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- J Cardiothorac Surg
- v.19; 2024
- PMC11295644
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J Cardiothorac Surg. 2024; 19: 479.
Published online 2024 Aug 2. doi:10.1186/s13019-024-02926-1
PMCID: PMC11295644
PMID: 39090642
Ozan Erturk,
1 Mert Ilker Hayıroglu,2 Anıl Karaagac,1 Yusuf Kagan Pocan,1 Mehmet Inanc Yesilkaya,1 Burak Bozkurt,1 Hakkı Aydogan,1 and Mehmet Kaplan1
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Associated Data
- Data Availability Statement
Abstract
Background
Atrial fibrillation (AF) is the most common complication after Coronary Artery Bypass Surgery (CABG). Despite advanced treatment methods, primary prevention is crucial. Many factors have been investigated as markers for AF, but further research is required.
CABG is currently superior to Primary Coronary Intervention (PCI) in some cases due to Left Anterior Descending Artery (LAD)- Internal Thoracic Artery (ITA) anastomosis. However, graft choice for non-LAD vessels is still controversial. Our study compared the incidence of arrhythmia between patients with single ITA or bilateral ITA (BITA).
Methods
The study included 84 isolated CABG patients. The patients were divided into two groups: single ITA and BITA. Patients who developed AF were recorded and compared.
Results
73.8%(n = 62) of the patients were male and 26.2%(n = 22) were female. While single ITA was used in 48.8%(n = 41) of the patients, BITA was used in 51.2%(n = 43). AF was detected in 15.5%(n = 13) of the patients. AF was observed in 5(12.2%) patients in the single ITA group and 8(18.6%) in the BITA group. 76.9%(n = 10) of the patients with AF rhythm had Diabetes Mellitus (DM)(p = 0.011). Biphasic P wave, length of P wave duration, and total Morpholog-Voltage-P Wave ECG (MVP ECG) score height were statistically significantly different.
Conclusions
The development of AF was similar in both groups. The presence of DM, high blood glucose levels, and ECG findings can detect a predisposition to postoperative AF. MVP ECG risk score is effective as an AF marker and can be used in surgical patient groups.
Introduction
Arrhythmias are frequent complications after coronary artery bypass surgery (CABG) that can cause severe morbidities or mortalities. Atrial Fibrillation (AF) is the most common postoperative arrhythmia and can be seen in a wide range, like %10–65 in isolated CABG patients [1–3]. Besides the risks of cerebrovascular diseases, peripheral and visceral embolism, and postoperative low cardiac output syndrome, it causes a severe increase in national healthcare expenses. Although there are many studies and improvements in arrhythmia management, primary prevention is still the most critical part of this struggle. For that purpose, it is crucial to detect the patients who are predisposed to arrhythmia and need more aggressive prevention. Many comorbid diseases, laboratory parameters, transthoracic echocardiography (TTE), and electrocardiography (ECG) measurements that are thought to be related to AF have been investigated to detect these patients. In particular, the Morphology-Voltage-P Wave ECG (MVP ECG) risk score, recently used to predict AF, stands out as an indirect indicator of atrial conductance. Although some have high predictive value, further investigations are needed for routine usage.
CABG is a Class IA recommendation in current guidelines and superior to primary percutaneous interventions (PCI) in some instances [4]. The main factor of this superiority is the left anterior descending artery (LAD) – internal thoracic artery (ITA) anastomosis and its long-term patency rates. Graft choice of other stenotic arteries is controversial. Full arterial revascularization has stood out in recent years. Current guidelines recommend bilateral ITA (BITA) use with Class IIA for experienced surgeons and suitable patients whose sternal wound complication risks are lower [4]. Right ITA (RITA)' s 10years patency rate is %90 overall, %95 for LAD anastomosis, %91 for circumflex coronary artery (CX), and %84 for right coronary artery (RCA) [5]. Our clinical observations hypothesized that even though BITA grafts have better patency rates over saphenous vein grafts, they can cause arrhythmia due to their high vasoreactivity potentials. In this study, we designed upon this hypothesis to compare post-operative arrhythmia incidence of single ITA or BITA-used patients. We evaluated the efficacy of AF predictor markers in post-operative AF (POAF) patients.
Methods
Patient population
Eighty-four isolated CABG patients with acute coronary syndrome who operated in our hospital between June 2021 and April 2022 were included in this study. Exclusion criteria included the following basis: (a) patients younger than 20 and older than 80years old; (b) patients who had preoperative arrhythmia; (c) no arterial graft usage; (d) accompanying other intrathoracic surgeries; (e) having preoperative thyroid disease; (f) previous myocardial infarction.
Patients grouped as single ITA or BITA were used. Graft choice was made based on the patient's age, the severity of coronary artery lesions, native coronary vasculatures, body structures, comorbidities, and graft qualities. Preoperative demographic data, laboratory results, comorbidities, ECG, and TTE measurements of patients were recorded. Patients were observed prospectively over the post-operative period. Preoperative, post-operative 1. hour, 1. day, and 1. week ECG recordings documented. Extra ECG recordings are for symptomatic patients with dyspnea, hypotension, or palpitation. Routine post-operative 1. week TTE measurements were made. Newly onset arrhythmias were recorded. AF was defined according to current guidelines [6].
All patients who developed AF rhythm were classified according to their hemodynamic stability. As initial treatment, amiodarone was administered as a rapid infusion of 300mg to hemodynamically stable patients, followed by a 24-h maintenance infusion of 900mg. After 24h, IV treatment was terminated, and oral amiodarone administration was started. No additional medication was administered to patients whose rhythm and rate were controlled. In patients whose rate control could not be achieved (> 110/min), oral metoprolol (50mg) was additionally given. In patients with hemodynamic instability, cardioversion was performed accompanied by amiodarone infusion. All AF patients were determined as first diagnosed paroxysmal AF and were converted to sinus rhythm within seven days.
Data gathering
Preoperative medications, comorbidities, and demographic data were recorded by face-to-face anamnesis. Laboratory results and intraoperative data were noted.
All ECG measurements are obtained from semiautomatic analyses of standard 12-lead ECG (25mm/s, 10mm/mV) converted to digital images and amplified 6–10 × by EP Calipers software version 3.6.1. P wave duration, morphology, and amplitude were measured from preoperative ECGs. The presence of interatrial block (IAB) was investigated. All patients were classified by MVP ECG risk score.
TTE studies were acquired on a GEVivid E95 unit (GE Healthcare; Vingmed Ultrasound, Horten, Norway) equipped with an M5S probe (frequency: 1.5–4.6MHz).
MVP ECG Risk score
MVP ECG Risk Score examines three factors. Each factor has points for specific situations. Eventually, the sum of points determines the AF risk of patients.
a
P Wave Morphology
P wave elongation is accepted as evidence for atrial depolarization transmission delay and is valuable for atrial arrhythmia development. Elongation in the P wave (≥ 120ms) is defined as partial IAB; either the P wave is regular in shape or notched. The biphasic pattern in the P wave is classified as severe IAB. P wave morphology is examined in inferior derivations of standard 12-lead ECG (Fig.1) [7].
Fig.1
Technique of measurement of P‐wave indices. P‐wave duration is measured from the first upward deflection of the P wave to return of the waveform to the isoelectric line in leads II, III, and aVF. P‐wave voltage is measured from the peak of the P wave to the isoelectric line of the T‐P interval in lead I
b
P Wave Amplitude (Voltage)
P wave amplitude is the measurement of the height of the P wave peak point from the isoelectric line (Fig.1). Its unit is denoted as mV. Attenuation of P wave amplitude is considered related to weakened atrial transmission patterns [7].
iii.
P Wave Duration
The first upward mark from the isoelectric line is accepted as the beginning of the P wave, and returning to the isoelectric line is defined as the end [8]. Measurement of this period is called P wave duration and is noted as ms (Fig.1). P waves, which are longer than 120ms, are an independent risk factor for AF development in many populations [9]. The longer the P wave duration, the higher the risk of AF development [10].
All Scoring system was detailed in Table1.
Table1
Morphology‐Voltage‐P‐wave duration (MVP) ECG risk score for atrial fibrillation
| Variable | Value | Score |
|---|---|---|
| Morphology (Inferior Leads) | Nonbiphasic (< 120ms) | 0 |
| Nonbiphasic (≥ 120ms) | 1 | |
| Biphasic | 2 | |
| Voltage (Lead I) | > 0.2mV | 0 |
| 0.1–0.2mV | 1 | |
| < 0.1mV | 2 | |
| P-Wave Duration | < 120ms | 0 |
| 120–140ms | 1 | |
| > 140ms | 2 | |
| Note (Total Score) | 0–2 | Low probability of AF |
| 3–4 | Intermediate Probability of AF | |
| 5–6 | High Probability of AF |
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Operative technique
Standardized anesthesia method used for all patients (2–2.5mg/kg intravenous (IV) propofol, 2.5–5mg/kg IV fentanyl and 0.6mg/kg IV rocuronium for induction; 6–10mg/kg/h propofol, 2mg/kg/h fentanyl and 0.03mg/kg/h rocuronium IV infusion for maintenance).
All patients operated with median sternotomy. After sternotomy, LITA and RITA (in one group) flaps were prepared with heparin administration. ITA flaps were kept in a tepid saline solution with local 0.05 papaverine administration. All operations were performed on the pump. A routinely arterial cannula was implanted in the ascending aorta, and two staged venous cannula were in the right atrial appendage. For cardioplegia and venting, a cannula was placed in ascending aorta. Antegrade cold blood cardioplegia was used for all patients, and 0.2ml/kg was used every 20min for maintenance under cross-clamp (CC). Myocardial protection was supported by systemic hypothermia (28-32º C).
Following cardiac arrest, distal anastomoses were completed. RITA was our first choice for LAD anastomosis according to length, flow dynamics, and distance to the LAD position. In unsuitable cases, RITA flaps were divided as free grafts and anastomosed to the best-developed, stenotic left coronary system artery. In this group of patients, LITA was anastomosed to LAD, and the proximal edge of the free RITA graft was sewn on the LITA flap. No other arterial grafts were used. Other stenotic coronary arteries were grafted with saphenous vein grafts.
Proximal anastomoses were completed under CC. Extracorporeal life support was applied one-third of the CC time for all patients after the removal of CC.
Statistical methods
All statistical analyses were done using SPSS software, IBM, version 21.0. The Kolmogorov–Smirnov test was performed to test if the variables were normally distributed and if the sample size > 50. The Shapiro–wilk test was used if the sample size < 50 The data were presented as median (interquartile range) for continuous parameters, while the data were provided as percentage and number values for categorical parameters. The independent t-test was performed to determine the difference between the groups of continuous parameters with normal distribution. All continuous variables showed skewed distributions and were compared using the Mann–Whitney U test. For categorical variables, the Chi-square test was used. To determine the predictors of postoperative atrial fibrillation, we first performed a univariate analysis. The variables with a significance of p < 0.1 in the univariate analysis were used in the multivariate analysis in order to detect independent predictors of postoperative atrial fibrillation.Cut-off values of MVP ECG risk score with a highest sensitivity and specificity was calculated by nonparametric receiver-operating characteristics (ROC) curve analysis. The level of statistical significance was established at p value ≤ 0.05. The effect size (Cohen’s d) and power value (1- β) for MVP ECG risk score, compared between post-operative atrial fibrillation (-) and post-operative atrial fibrillation ( +), were calculated using G*Power software (version 3.1.9.2.) The alpha level used for this analysis was < 0.05. The effect size and power value were 0.554 and 0.922 for MVP ECG risk score.
Results
Population demographics and intraoperative data
The study population comprised 84 patients with a mean age of 61(55–67). The population was predominantly male (%73.8). Hypertension was the most frequent comorbidity in the overall population (%58.3), and chronic renal failure was the least (%16.7).
Single ITA was used for 41 patients (%48.8) and BITA for 43 patients (%51.2). Overall cardiopulmonary bypass (CPB) time was 143.46 ± 33.31min, and overall CC time was 105.58 ± 29.02min. All other demographic and intraoperative data are listed in Table2.
Table2
Demographic and intraoperative data
| Age | 61.52 ± 8.30 |
|---|---|
| Gender | |
| Female | 22 (26.2%) |
| Male | 62 (73.8%) |
| CABG | |
| X1 | 1 (1.2%) |
| X2 | 20 (23.8%) |
| X3 | 31 (36.9%) |
| X4 | 31 (36.9%) |
| X5 | 0 (0%) |
| X6 | 1 (1.2%) |
| LAD | |
| LITA | 57 (67.9%) |
| RITA | 26 (31.0%) |
| LITA + SVG | 1 (1.2%) |
| Single ITA | 41 (48.8%) |
| LITA + RITA | 43 (51.2%) |
| CPB Time (min) | 143.46 ± 33.31 |
| CC Time (min) | 105.58 ± 29.02 |
| Hypertension | 49 (58.3%) |
| Hyperlipidaemia | 34 (40.5%) |
| Chronic Renal Disease | 14 (16.7%) |
| DM | 38 (45.2%) |
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CABG Coronary Artery Bypass Graft, CC Cross Clamp, CPB Cardiopulmonary Bypass, DM Diabetes Mellitus, LAD Left Anterior Descending Artery, LITA Left Internal Thoracic Artery, RITA Right Internal Thoracic Artery, SVG Saphenous Vein Graft
Continuous variables are presented as median (interquartile range)
Nominal variables presented as frequency (%)
A comparison of demographic and intraoperative data of patients grouped according to graft choice is shown in Table3. CC and CPB times were significantly higher in BITA used group.
Table3
Comparison of demographic and operative data by single ITA and BITA groups
| Single ITA (n = 41) | LITA + RITA (n = 43) | p | |
|---|---|---|---|
| Age | 63.83 ± 7.82 | 59.33 ± 8.22 | 0.012 |
| Gender | 0.034 | ||
| Female | 15 (36.6%) | 7 (16.3%) | |
| Male | 26 (63.4%) | 36 (83.7%) | |
| CABG | 0.256 | ||
| X1 | 1 (2.4%) | 0 (0%) | |
| X2 | 9 (22.0%) | 11 (25.6%) | |
| X3 | 19 (46.3%) | 12 (27.9%) | |
| X4 | 12 (29.3%) | 19 (44.2%) | |
| X6 | 0 (0%) | 1 (2.3%) | |
| CPB Time (min) | 132.39 ± 31.31 | 154.02 ± 32.02 | 0.002 |
| CC Time (min) | 99.15 ± 28.53 | 111.72 ± 28.46 | 0.046 |
| Hypertension | 22 (53.7%) | 27 (62.8%) | 0.396 |
| Hyperlipidaemia | 14 (34.1%) | 20 (46.5%) | 0.248 |
| DM | 19 (46.3%) | 19 (44.2%) | 0.843 |
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CABG Coronary Artery Bypass Graft, CC Cross Clamp, CPB Cardiopulmonary Bypass, DM Diabetes Mellitus, LAD Left Anterior Descending Artery, LITA Left Internal Thoracic Artery, RITA Right Internal Thoracic Artery, SVG Saphenous Vein Graft
Continuous variables are presented as median (interquartile range)
Nominal variables presented as frequency (%)
Graft configurations of patients grouped according to AF development are detailed in Table4.
Table4
Comparison of demographic, clinical characteristics and echocardiographic parameters of the patients undergoing coronary artery bypass grafting according to post-operative atrial fibrillation
| Overall study population n = 84 | Post-operative atrial fibrillation (-), n = 71 | Post-operative atrial fibrillation ( +), n = 13 | p value | |
|---|---|---|---|---|
| Age, y | 61.0 (55.0 – 67.0) | 61.0 (56.0 – 67.0) | 57.0 (51.0 – 73.0) | 0.729 |
| Male gender | 62 (73.8%) | 52 (73.2%) | 10 (76.9%) | 0.779 |
| Hypertension | 49 (58.3%) | 40 (56.3%) | 9 (69.2%) | 0.379 |
| Diabetes Mellitus | 38 (45.2%) | 28 (39.4%) | 10 (76.9%) | 0.011 |
| Hyperlipidemia | 34 (40.5%) | 30 (42.3%) | 4 (30.8%) | 0.432 |
| Chronic renal failure | 14 (16.7%) | 10 (14.1%) | 4 (30.8%) | 0.217 |
| Echocardiographic parameters | ||||
| Ejection fraction | 52.0 (45.0 – 55.0) | 50.0 (45.0 – 55.0) | 55.0 (50.0 – 60.0) | 0.057 |
| Left atrium anteroposterior | 36.0 (34.0 – 39.0) | 36.0 (35.0 – 39.0) | 36.0 (32.0 – 38.0) | 0.510 |
| Left atrium mediolateral | 38.0 (34.0 – 43.0) | 38.0 (35.0 – 43.0) | 36.0 (30.0 – 42.0) | 0.381 |
| Left ventricle end-diastolic diameter | 48.0 (45.0 – 52.0) | 48.0 (45.0 – 52.0) | 47.0 (45.0 – 49.0) | 0.372 |
| Left ventricle end-systolic diameter | 30.0 (27.0 – 35.0) | 31.0 (27.0 – 35.0) | 28.0 (28.0 – 33.0) | 0.234 |
| Interventricular septum, mm | 11.0 (10.0 – 12.0) | 11.0 (10.0 – 12.0) | 10.0 (10.0 – 11.0) | 0.079 |
| Posterior wall, mm | 10.0 (10.0 – 11.0) | 10.0 (10.0 – 12.0) | 10.0 (10.0 – 11.0) | 0.618 |
| Coronary Artery Bypass Grafting Content | ||||
| LAD-LITA | 58 (69.0%) | 50 (70.4%) | 8 (61.5%) | 0.529 |
| CX-LITA | 23 (27.4%) | 18 (25.4%) | 5 (38.5%) | 0.330 |
| INT-LITA | 4 (4.8%) | 4 (5.6%) | 0 (0.0%) | 1.000 |
| LAD-RITA | 26 (31.0%) | 21 (29.6%) | 5 (38.5%) | 0.529 |
| INT-RITA | 2 (2.4%) | 2 (2.8%) | 0 (0.0%) | 1.000 |
| CX-RITA | 10 (11.9%) | 9 (12.7%) | 1 (7.7%) | 1.000 |
| DIA-RITA | 1 (1.2%) | 1 (1.4%) | (0.0%) | 1.000 |
| RCA-RITA | 6 (7.1%) | 4 (5.6%) | 2 (15.4%) | 0.231 |
| LITA | 83 (98.8%) | 70 (98.6%) | 13 (100.0%) | 1.000 |
| LITA + RITA | 43 (51.2%) | 35 (49.3%) | 8 (61.5%) | 0.610 |
| LAD-SVG | 1 (1.2%) | 1 (1.4%) | 0 (0.0%) | 1.000 |
| RCA-SVG | 46 (54.8%) | 40 (56.3%) | 6 (46.2%) | 0.499 |
| CX-SVG | 40 (47.6%) | 36 (50.7%) | 4 (30.8%) | 0.180 |
| INT-SVG | 8 (9.5%) | 7 (9.9%) | 1 (7.7%) | 1.000 |
| DIA-SVG | 38 (45.2%) | 31 (43.7%) | 7 (53.8%) | 0.499 |
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CX Circumflex Coronary Artery, DIA Diagonal Coronary Artery, INT Intermedier Coronary Artery, LAD Left Anterior Descending Artery, LITA Left Internal Thoracic Artery, RCA Right Coronary Artery, RITA Right Internal Thoracic Artery, SVG Saphenous Vein Graft
Continuous variables are presented as median (interquartile range)
Nominal variables presented as frequency (%)
Postoperative data
In our postoperative management and early follow-ups %23.8 of patients (n = 20) were supported with inotropes in early postoperative hours. %10.7 of patients (n = 9) had metoprolol infusion because of sinus tachycardia.
Thirteen patients (%15.5) were diagnosed with AF. Eight patients were in BITA used group. No statistically significant difference was detected between BITA and single ITA groups regarding AF development (Table4).
To investigate the factors that cause AF rhythm, the patients were divided into two groups: those who developed AF rhythm and those who did not, and demographic data, TTE, ECG, and laboratory results were examined.
Demographic data of AF risk factors
While the average age of patients in AF rhythm was 57.0 (51.0 – 73.0) years, the average age in sinus rhythm was 61.0 (56.0 – 67.0). No difference was detected between gender and age. Among the comorbidities, only the presence of Diabetes Mellitus (DM) was seen in 76.9% (n = 10) of the patients with AF rhythm. In comparison, it was determined to be only 39.4% (n = 28) in those without AF and was considered statistically significant (p = 0.011) (Table4).
TTE parameters of AF risk factors
In the comparison made to investigate the importance of atrial and ventricular diameters in monitoring AF rhythm, the median ejection fraction (EF) values of patients in AF were 55.0% (50.0—60.0), and those without AF were 50.0% (45.0—55.0), the closest value to a significant evaluation (Table4).
Laboratory and ECG parameters of AF risk factors
Preoperative laboratory data of the patients were also examined. As a result, the median blood glucose value of patients in AF rhythm was 132 (115 – 177) mg/dL, while it was 113 (95 – 141) mg/dL in patients not in AF rhythm, and this elevated level was found to be significant in terms of AF rhythm development (p = 0.048).
When comparing ECG findings, one of the most valuable markers for the development of AF, between patient groups with and without AF, the morphology of the P wave comes to the fore. While biphasic P wave was observed in 30.8% (n = 4) of the patients with AF, biphasic P wave was observed in only 5.6% (n = 4) of the patients without AF and was evaluated as significant (p = 0.018). While the P wave duration was measured as 129 (122 – 137) ms as a median value in patients with AF, it was estimated as 113 (101 – 125) ms in those without AF and was found to be significant (p = 0.005). The total MVP ECG score was calculated as 4.0 (3.0 – 4.0) in patients with AF and 1.0 (1.0 – 3.0) in patients with sinus rhythm and was found to be significantly lower (p < 0.001). P wave voltage was not observed to be statistically different. The data is given in detail in Table5.
Table5
Comparison of laboratory and echocardiography parameters of the patients undergoing coronary artery bypass grafting according to post-operative atrial fibrillation
| Overall study population n = 84 | Post-operative atrial fibrillation (-), n = 71 | Post-operative atrial fibrillation ( +), n = 13 | p value | |
|---|---|---|---|---|
| Preoperative laboratory variables | ||||
| Hb (g/dl) | 13.5 (12.4 – 15.1) | 13.6 (12.4 – 15.1) | 13.0 (11.7 – 14.5) | 0.421 |
| WBC (cells/µL) | 8.4 (6.6 – 10.1) | 8.1 (6.7 – 10.1) | 8.9 (6.1 – 9.8) | 0.625 |
| Platelet count (/mm3) | 249 (203 – 300) | 255 (203 – 304) | 233 (216 – 268) | 0.833 |
| Creatinine (mg/dL) | 0.8 (0.7 – 1.0) | 0.8 (0.7 – 1.0) | 0.8 (0.6 – 1.2) | 0.882 |
| TSH | 1.4 (1.1 – 2.3) | 1.4 (0.9 – 2.3) | 1.3 (1.1 – 2.8) | 0.975 |
| AST | 20 (15 – 28) | 20 (15 – 28) | 16 (13 – 28) | 0.179 |
| ALT | 18 (13 – 29) | 18 (13 – 29) | 17 (12 – 29) | 0.692 |
| Glucose (mg/dl) | 114 (99 – 145) | 113 (95 – 141) | 132 (115 – 177) | 0.048 |
| HDL | 38 (34 – 46) | 38 (34 – 45) | 41 (35 – 46) | 0.612 |
| LDL | 100 (81 – 122) | 101 (82 – 124) | 99 (74 – 121) | 0.473 |
| Total cholesterol | 176 (153 – 202) | 178 (152 – 202) | 173 (163 – 202) | 0.961 |
| Electrocardiographic parameters | ||||
| Morphology in inferior leads | ||||
| Non-biphasic (< 120ms) | 50 (59.5%) | 48 (67.6%) | 2 (15.4%) | < 0.001 |
| Non-biphasic (> 120ms) | 26 (31.0%) | 19 (26.8%) | 7 (53.8%) | 0.061 |
| Biphasic | 8 (9.5%) | 4 (5.6%) | 4 (30.8%) | 0.018 |
| Voltage in lead I, mV | 0.14 (0.12 – 0.16) | 0.14 (0.11 – 0.16) | 0.14 (0.12 – 0.15) | 0.858 |
| P-wave duration, ms | 115 (104—128) | 113 (101 – 125) | 129 (122 – 137) | 0.005 |
| MVP ECG risk score | 1.0 (1.0 – 3.0) | 1.0 (1.0 – 3.0) | 4.0 (3.0 – 4.0) | < 0.001 |
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ALT Alanine Transaminase, AST Aspartate Transaminase, Hb Hemoglobine, HDL High-Density Lipoprotein, LDL Low-Density Lipoprotein, MVP ECG Morphology-Voltaj-P Wave Duration Electrocardiography, TSH Thyroid Stimulating Hormone, WBC White Blood Cell
Continuous variables are presented as median (interquartile range)
Nominal variables presented as frequency (%)
Multivariable analysis
The variables with a significance of p < 0.1 were used in the multivariate analysis. DM [p = 0.029, OR = 9.627(1.263 – 73.404)] and MVP ECG Risk Score [p = 0.010, OR = 2.735(1.267 – 5.904)] was found statistically significant for developing post-operative arrhythmia (Table6). A ROC analysis showed that the optimal cut-off value of the MVP ECG risk score to predict postoperative AF was ≥ 3 with 84% sensitivity and 68% specificity (AUC: 0.83; 95% CI: 0.72–0.94; p < 0.001) (Fig.2).
Table6
Univariable analysis and multivariable model for post-operative atrial fibrillation according to admission demographic and clinical characteristics, laboratory parameters, echocardiography variables
| Univariable analysis | P value | OR (95% CI) | Multivariable analysis | P value | OR (95% CI) |
|---|---|---|---|---|---|
| Diabetes mellitus | 0.020 | 5.119 (1.294 – 20.250) | Diabetes mellitus | 0.029 | 9.627 (1.263 – 73.404) |
| Ejection fraction | 0.079 | 1.096 (0.989 – 1.215) | |||
| MVP ECG risk score | 0.001 | 2.758 (1.553 – 4.896) | MVP ECG risk score | 0.010 | 2.735 (1.267 – 5.904) |
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OR Odds Ratio, MVP ECG Morphology-Voltage-P Wave Duration Electrocardiography
All clinically relevant parameters were included in the model. OR Hazard ratio, CI confidence interval
Fig.2
ROC analysis of MVP ECG score
Comment
Our aim in this study was to investigate the frequency of arrhythmia according to graft choice and detect the efficacy of proarrhythmic markers on surgical patients.
Arrhythmias are the most frequent complications after the CABG procedure and can cause severe morbidity and mortality [11, 12]. Because of that, some ventricular and atrial proarrhythmic markers have been defined and proven beneficial in some cardiologic patient populations over recent years [13–15]. Unfortunately, there is a lack of studies in surgical patient groups. Early detection of predisposed surgical patients is crucial for the prevention of complications.
In a recent study, Mitchell et al. evaluated 2270 patients and detected atrial tachyarrhythmia in 670 (%30). They reported the incidence of post-operative tachyarrhythmia as %25–35 with a %95 confidence interval [3]. In another study, Maisel et al. reported the incidence of AF after cardiac surgery as %10–65 [2].Although the relationship between AF and poor clinical outcomes is known, there are also studies in the literature that obtain contrary results. For example, Jameie et al. did not find a correlation between postoperative AF and worse clinical outcomes in their large-scale study [16]. Grau et al. followed up BITA and single ITA patients for 17years after surgery and detected AF in the BITA group %19.9 and 19.2%19.2 in the single ITA population. They noticed no significant difference between the two groups [17]. Our study observed AF in 13 patients (%15.5). The number of patients in AF rhythm was 5 (12.2%) in the single ITA group and 8 (18.6%) in the BITA group. No difference could be determined due to graft preference regarding the frequency of atrial arrhythmia development. However, although the mean age of the BITA-used group was significantly lower, similar atrial arrhythmia rates were observed as an essential point.
AF rhythm was our study's most frequently observed arrhythmia type. As a result, a detailed examination of the factors causing POAF development was carried out. When the demographic and laboratory data of patients who develop AF are compared with those who do not, we see mainly the presence of DM and preoperative blood glucose levels. In our study, these data were significant predisposing factors for developing AF rhythm. In a similar study, Hurt et al. they investigated the frequency of postoperative AF based on metabolic syndrome and DM. They found that the frequency of AF was significantly higher even in metabolic syndrome patients with DM (47%) compared to metabolic syndrome patients without DM (25%) [18].
TTE data related to the development of AF were reported by Açıl et al. It was examined in a study conducted by. As a result of the study, it was revealed that patients with POAF rhythm had statistically significantly larger left atrial diameters [19]. In a similar study, Magne et al. They found higher left ventricular end-diastolic volume and lower EF in POAF patients [20]. No significant difference was observed in the TTE parameters examined in our study that would predispose to the development of AF.
ECG parameters, one of the focal points of our study, were found to be more sensitive than other data as one of the indicators of the newly developing AF rhythm. In the preoperative ECGs of the patients, biphasic P wave, > 120ms wave duration, and high total MVP ECG score were observed to be correlated with the development of AF. While the average P wave duration of patients who developed AF was 129 (122 – 137) ms, it was measured as 113 (101 – 125) ms in patients who were in sinus rhythm. The total MVP ECG score was calculated as 4.0 (3.0 – 4.0) in the AF group and 1.0 (1.0 – 3.0) in the non-AF group. A similar study with 676 patients stated that the MVP ECG score, as a non-invasive, easily measurable value, is an effective method for predicting the development of AF [7]. Similarly, Na Yang et al. showed that patients with AF who underwent pulmonary vein isolation were more prone to developing recurrent AF according to the MVP ECG score [21].
Pay et al., in their study of 328 patients, showed that the MVP ECG score was effective in ICD patients with low EF. Although it obtains results similar to the literature, it is also an important study in terms of showing its effectiveness on cardiological patient groups [22].
In conclusion, The frequency of AF development was similar to the literature. The presence of preoperative DM and ECG parameters among surgical patients were evaluated as meaningful and valuable indicators of AF development. Our study showed no increase in arrhythmia frequency due to using a single ITA or BITA. Even though arrhythmogenicity increased due to surgery, we found that the developed arrhythmias were not due to graft choice.
The literature states that the MVP ECG score is highly predictive in determining atrial arrhythmias [21, 22]. It can also be used to determine the AF risk of surgical patients [21]. Although many factors determine the risk of AF, we believe that the value of a non-invasive method that can be calculated via ECG will increase with new research on other surgical groups. More advanced patient rhythm monitoring methods and studies involving more patients will be guiding.
Limitations of study
More detailed results can be obtained through studies that increase the number of patients and, if possible, take 72-h Holter ECG records of the patients and calculate the arrhythmia frequency more accurately. There are severel confounding factors such as fever and stress response which can effect the results of our study and appear as a limitation. Moreover, there is a lack of data regarding the BNP values of the study population.
Authors’ contributions
Erturk, O (Corresponding Author) wrote the main manuscript. Hayıroglu, MI prepared the tables to help with arrhythmia theoretical knowledge. Karaagac, A-Pocan, YK prepared Fig Fig2.2. Yesilkaya, MI-Bozkurt, B-Aydogan, H- Kaplan, M and all other authors reviewed the manuscript.
Funding
No Funding.
Availability of data and materials
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
Haydarpaşa Numune Research and Training Hospital Ethics Comitee (regional ethics comitee) approved our study. Decision Number: HNEAH-KAEK 2021/KK/213, Decision Date: 06.09.2021.
Consent of publication
Every human participant gave permission to use their medical records in this study.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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