrillation after pulmonary transplantation: incidence, impact on mortality, treatment effectiveness, and risk factors.
              • Rena O.
              • Papalia E.
              • Oliaro A.
              • Casadio C.
              • Ruffini E.
              • Filosso P.L.
              • et al.
              Supraventricular arrhythmias after resection surgery of the lung.
              • Bobbio A.
              • Caporale D.
              • Internullo E.
              • Ampollini L.
              • Bettati S.
              • Rossini E.
              • et al.
              Postoperative outcome of patients undergoing lung resection presenting with new-onset atrial fibrillation managed by amiodarone or diltiazem.
              • Ciriaco P.
              • Mazzone P.
              • Canneto B.
              • Zannini P.
              Supraventricular arrhythmia following lung resection for non-small cell lung cancer and its treatment with amiodarone.
              • Barbetakis N.
              • Vassiliadis M.
              Is amiodarone a safe antiarrhythmic to use in supraventricular tachyarrhythmias after lung cancer surgery?.
              (LOE B).
          • 5.4.2.2.
            It is reasonable to administer antiarrhythmic medications in an attempt to maintain sinus rhythm for patients with recurrent or refractory POAF
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • Hilleman D.E.
            • Hunter C.B.
            • Mohiuddin S.M.
            • Maciejewski S.
            Pharmacologic management of atrial fibrillation following cardiac surgery.
            (LOE B).
            • 5.4.2.2.1.
              Amiodarone, sotalol, flecainide, propafenone, or dofetilide can be useful to maintain sinus rhythm in patients with POAF, depending on underlying heart disease, renal status and other comorbidities (see Table 7)
              • January C.T.
              • Wann L.S.
              • Alpert J.S.
              • Calkins H.
              • Cleveland J.C.
              • Cigarroa J.E.
              • et al.
              2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
              (LOE B).
          • Class IIb
          • 5.4.2.3.
            Flecainide or propafenone may be considered for pharmacologic cardioversion of POAF and maintenance of sinus rhythm if the patient has had no previous history of myocardial infarction, coronary artery disease, impaired LV function, significant LV hypertrophy, or valvular heart disease that is considered moderate or greater. These agents may need to be combined with an AV nodal blocking agent
            • Barbetakis N.
            • Vassiliadis M.
            Is amiodarone a safe antiarrhythmic to use in supraventricular tachyarrhythmias after lung cancer surgery?.
            • Hilleman D.E.
            • Spinler S.A.
            Conversion of recent-onset atrial fibrillation with intravenous amiodarone: A meta-analysis of randomized controlled trials.
            • Reisinger J.
            • Gatterer E.
            • Lang W.
            • Vanicek T.
            • Eisserer G.
            • Bachleitner T.
            • et al.
            Flecainide versus ibutilide for immediate cardioversion of atrial fibrillation of recent onset.
            • Di Biasi P.
            • Scrofani R.
            • Paje A.
            • Cappiello E.
            • Mangini A.
            • Santoli C.
            Intravenous amiodarone vs propafenone for atrial fibrillation and flutter after cardiac operation.
            • Geelen P.
            • O'Hara G.E.
            • Roy N.
            • Talajic M.
            • Roy D.
            • Plante S.
            • Turgeon J.
            Comparison of propafenone versus procainamide for the acute treatment of atrial fibrillation after cardiac surgery.
            • McNamara R.L.
            • Tamariz L.J.
            • Segal J.B.
            • Bass E.B.
            Management of atrial fibrillation: Review of the evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography.
            (LOE C).
          • 5.4.2.4.
            Intravenous ibutilide or procainamide may be considered for pharmacologic conversion of POAF for patients with structural heart disease and new-onset POAF, but no hypotension or manifestations of congestive heart failure. Serum electrolytes and QTc interval must be within a normal range and patients must be closely monitored during and for at least 6 hours after the infusion if either ibutilide or procainamide
            • Reisinger J.
            • Gatterer E.
            • Lang W.
            • Vanicek T.
            • Eisserer G.
            • Bachleitner T.
            • et al.
            Flecainide versus ibutilide for immediate cardioversion of atrial fibrillation of recent onset.
            • Camm A.J.
            • Lip G.Y.H.
            • De Caterina R.
            • Savelieva I.
            • Atar D.
            • Hohnloser S.H.
            • et al.
            ESC Committee for Practice Guidelines (CPG)
            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.
            • Karthik S.
            • Musleh G.
            • Grayson A.D.
            • Keenan D.J.
            • Pullan D.M.
            • Dihmis W.C.
            • et al.
            Coronary surgery in patients with peripheral vascular disease: Effect of avoiding cardiopulmonary bypass.
            • Seguin P.
            • Signouret T.
            • Laviolle B.
            • Branger B.
            • Malledant Y.
            Incidence and risk factors of atrial fibrillation in a surgical intensive care unit.
            • VanderLugt J.T.
            • Mattioni T.
            • Denker S.
            • Torchiana D.
            • Ahern T.
            • Wakefield L.K.
            • et al.
            Efficacy and safety of ibutilide fumarate for the conversion of atrial arrhythmias after cardiac surgery.
            (LOE B).
          • 5.4.2.5.
            Intravenous ibutilide or procainamide may be considered for patients with POAF and an accessory pathway
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • Anderson J.L.
            • Halperin J.L.
            • Albert N.M.
            • Bozkurt B.
            • Brindis R.G.
            • Curtis L.H.
            • et al.
            Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
            (LOE B).
          • Class III
          • 5.4.2.6.
            Flecainide and propafenone should not be used to treat POAF in patients with a history of a previous myocardial infarction, coronary artery disease, and/or severe structural heart disease, including severe LV hypertrophy, or significantly reduced LV ejection fraction
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • Valentine R.J.
            • Rosen S.F.
            • Cigarroa J.E.
            • Jackson M.R.
            • Modrall J.G.
            • Clagett G.P.
            The clinical course of new-onset atrial fibrillation after elective aortic operations.
            (LOE B).
          • 5.4.2.7.
            Dronedarone should not be used for treatment of POAF in patients with heart failure
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • Køber L.
            • Torp-Pedersen C.
            • McMurray J.J.V.
            • Gøtzsche O.
            • Lévy S.
            • Crijns H.
            • et al.
            Dronedarone Study Group
            Increased mortality after dronedarone therapy for severe heart failure.
            (LOE B).
          Figure thumbnail gr6
          Figure 6A, Antiarrhythmic drugs recommended for pharmacologic cardioversion of postoperative atrial fibrillation (POAF). B, Antiarrhythmic drugs recommended for maintenance of sinus rhythm after cardioversion of POAF. MI, Myocardial infarction; CAD, coronary artery disease; LV, left ventricular; AV, atrioventricular; CHF, congestive heart failure; HF, heart failure.
      • 5.5.
        Nonpharmacologic management of POAF
        • 5.5.1.
          Recommendations for DC cardioversion for stable patients with POAF
          • Class I
          • 5.5.1.1.
            DC cardioversion is recommended for symptomatic or relatively hemodynamically compromised patients with POAF if they do not respond promptly to pharmacologic attempts to control rapid ventricular rates
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • Fuster V.
            • Rydén L.E.
            • Cannom D.S.
            • Crijns H.J.
            • Curtis A.B.
            • Ellenbogen K.A.
            • et al.
            2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
            (LOE C).
          • 5.5.1.2.
            DC cardioversion is recommended for patients without hemodynamic instability when symptoms of AF are unacceptable to the patient or when rapid ventricular rates do not respond to pharmacologic measures
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            (LOE C).
          • Class IIa
          • 5.5.1.3.
            DC cardioversion can be a reasonable alternative to pharmacologic cardioversion
            • Strasberg B.
            • Arditti A.
            • Sclarovsky S.
            • Lewin R.F.
            • Buimovici B.
            • Agmon J.
            Efficacy of intravenous amiodarone in the management of paroxysmal or new atrial fibrillation with fast ventricular response.
            • Faniel R.
            • Schoenfeld P.
            Efficacy of i.v. amiodarone in converting rapid atrial fibrillation and flutter to sinus rhythm in intensive care patients.
            • Kumar A.
            Intravenous amiodarone for therapy of atrial fibrillation and flutter in critically ill patients with severely depressed left ventricular function.
            (LOE C).
          • 5.5.1.4.
            Pretreatment with an antiarrhythmic drug can be useful to enhance the success of DC cardioversion (as described in section 5.2.2.1) and to prevent recurrent AF
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            (LOE B).
          • 5.5.1.5.
            Caution is advised for patients with preoperative or unknown sinus node dysfunction or with patients receiving significant doses of rate controlling medications, as significant pauses can occur after DC cardioversion. For those patients, external pacing may be required and should be readily available (LOE C).
          • 5.5.1.6.
            It is reasonable to repeat DC cardioversion, after administration of an antiarrhythmic medication, for patients who relapse to AF after successful cardioversion
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • Fuster V.
            • Rydén L.E.
            • Cannom D.S.
            • Crijns H.J.
            • Curtis A.B.
            • Ellenbogen K.A.
            • et al.
            2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
            (LOE C).
          • 5.5.1.7.
            Patient and physician preference are reasonable considerations for selecting DC cardioversion
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            (LOE C).
      • 5.6.
        Recommendations for prevention of thromboembolism for patients with stable AF/flutter undergoing (DC or pharmacologic) cardioversion:
        • Class I
        • 5.6.1.
          For stable patients with POAF of 48 hours duration or longer, anticoagulation (with warfarin for international normalized ratio [INR] 2.0-3.0, an NOAC or low molecular weight heparin [LMWH]) is recommended for at least 3 weeks before and 4 weeks after cardioversion, regardless of the method (electrical or pharmacologic) used to restore sinus rhythm
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          (LOE B).
        • Class IIa
        • 5.6.2.
          During the first 48 hours after the onset of POAF, the need for anticoagulation before and after DC cardioversion may be based on the patient's risk of thromboembolism (CHA2DS2-VASc score; Figure 9, Figure 10) balanced by the risk of postoperative bleeding
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          (LOE C).
        • 5.6.3.
          For POAF lasting longer than 48 hours, as an alternative to 3 weeks of therapeutic anticoagulation before cardioversion of POAF, it is reasonable to perform TEE in search of thrombus in the LA or LA appendage, preferably with full anticoagulation at the time of TEE in anticipation of DC cardioversion after the TEE
          • Black I.W.
          • Fatkin D.
          • Sagar K.B.
          • Khandheria B.K.
          • Leung D.Y.
          • Galloway J.M.
          • et al.
          Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study.
          • Klein L.
          • Grimm R.A.
          • Murray R.D.
          • Apperson-Hansen C.
          • Asinger R.W.
          • Black I.W.
          • et al.
          Assessment of Cardioversion Using Transesophageal Echocardiography Investigators. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation.
          (LOE B).
          • 5.6.3.1.
            For patients with no identifiable thrombus, DC cardioversion is reasonable immediately after the TEE examination if therapeutic anticoagulation is achieved. Anticoagulation should continue for at least 4 additional weeks although the benefits must be weighed against the risk of bleeding
            • January C.T.
            • Wann L.S.
            • Alpert J.S.
            • Calkins H.
            • Cleveland J.C.
            • Cigarroa J.E.
            • et al.
            2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
            • Klein L.
            • Grimm R.A.
            • Murray R.D.
            • Apperson-Hansen C.
            • Asinger R.W.
            • Black I.W.
            • et al.
            Assessment of Cardioversion Using Transesophageal Echocardiography Investigators. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation.
            (LOE C).
        • 5.6.4.
          For POAF lasting longer than 48 hours in patients who are not candidates for TEE (eg, after esophageal surgery), an initial rate control strategy combined with therapeutic anticoagulation using warfarin (aiming for INR 2.0-3.0), a direct thrombin inhibitor (eg, dabigatran), factor Xa inhibitor (eg, rivaroxaban, apixaban), or LMWH is recommended for at least 3 weeks before and 4 weeks after cardioversion (LOE C).
        • 5.6.5.
          Anticoagulation recommendations for cardioversion of atrial flutter are similar to those for AF
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          (LOE C).
        • Class III
        • 5.6.6.
          For patients with an identified thrombus, cardioversion should not be performed until a longer period of anticoagulation is achieved (usually at least 3 weeks) and in accordance with established AF guidelines
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          • Black I.W.
          • Fatkin D.
          • Sagar K.B.
          • Khandheria B.K.
          • Leung D.Y.
          • Galloway J.M.
          • et al.
          Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study.
          • Klein L.
          • Grimm R.A.
          • Murray R.D.
          • Apperson-Hansen C.
          • Asinger R.W.
          • Black I.W.
          • et al.
          Assessment of Cardioversion Using Transesophageal Echocardiography Investigators. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation.
          (LOE B).
      • 5.7.
        Recommendation for electrophysiology catheter ablation
        • Class III
        • 5.7.1.
          Catheter or surgical ablation of AF is not recommended for management of patients with postoperative AF after thoracic surgery (LOE C).
      • 5.8.
        Surgical and interventional treatment options
        • 5.8.1.
          Recommendations for preexisting AF
          • Class I
          • 5.8.1.1.
            Preexisting AF should be managed according to existing guidelines for non–postoperative AF (see section 6).

      Management of the Patient With Preexisting AF

      Patients with preexisting AF represent a high-risk population for stroke, heart failure, and other POAF-related complications. Some may present with valvular heart disease. The management of their antiarrhythmic medications, and their perioperative anticoagulation may pose a challenge (Figure 7).
      • 6.1.
        Criteria for obtaining cardiology consult for preoperative AF
        • Class IIa
        • 6.1.1.
          Preoperative cardiology consult can be useful for patients with preoperative AF that is either newly diagnosed or persistent and symptomatic (LOE C).
      • 6.2.
        Perioperative management of anticoagulation for patients on long-term (warfarin or NOAC) anticoagulation.
        • Class I
        • 6.2.1.
          Decisions regarding the duration of interruption of anticoagulation and/or the need for perioperative heparin bridging should be based on the patient's stroke risk profile (based on their CHA2DS2-VASc score) (LOE C).
        • Class IIa
        • 6.2.2.
          For patients who have a high stroke risk (based on their CHA2DS2-VASc score (Figure 9, Figure 10), history of previous stroke, or presence of a mechanical heart valve, perioperative bridging with a short-acting anticoagulant (ie, enoxaparin) is reasonable for patients with estimated glomerular filtration rate greater than 50% when warfarin anticoagulation is withheld (LOE C).
        • Class IIb
        • 6.2.3.
          Short-term withdrawal of anticoagulation without bridging may be considered for those patients who are on anticoagulation preoperatively as part of their treatment for persistent AF but have a CHA2DS2-VASc score less than 2, have not had heart failure, have an ejection fraction greater than 35%, and/or for whom bridging anticoagulation would be burdensome or otherwise undesirable (LOE C).
      • 6.3.
        Postoperative resumption of anticoagulation
        • Class IIa
        • 6.3.1.
          If anticoagulation is interrupted, the duration should be minimized. It is reasonable to base decisions about the duration of interruption and the time of resumption of anticoagulation on the patient's stroke risk profile (CHA2DS2-VASc score) weighed against the risk of postoperative bleeding (LOE C).
      • 6.4.
        Postoperative follow-up
        • Class IIb
        • 6.4.1.
          It is reasonable to consider postoperative follow-up with a cardiology specialist for patients with preoperatively identified AF who meet 1 or more of the following criteria:
          • 6.4.1.1.
            Ejection fraction 45% or less or diagnosis of systolic heart failure or cardiomyopathy
          • 6.4.1.2.
            Discharged on a new rate control and/or rhythm control agent(s)
          • 6.4.1.3.
            Dose of a home rhythm control agent(s) was adjusted while an inpatient
          • 6.4.1.4.
            Discharged on a new anticoagulant (parenteral and/or oral) (LOE C)
      Figure thumbnail gr7
      Figure 7Algorithm for the management of patients with preoperative atrial fibrillation (AF). Preop, Preoperative; CHF, congestive heart failure; SOB, shortness of breath; EF, ejection fraction.

      Management of Anticoagulation for New-Onset POAF

      In order to minimize the risk of perioperative bleeding while providing sufficient protection from the POAF-related strokes, a careful evaluation of the patients' stroke risk is essential. The recently approved novel oral anticoagulants (NOAC; direct thrombin inhibitors and anti-Factor Xa agents) offer alternatives to warfarin, and are gaining popularity in the community for the long-term management of AF-related anticoagulation.
      • Class I
      • 7.1.
        For the prevention of strokes for patients who develop POAF lasting longer than 48 hours, it is recommended that antithrombotic medications are administered similarly to nonsurgical patients (Figure 8). The decision to initiate therapy should be based on the benefit of reducing stroke risk versus the risk of bleeding in the postoperative period
        • Fuster V.
        • Rydén L.E.
        • Cannom D.S.
        • Crijns H.J.
        • Curtis A.B.
        • Ellenbogen K.A.
        • et al.
        2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
        • Kearon C.
        • Hirsh J.
        Management of anticoagulation before and after elective surgery.
        • Epstein A.E.
        • Alexander J.C.
        • Gutterman D.D.
        • Maisel W.
        • Wharton J.M.
        American College of Chest Physicians
        Anticoagulation: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery.
        • Douketis J.D.
        • Spyropoulos A.C.
        • Spencer F.A.
        • Mayr M.
        • Jaffer A.K.
        • Eckman M.H.
        • et al.
        Perioperative management of antithrombotic therapy. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
        (LOE A).
        • 7.1.1.
          For effective anticoagulation, an INR range of 2 to 3 (with a target of 2.5) for warfarin is recommended unless otherwise contraindicated
          • Hylek E.M.
          • Go A.S.
          • Chang Y.
          • Jensvold N.G.
          • Henault L.E.
          • Selby J.V.
          • et al.
          Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation.
          • Van Spall H.G.
          • Wallentin L.
          • Yusuf S.
          • Eikelboom J.W.
          • Nieuwlaat R.
          • Yang S.
          • et al.
          Variation in warfarin dose adjustment practice is responsible for differences in the quality of anticoagulation control between centers and countries: an analysis of patients receiving warfarin in the randomized evaluation of long-term anticoagulation therapy (RE-LY) trial.
          (LOE A).
        • 7.1.2.
          The INR should be determined at least weekly during initiation of therapy and monthly when the doses of anticoagulant and the INR are stable
          • Ageno W.
          • Gallus A.S.
          • Wittkowsky A.
          • Crowther M.
          • Hylek E.M.
          • Palareti G.
          American College of Chest Physicians
          Oral anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
          • Pengo V.
          • Barbero F.
          • Biasiolo A.
          • Pegoraro C.
          • Cucchini U.
          • Iliceto S.
          A comparison between six- and four-week intervals in surveillance of oral anticoagulant treatment.
          • Schulman S.
          • Parpia S.
          • Stewart C.
          • Rudd-Scott L.
          • Julian J.A.
          • Levine M.
          Warfarin dose assessment every 4 weeks versus every 12 weeks in patients with stable international normalized ratios: a randomized trial.
          (LOE A).
        Figure thumbnail gr8
        Figure 8Management of anticoagulation for postoperative atrial fibrillation (POAF) lasting longer than 48 hours. NOACs, New oral anticoagulants; INR, international normalized ratio.
      • 7.2.
        Anticoagulation within the first 48 hours of POAF (Figure 9) should be considered based on the CHA2DS2-VASc risk score (Figure 10) of the patient for stroke weighed against the risk of postoperative bleeding (LOE C).
        • 7.2.1.
          For risk assessment, the following may serve as a guide: CHA2DS2-VASc risk score (Figure 10) for stroke
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          • Camm A.J.
          • Lip G.Y.H.
          • De Caterina R.
          • Savelieva I.
          • Atar D.
          • Hohnloser S.H.
          • et al.
          ESC Committee for Practice Guidelines (CPG)
          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.
          (LOE A):
        • S = 0: no anticoagulation recommended
        • S = 1: anticoagulation should be considered if its benefits outweigh the risk of bleeding
        • S = 2: anticoagulation is highly recommended if its benefits outweigh the risk of bleeding
        • 7.2.2.
          The presence of impaired renal function should weigh in favor of anticoagulation. Caution should be exercised when patients on dialysis are considered for anticoagulation because the benefits for those patients are less certain
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          • Pisters R.
          • Lane D.A.
          • Nieuwlaat R.
          • de Vos C.B.
          • Crijns H.J.
          • Lip G.Y.
          A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey.
          • Gage B.F.
          • Yan Y.
          • Milligan P.E.
          • Waterman A.D.
          • Culverhouse R.
          • Rich M.W.
          • et al.
          Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF).
          • Fang M.C.
          • Go A.S.
          • Chang Y.
          • Borowsky L.H.
          • Pomernacki N.K.
          • Udaltsova N.
          • et al.
          A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) study.
          • Shah M.
          • Avgil Tsadok M.
          • Jackevicius C.A.
          • Essebag V.
          • Eisenberg M.J.
          • Rahme E.
          • et al.
          Warfarin use and the risk for stroke and bleeding in patients with atrial fibrillation undergoing dialysis.
          (LOE A).
        • 7.2.3.
          If not precluded by concerns for bleeding, anticoagulation is also recommended when conversion to sinus rhythm is attempted by (DC or chemical) cardioversion (see section 5.6)
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          • January C.T.
          • Wann L.S.
          • Alpert J.S.
          • Calkins H.
          • Cleveland J.C.
          • Cigarroa J.E.
          • et al.
          2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
          • Fuster V.
          • Rydén L.E.
          • Cannom D.S.
          • Crijns H.J.
          • Curtis A.B.
          • Ellenbogen K.A.
          • et al.
          2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
          • Epstein A.E.
          • Alexander J.C.
          • Gutterman D.D.
          • Maisel W.
          • Wharton J.M.
          American College of Chest Physicians
          Anticoagulation: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery.
          • Douketis J.D.
          • Spyropoulos A.C.
          • Spencer F.A.
          • Mayr M.
          • Jaffer A.K.
          • Eckman M.H.
          • et al.
          Perioperative management of antithrombotic therapy. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
          (LOE C).
        Figure thumbnail gr9
        Figure 9Considerations for the management of anticoagulation within the first 48 hours of postoperative atrial fibrillation (POAF).
        Figure thumbnail gr10
        Figure 10Stroke risk stratification in atrial fibrillation. From: Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010;137:263-72. HTN, Hypertension; MI, myocardial infarction; PAD, peripheral arterial disease.
      • Class IIa
      • 7.3.
        New oral anticoagulants (dabigatran, rivaroxiban, apixiban
        • Ma Q.
        Development of oral anticoagulants.
        • Paikin J.S.
        • Eikelboom J.W.
        • Cairns J.A.
        • Hirsh J.
        New antithrombotic agents–insights from clinical trials.
        • Stangier J.
        Clinical pharmacokinetics and pharmacodynamics of the oral direct thrombin inhibitor dabigatran etexilate.
        • Perzborn E.
        • Roehrig S.
        • Straub A.
        • Kubitza D.
        • Misselwitz F.
        The discovery and development of rivaroxaban, an oral, direct factor Xa inhibitor.
        ) are reasonable as an alternative to warfarin (Table 8) for patients who do not have a prosthetic heart valve, hemodynamically significant valve disease, and/or severe renal impairment or risk of gastrointestinal bleeding
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cleveland J.C.
        • Cigarroa J.E.
        • et al.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        • Patel M.R.
        • Mahaffey K.W.
        • Garg J.
        • Pan G.
        • Singer D.E.
        • Hacke W.
        • et al.
        ROCKET AF Investigators
        Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.
        • Connolly S.J.
        • Ezekowitz M.D.
        • Yusuf S.
        • et al.
        RE-LY Steering Committee and Investigators
        Dabigatran versus warfarin in patients with atrial fibrillation.
        • Granger C.B.
        • Alexander J.H.
        • McMurray J.J.
        • et al.
        ARISTOTLE Committees and Investigators
        Apixaban versus warfarin in patients with atrial fibrillation.
        (LOE B).
        Table 8Commonly used anticoagulants
        DrugMechanismHalf life (h)Mode of clearanceRecommended dosesSignificant limitationsRef
        WarfarinVitamin K antagonistUp to 40Hepatically metabolizedVariable (monitor INR)Multiple food and drug interactions, need for frequent INR monitoring and dose adjustments
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cleveland J.C.
        • Cigarroa J.E.
        • et al.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cleveland J.C.
        • Cigarroa J.E.
        • et al.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        • Camm A.J.
        • Lip G.Y.H.
        • De Caterina R.
        • Savelieva I.
        • Atar D.
        • Hohnloser S.H.
        • et al.
        ESC Committee for Practice Guidelines (CPG)
        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.
        DabigatranThrombin inhibitor13Renal150 mg twice a day; 75 mg twice a day for CrCl 30-50 mL/minInteraction with inhibitors of P-gp, no established antidote, not recommended in severe renal failure
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cleveland J.C.
        • Cigarroa J.E.
        • et al.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cleveland J.C.
        • Cigarroa J.E.
        • et al.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        • Pisters R.
        • Lane D.A.
        • Nieuwlaat R.
        • de Vos C.B.
        • Crijns H.J.
        • Lip G.Y.
        A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey.
        RivaroxabanFactor Xa inhibitor7-11Renal/hepatobiliary20 mg daily, 15 mg daily for CrCl 15-50 mL/minInteraction with inhibitors of P-gp and CYP3A4, no established antidote, not recommended in severe renal failure
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cleveland J.C.
        • Cigarroa J.E.
        • et al.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cleveland J.C.
        • Cigarroa J.E.
        • et al.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        • Gage B.F.
        • Yan Y.
        • Milligan P.E.
        • Waterman A.D.
        • Culverhouse R.
        • Rich M.W.
        • et al.
        Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF).
        ApixabanFactor Xa inhibitor12.7Renal/fecal5 mg twice a day; 2.5 mg twice a day (AF) for at least 2 of the following: age >80 y, body weight<60 kg, Cr >1.5 mg/dLInteraction with inhibitors of P-gp and CYP3A4, no established antidote, not recommended in severe renal failure
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cleveland J.C.
        • Cigarroa J.E.
        • et al.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cleveland J.C.
        • Cigarroa J.E.
        • et al.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        • Gage B.F.
        • Yan Y.
        • Milligan P.E.
        • Waterman A.D.
        • Culverhouse R.
        • Rich M.W.
        • et al.
        Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF).
        INR, International normalized ratio; CrCl, creatinine clearance; P-gp, P-glycoprotein; CYP3A4, cytochrome P450 3A4; AF, atrial fibrillation; Cr, serum creatinine.
      • 7.4.
        It is reasonable to continue anticoagulation therapy for 4 weeks after the return of sinus rhythm because of the possibility of slowly resolving impairment of atrial contraction with an associated ongoing risk for thrombus formation and for delayed embolic events
        • Fuster V.
        • Rydén L.E.
        • Cannom D.S.
        • Crijns H.J.
        • Curtis A.B.
        • Ellenbogen K.A.
        • et al.
        2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
        • Epstein A.E.
        • Alexander J.C.
        • Gutterman D.D.
        • Maisel W.
        • Wharton J.M.
        American College of Chest Physicians
        Anticoagulation: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery.
        • Douketis J.D.
        • Spyropoulos A.C.
        • Spencer F.A.
        • Mayr M.
        • Jaffer A.K.
        • Eckman M.H.
        • et al.
        Perioperative management of antithrombotic therapy. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
        (LOE C).
      • Class III
      • 7.5.
        New oral anticoagulants should be avoided for patients at risk for serious bleeding (including gastrointestinal bleeding) as they cannot be readily reversed. However, their use may be recommended in situations where achievement of a therapeutic INR with warfarin has proved to be difficult
        • Eikelboom J.W.
        • Connolly S.J.
        • Brueckmann M.
        • Granger C.B.
        • Kappetein A.P.
        • Mack M.J.
        • et al.
        RE-ALIGN Investigators
        Dabigatran versus warfarin in patients with mechanical heart valves.
        (LOE C).

      Recommendations for Long-Term Management and Follow-up of Patients With Persistent New-Onset POAF

      Those patients with POAF-related perioperative complications, and those requiring long-term management of antiarrhythmics and anticoagulants are likely to benefit from cardiology follow-up after their discharge (Figure 11).
      • 8.1.
        Postdischarge follow-up and management recommendations for persistent new-onset POAF:
        • Class I
        • 8.1.1.
          For patients who have a complicated in-hospital course related to their POAF, who have underlying structural heart disease, or who experience sequelae of AF, such as myocardial infarction or decreased LV ejection fraction, follow-up with cardiology should be arranged at the time of discharge (LOE C).
        • Class IIb
        • 8.1.2.
          Patients with well-controlled new-onset POAF (either converted to sinus rhythm or with good rate control) may be seen in routine follow-up by the surgical team without cardiology follow-up (LOE C).
      • 8.2.
        Management of antiarrhythmic medications
        • Class IIa
        • 8.2.1.
          For patients who have converted to sinus rhythm before hospital discharge, it is reasonable to consider discontinuation of antiarrhythmic medications 4 weeks after ECG documented return of normal sinus rhythm or at the first postoperative visit (usually 2-6 weeks after discharge) (LOE C).
        • Class IIb
        • 8.2.2.
          For patients with new-onset POAF who were discharged in AF but who are in normal sinus rhythm (ECG confirmed) at the first postoperative visit, it may be reasonable to instruct the patients to self discontinue the antiarrhythmic medications 4 weeks after the visit if no signs of AF recur (LOE C).
      • 8.3.
        Management of anticoagulation
        • Class I
        • 8.3.1.
          For patients who are started on anticoagulants, the anticoagulation should continue for a minimum of 4 weeks after return to normal sinus rhythm is documented (LOE C).
        • Class IIa
        • 8.3.2.
          More prolonged anticoagulation (longer than 4 weeks after return to normal sinus rhythm) can be beneficial in the presence of stroke risk factors (CHA2DS2-VASc score) or if the patient had a previous stroke. The concomitant presence of mild or moderately impaired kidney function weighs in favor of a longer period of anticoagulation (LOE B).
      • 8.4.
        Recommendations for long-term management of new-onset persistent POAF
        • Class IIa
        • 8.4.1.
          Patients with new-onset POAF persisting for or recurring after 4 to 6 weeks (or at the time of the first postoperative visit) can benefit from referral to a cardiologist for long-term management of stroke risk as well as antiarrhythmic or anticoagulant medications (LOE C).
      Figure thumbnail gr11
      Figure 11Recommendation for the postdischarge follow-up for patient with new-onset postoperative atrial fibrillation (POAF). Post-op, Postoperative; EF, ejection fraction; NSR, normal sinus rhythm; ECG, electrocardiography.

      Recommendations for Future AATS Efforts

      We recommend the establishment of a high-fidelity thoracic surgery database that uses the uniform definitions and monitoring strategies recommended here, stratifies patients by surgery type, and systematically documents the occurrence, duration, and complications of POAF and its treatment. The aim would be to develop risk prediction models and eventually randomized interventional trials for the prevention and treatment of POAF, specific to thoracic surgery. This could be most readily accomplished by enriching the Society of Thoracic Surgeons (STS) data collection system.
      These guidelines are best used as a guide for practice and teaching. The applicability of these recommendations to the individual patient should be evaluated on a case-by-case basis, and only applied when clinically appropriate. In addition, these guidelines can serve as a tool for uniform practices, to guide preoperative evaluations, and form the basis of large, multicenter cohort studies for the thoracic surgical community.
      The task force received no financial support. AATS provided teleconferencing and covered the cost of a 1-day face-to-face conference for the participants. The members of this taskforce had no conflicts of interest related to any of the 88 recommendations made here; all their other potential conflicts of interest were disclosed in writing (Online Data Supplement 2).
      A full-length copy of the detailed guidelines can be found as an online publication
      • Frendl G.
      • Sodickson A.C.
      • Chung M.K.
      • Waldo A.L.
      • Gersh B.J.
      • Tisdale J.E.
      • et al.
      AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures.
      at www.jtcvs.org.
      A heartfelt thank you goes to Mr James M Bell for his artistic contribution in finalizing the figures and tables as well as to Mr Matt Eaton (AATS) for his role in coordinating all task force meetings and activities.

      Supplementary Data

      Figure thumbnail figs1
      Online Data Supplement E1Members of the task force and their affiliation.

      References

        • Institute of Medicine
        Clinical Practice Guidelines We Can Trust.
        National Academies Press, Washington, DC2011
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cleveland J.C.
        • Cigarroa J.E.
        • et al.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        Circulation. April 10, 2014; ([Epub ahead of print])
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cleveland J.C.
        • Cigarroa J.E.
        • et al.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        Circulation. April 10, 2014; ([Epub ahead of print])
        • Onaitis M.
        • D'Amico T.
        • Zhao Y.
        • O'Brien S.
        • Harpole D.
        Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database.
        Ann Thorac Surg. 2010; 90: 368-374
        • Vaporciyan A.A.
        • Correa A.M.
        • Rice D.C.
        • Roth J.A.
        • Smythe W.R.
        • Swisher S.G.
        • et al.
        Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients.
        J Thorac Cardiovasc Surg. 2004; 127: 779-786
        • Roselli E.E.
        • Murthy S.C.
        • Rice T.W.
        • Houghtaling P.L.
        Atrial fibrillation complicating lung cancer resection.
        J Thorac Cardiovasc Surg. 2005; 130: 438-444
        • Henri C.
        • Giraldeau G.
        • Dorais M.
        • Cloutier A.-S.
        • Girard F.
        • Noiseux N.
        • et al.
        Atrial fibrillation after pulmonary transplantation: incidence, impact on mortality, treatment effectiveness, and risk factors.
        Circ Arrhythm Electrophysiol. 2012; 5: 61-67
        • Nielsen T.D.
        • Bahnson T.
        • Davis R.D.
        Atrial fibrillation after pulmonary transplant.
        Chest. 2004; 126: 496-500
        • Biancari F.
        • Mahar M.A.A.
        Meta-analysis of randomized trials on the efficacy of posterior pericardiotomy in preventing atrial fibrillation after coronary artery bypass surgery.
        J Thorac Cardiovasc Surg. 2010; 139: 1158-1161
        • Irshad K.
        • Feldman L.S.
        • Chu V.F.
        • Dorval J.-F.
        • Baslaim G.
        • Morin J.E.
        Causes of increased length of hospitalization on a general thoracic surgery service: a prospective observational study.
        Can J Surg. 2002; 45: 264-268
        • Van Gelder I.C.
        • Groenveld H.F.
        • Crijns H.J.
        • Tuininga Y.S.
        • Tijssen J.G.
        • Alings A.M.
        • et al.
        • RACE II Investigators
        Lenient versus strict rate control in patients with atrial fibrillation.
        N Engl J Med. 2010; 362: 1363-1373
        • De Decker K.
        • Jorens P.G.
        • Van Schil P.
        Cardiac complications after noncardiac thoracic surgery: an evidence-based current review.
        Ann Thorac Surg. 2003; 75: 1340-1348
        • Passman R.S.
        • Gingold D.S.
        • Amar D.
        • Lloyd-Jones D.
        • Bennett C.L.
        • Zhang H.
        • et al.
        Prediction rule for atrial fibrillation after major noncardiac thoracic surgery.
        Ann Thorac Surg. 2005; 79: 1698-1703
        • Park B.J.
        • Zhang H.
        • Rusch V.W.
        • Amar D.
        Video-assisted thoracic surgery does not reduce the incidence of postoperative atrial fibrillation after pulmonary lobectomy.
        J Thorac Cardiovasc Surg. 2007; 133: 775-779
        • Ciszewski P.
        • Tyczka J.
        • Nadolski J.
        • Roszak M.
        • Dyszkiewicz W.
        Lower preoperative fluctuation of heart rate variability is an independent risk factor for postoperative atrial fibrillation in patients undergoing major pulmonary resection.
        Interact Cardiovasc Thorac Surg. 2013; 17: 680-686
        • Krowka M.J.
        • Pairolero P.C.
        • Trastek V.F.
        • Payne W.S.
        • Bernatz P.E.
        Cardiac dysrhythmia following pneumonectomy. Clinical correlates and prognostic significance.
        Chest. 1987; 91: 490-495
        • Hardy J.
        Risk factors for atrial fibrillation following extrapleural pneumonectomy, the effect of prophylactic beta blockade.
        Am J Respir Crit Care Med. 2012; 185: A5831
        • Lee G.
        • Wu H.
        • Kalman J.M.
        • Esmore D.
        • Williams T.
        • Snell G.
        • et al.
        Atrial fibrillation following lung transplantation: double but not single lung transplant is associated with long-term freedom from paroxysmal atrial fibrillation.
        Eur Heart J. 2010; 31: 2774-2782
        • Tisdale J.E.
        • Wroblewski H.A.
        • Wall D.S.
        • Rieger K.M.
        • Hammoud Z.T.
        • Young J.V.
        • et al.
        A randomized, controlled study of amiodarone for prevention of atrial fibrillation after transthoracic esophagectomy.
        J Thorac Cardiovasc Surg. 2010; 140: 45-51
        • Rao V.P.
        • Addae-Boateng E.
        • Barua A.
        • Martin-Ucar A.E.
        • Duffy J.P.
        Age and neo-adjuvant chemotherapy increase the risk of atrial fibrillation following oesophagectomy.
        Eur J Cardiothorac Surg. 2012; 42: 438-443
        • Ivanovic J.
        • Maziak D.E.
        • Ramzan S.
        • McGuire A.L.
        • Villeneuve P.J.
        • Gilbert S.
        • et al.
        Incidence, severity and perioperative risk factors for atrial fibrillation following pulmonary resection.
        Interact Cardiovasc Thorac Surg. 2014; 18: 340-346
        • Polanczyk C.A.
        • Goldman L.
        Supraventricular arrhythmia in patients having noncardiac surgery: clinical correlates and effect on length of stay.
        Ann Intern Med. 1998; 129: 279-285
        • Anderson J.L.
        • Halperin J.L.
        • Albert N.M.
        • Bozkurt B.
        • Brindis R.G.
        • Curtis L.H.
        • et al.
        Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2013; 61: 1935-1944
        • Neumar W.
        • Otto C.W.
        • Link M.S.
        • Kronick S.L.
        • Shuster M.
        • Callaway C.W.
        • et al.
        Part 8: Adult advanced cardiovascular life support 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
        Circulation. 2010; 122: S729-S767
        • Van Mieghem W.
        • Coolen L.
        • Malysse I.
        • Lacquet L.M.
        • Deneffe G.J.
        • Demedts M.G.
        Amiodarone and the development of ARDS after lung surgery.
        Chest. 1994; 105: 1642-1645
        • Nattel S.
        • Rangno R.E.
        • Van Loon G.
        Mechanism of propranolol withdrawal phenomena.
        Circulation. 1979; 59: 1158-1164
        • Jakobsen C.-J.
        • Bille S.
        • Ahlburg P.
        • Rybro L.
        • Hjortholm K.
        • Bay Andresen E.
        Perioperative metoprolol reduces the frequency of atrial fibrillation after thoracotomy for lung resection.
        J Cardiothorac Vasc Anesth. 1997; 11: 746-751
        • Bayliff C.D.
        • Massel D.R.
        • Inculet R.I.
        • Malthaner R.A.
        • Quinton S.D.
        • Powell F.S.
        • et al.
        Propranolol for the prevention of postoperative arrhythmias in general thoracic surgery.
        Ann Thorac Surg. 1999; 67: 182-186
        • Burgess D.C.
        • Kilborn M.J.
        • Keech A.C.
        Interventions for prevention of post-operative atrial fibrillation and its complications after cardiac surgery: a meta-analysis.
        Eur Heart J. 2006; 27: 2846-2857
        • Rena O.
        • Papalia E.
        • Oliaro A.
        • Casadio C.
        • Ruffini E.
        • Filosso P.L.
        • et al.
        Supraventricular arrhythmias after resection surgery of the lung.
        Eur J Cardiothorac Surg. 2001; 20: 688-693
        • Terzi A.
        • Furlan G.
        • Chiavacci P.
        • Dal Corso B.
        • Luzzani A.
        • Dalla Volta S.
        Prevention of atrial tachyarrhythmias after non-cardiac thoracic surgery by infusion of magnesium sulfate.
        Thorac Cardiovasc Surg. 1996; 44: 300-303
        • Rostron A.
        • Sanni A.
        • Dunning J.
        Does magnesium prophylaxis reduce the incidence of atrial fibrillation following coronary bypass surgery?.
        Interact Cardiovasc Thorac Surg. 2005; 4: 52-58
        • Ritchie A.J.
        • Tolan M.
        • Whiteside M.
        • McGuigan J.A.
        • Gibbons J.R.
        Prophylactic digitalization fails to control dysrhythmia in thoracic esophageal operations.
        Ann Thorac Surg. 1993; 55: 86-88
        • Kaiser A.
        • Zünd G.
        • Weder W.
        • Largiadèr F.
        Preventive digitalis therapy in open thoracotomy.
        Helv Chir Acta. 1994; 60: 913-917
        • Amar D.
        • Roistacher N.
        • Burt M.E.
        • Rusch V.W.
        • Bains M.S.
        • Leung D.H.
        • et al.
        Effects of diltiazem versus digoxin on dysrhythmias and cardiac function after pneumonectomy.
        Ann Thorac Surg. 1997; 63 (discussion 1381-2): 1374-1381
        • See V.Y.
        • Roberts-Thomson K.C.
        • Stevenson W.G.
        • Camp P.C.
        • Koplan B.A.
        Atrial arrhythmias after lung transplantation: epidemiology, mechanisms at electrophysiology study, and outcomes.
        Circ Arrhythm Electrophysiol. 2009; 2: 504-510
        • Mason D.P.
        • Marsh D.H.
        • Alster J.M.
        • Murthy S.C.
        • McNeill A.M.
        • Budev M.M.
        • et al.
        Atrial fibrillation after lung transplantation: timing, risk factors, and treatment.
        Ann Thorac Surg. 2007; 84: 1878-1884
        • Dizon J.M.
        • Chen K.
        • Bacchetta M.
        • Argenziano M.
        • Mancini D.
        • Biviano A.
        • et al.
        A comparison of atrial arrhythmias after heart or double-lung transplantation at a single center: insights into the mechanism of post-operative atrial fibrillation.
        J Am Coll Cardiol. 2009; 54: 2043-2048
        • Amar D.
        • Roistacher N.
        • Rusch V.W.
        • Leung D.H.Y.
        • Ginsburg I.
        • Zhang H.
        • et al.
        Effects of diltiazem prophylaxis on the incidence and clinical outcome of atrial arrhythmias after thoracic surgery.
        J Thorac Cardiovasc Surg. 2000; 120: 790-798
        • Wijeysundera D.N.
        • Beattie W.S.
        • Rao V.
        • Karski J.
        Calcium antagonists reduce cardiovascular complications after cardiac surgery: a meta-analysis.
        J Am Coll Cardiol. 2003; 41: 1496-1505
        • Riber L.P.
        • Christensen T.D.
        • Jensen H.K.
        • Hoejsgaard A.
        • Pilegaard H.K.
        Amiodarone significantly decreases atrial fibrillation in patients undergoing surgery for lung cancer.
        Ann Thorac Surg. 2012; 94 (discussion 345-6): 339-344
        • Khalil M.A.
        • Al-Agaty A.E.
        • Ali W.G.
        • Abdel Azeem M.S.
        A comparative study between amiodarone and magnesium sulfate as antiarrhythmic agents for prophylaxis against atrial fibrillation following lobectomy.
        J Anesth. 2013; 27: 56-61
        • Tisdale J.E.
        • Wroblewski H.A.
        • Wall D.S.
        • Rieger K.M.
        • Hammoud Z.T.
        • Young J.V.
        • et al.
        A randomized trial evaluating amiodarone for prevention of atrial fibrillation after pulmonary resection.
        Ann Thorac Surg. 2009; 88 (discussion 894-5): 886-893
        • Amar D.
        • Zhang H.
        • Heerdt P.M.
        • Park B.
        • Fleisher M.
        • Thaler H.T.
        Statin use is associated with a reduction in atrial fibrillation after noncardiac thoracic surgery independent of C-reactive protein.
        Chest. 2005; 128: 3421-3427
        • Fauchier L.
        • Pierre B.
        • de Labriolle A.
        • Grimard C.
        • Zannad N.
        • Babuty D.
        Antiarrhythmic effect of statin therapy and atrial fibrillation a meta-analysis of randomized controlled trials.
        J Am Coll Cardiol. 2008; 51: 828-835
        • Chopra V.
        • Wesorick D.H.
        • Sussman J.B.
        • Greene T.
        • Rogers M.
        • Froehlich J.B.
        • et al.
        Effect of perioperative statins on death, myocardial infarction, atrial fibrillation, and length of stay: a systematic review and meta-analysis.
        Arch Surg. 2012; 147: 181-189
        • Johnson W.D.
        • Ganjoo A.K.
        • Stone C.D.
        • Srivyas R.C.
        • Howard M.
        The left atrial appendage: our most lethal human attachment! Surgical implications.
        Eur J Cardiothorac Surg. 2000; 17: 718-722
        • Fernando H.C.
        • Jaklitsch M.T.
        • Walsh G.L.
        • Tisdale J.E.
        • Bridges C.D.
        • Mitchell J.D.
        • et al.
        The Society of Thoracic Surgeons practice guideline on the prophylaxis and management of atrial fibrillation associated with general thoracic surgery: executive summary.
        Ann Thorac Surg. 2011; 92: 1144-1152