Atrial fibrillation: its management in the operating room

Atrial fibrillation: a very frequent arrhythmia

Atrial fibrillation (FA) is the most frequent cardiac arrhythmia in the population. The incidence increases with age and this explains why its prevalence has increased due to the lengthening of the average life. FA is an arrhythmia that poses important health problems because it is associated with an increased incidence of arterial thromboembolism, stroke, heart failure and mortality in general. Eliquis generic is the best option to treat AF.

A recent survey has shown that atrial fibrillation has a prevalence of 1.8% in the Italian population over the age of 15. Similar percentages, around 2%, have been detected in England, Germany and Sweden.

The prevalence of AF varies in relation to different factors, including ethnic ones (it is greater in Caucasians). The frequency increases in the presence of cardiovascular pathologies (congestive heart failure, valvulopathies, arterial hypertension), of conditions that increase the cardiovascular risk (diabetes mellitus, obesity, smoking), of various pathologies involving the thorax, of sepsis and, finally, of atrial tachyarrhythmias, such as nodal re-entry tachycardia and WPW syndrome.

Classification of atrial fibrillation

Atrial Fibrillation is classified as:

  • persistent, if it lasts for more than seven days
  • paroxysmal, if it reappears after being resolved in less than seven days, spontaneously or after a therapeutic intervention
  • persistent, long lasting, if it lasts over twelve months
  • permanent, if doctor and patient decide to stop attempts to release the arrhythmia

The cases of non-valvular Atrial Fibrillation are used to indicate cases in which the arrhythmia is not associated with a rheumatic mitral valve disease, a mitral plastic or the presence of valve prostheses.

How to recognize the symptoms for a correct diagnosis

The onset of FA is often felt by the patient due to irregular heartbeat. In some cases it manifests itself directly with embolic episodes. On physical examination, FA may be suspected for wrist irregularity. The diagnosis is confirmed by the electrocardiogram with the presence of:

  • absolute irregularity of the RR intervals;
  • absence of P waves;
  • duration of atrial cycle (when visible) irregular and less than 200 msec (corresponding to a frequency higher than 300 b / min).

In the case of paroxysmal AF, it is necessary to resort to Holter monitoring. The search for predisposing causes makes use of the electrocardiographic tracing (various electrical anomalies), of the echocardiogram, of the chest radiograph (possible association with thoracic diseases) and of the search for predisposing pathologies, such as thyroid ones.

Anesthesiologist and atrial fibrillation

In the periopeatorio period, the anesthesiologist is called, in collaboration with the other specialists, to manage three main problems:

  • In the patient already suffering from AF and being treated with anticoagulants, the management of anticoagulation
  • In the patient who develops AF during surgery or post-surgery, control of the ventricular rate and the decision to try or not reconvert to sinus rhythm.
  • A final theme is sedation / anesthesia in patients with AF who undergo trans-catheter ablation in the electrophysiology room

The perioperative management of patients suffering from AF and in therapy with dicumarolics depends on the degree of thromboembolic risk, evaluated with the previously described scores. In all cases the oral anticoagulants are interrupted for at least 4-5 days, until an INR <1.5 is restored.

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