Surgery & heart rhythms

[Susan BAV]

Hope this info is useful; sorry it's so long

Hope this info is useful; sorry it's so long

Hi - I had AVR early last October and was in the hospital for just a week but the afternoon I got home I went into a-fib. I didn't realize what it was at that time. But it was, for me, like a freight train with no brakes rolling down a track. And it would hit hard.

Because I was over two hours from the hospital where I'd had the surgery, I didn't want to trot back there if I didn't need to. And I didn't want to go to a nearby hospital and confuse my care. It went away over night but it came back each day, either late morning or early afternoon and beat the tarnation out of me. I still didn't realize what it was but my local doctor did an ekg and I was at 198 beats per minute!

The cardiologist prescribed digoxin and I thought it finally helped but the a-fib came back. The doctors kept telling me to go to the ER but I really didn't realize how serious the a-fib was and I didn't want to go to a local hospital and I didn't want to have to go back up to Los Angeles.

A week of this later, with about 8-12+ hours each day of this a-fib, I was readmitted to the hospital in LA and they put me on Sotalol (betapace) which, after several high doses, knocked it right out for me. What a relief! I had to take that for three months, and Coumadin too, but now I'm off of everything but aspirin and no more a-fib!

The doctors told me that maybe half of heart surgery patients have bouts with a-fib and that the heart has a memory for it and likes to go back to that pattern. I talked to my paternal uncle later and he's been in a-fib for 20 years! But he doesn't feel it.

 

[Susan BAV]

oh, a little more

oh, a little more

Hi again - I forgot to mention that before the surgery I was having a lot of PVCs and "some V-Tach," as per a Holter monitor. I was actually having a lot of V-Tach. Since getting off the medications, I have only had a sensation of a few PVCs and my resting heart rate is often around 90, as it was before the surgery.

 

[Kathy]

I was told that 40% of mitral valve repair patients have periods of a-fib after surgery and 10% require pacemakers.

I experienced some a-fib for 3 months post-surgery and then converted to sinus rhythm. I am still on meds to control it. The card said that we would think about discontinuing them a year after surgery.

 

[Marge]

I'm still kind of concerned about this a-fib business. I had my last pre-surgery consult with my surgeon today and he said, yeah, lots of people have episodes of a-fib when they have mitral valve surgery, but that there was no particular reason to think I would, but if I did it probably would be brief.

So naturally I found something to worry about: amiodarone. How common is it to use that in connection with valve surgery? Runner, I read what you said about it, and tried to do some research. Reading Dr. Rich, that sounds like a very scary drug -- one I'd rather avoid having to take!! How many of you have had experience with it? Do they give you a choice?

I know that Joe Parker, one of our more recent valve replacements, is on amiodarone.

For Dr. Rich's take on the drug, see http://heartdisease.about.com/cs/arrhythmias/a/amiodarone.htm

 

[Johnny Stephens]

I took it for a month, starting in the hospital. I had bouts of ventricular tachycardia (one time my heart was beating 180+ bpm). My docs explained to me the risks of amiodarone - especially of concern were my lungs. However, they felt the benefits outweighed the risk of NOT using it, so use it I did.

Quit taking it a month later, because it had completely stopped my arrhytmias. Phew!

 

[terry40]

Hi Marge

Hi Marge

Pre-surgery I had TNTC, PVCs, for about 5 years, they finally put me on a med. sectral, ( beta blocker) that controled it, after surgery in the hospital, I experienced 2 days of Afib, was medicated and it stopped.

In the Hospital they changed my beta blocker to Toprol XL, the PVCs started up again, so I had my Family Doc, clear it with my Cardio Doc, to put me back on Sectral again, only they doubled my pre-surgery dose, it would also help decrease my heart rate which was running at about 110 at rest.

I am now down to a normal Heart rate with only a few PVCs a day, which is normal and no sign of Afib.

I agree with the others, surgery irratates the heart and it's electrical system, but time and treatment will heal most of us.

best of luck,

teryy40

 

[BillCobit]

Rhythm and conduction disturbances

Rhythm and conduction disturbances

Hi Marge -

Some more of what Ken said, plus some info on other rhythm disturbances.


http://www.ctsnet.org/edmunds/Chapter13section3.html

COMPLICATIONS SPECIFIC TO ORGAN SYSTEMS
Heart and Pericardium
Postoperative complications involving the heart and pericardium are common after cardiac surgery primarily because of arrhythmias, conduction disturbances, and manifestations of ischemia. Prevention and control of these complications have had a major role in the evolution of cardiac surgery and in the successful outcome of most operations.

Supraventricular Arrythmias
Atrial arrhythymias, primarily atrial fibrillation or, less commonly, atrial fluttter, occur in 10?40percent of patients after open cardiac surgery. [121 ] ? [123 ] The usual onset is 1?3 days after operation, with a peak incidence at 48 hours; however, the arrythymia may occur at any time, including shortly after discharge. [121 ] , [123 ] Increasing age is the most consistent predisposing factor; less-constant antecedent conditions include valve surgery, history of rheumatic fever, duration of aortic cross-clamp time and cardiopulmonary bypass, method of cardioplegia, and abrupt stoppage of ß-blocking agents. Acidosis, hypokalemia, or hypoxemia may contribute to the onset of the arrhythmia and should be corrected prior to initiating definitive therapy. [121 ] , [123 ] ? [125 ]

In postoperative patients the diagnosis of atrial fibrillation or flutter is usually made from the electrocardiographic monitor or occasionally from a postoperative electrocardiogram. [123 ] , [126 ] A few patients experience symptoms of lightheadedness or palpitations, and inferequently a patient develops hypotension and reduced cardiac output from very rapid atrial fibrillation or flutter and requires prompt resuscitation. The diagnosis is made by electrocardiogram; in equivocal cases the atrial electrogram obtained from temporary atrial wires is helpful. [127 ] Immediate electrical cardioversion is recommended for unstable, symptomatic patients. Stable patients with atrial flutter usually are converted to lower ventricular rates by overdrive pacing followed by anti-arrhythmic drugs. [121 ] In all patients antiarrhythmic drugs are given first to control ventricular rate by slowing intranodal conduction and second to achieve conversion to sinus rhythm. Class Ia drugs (e.g., Procainamide), and calcium-channel blockers frequently are prescribed, but all depress myocardial contractility to some degree. Digoxin is effective for chronic control. Amiodarone may be needed for refractory patients.

Attempts to prevent atrial fibrillation and flutter by prophylactic therapy are only partially successful. Large studies suggest that ß-blockers, such as propanalol, atenolol, and metoprolol, reduce the incidence of postoperative arrhythmias to some degree, but digoxin, calcium-channel blockers, and amiodarone are ineffective. [121 ] , [128 ] ? [132 ] , [134 ] Treated postoperative atrial arrhythmias are usually well tolerated, and many patients revert to sinus rhythm during the first month after hospital discharge and no longer need drugs prescribed for rate control. [130 ] , [131 ] , [135 ] Patients who remain in atrial fibrillation have a two- or threefold increase in the risk of stroke, and long-term anticoagulation is recommended in the absence of contraindications. [123 ] , [126 ] Despite the morbidity of atrial fibrillation, early and late mortality rates do not appear increased by the dysrhythmia.

VENTRICULAR ARRHYTHMIAS
Postoperative ventricular arrhythmias range from occasional premature beats, bigeminy, trigeminy, and nonsustained ventricular tachycardia to sustained ventricular tachycardia and ventricular fibrillation. The benign arrhythmias occur in 20?60 percent of patients and infrequently produce symptoms or require treatment. [121 ] The incidence of sustained tachycardia or ventricular fibrillation after cardiac surgery ranges 0.4?1.4 percent. [121 ] , [136 ] These potentially lethal arrhythmias often are unexpected and may occur at any time during hospitalization and soon after discharge.

Predisposing factors include myocardial ischemia, low cardiac output, metabolic derangements, drug interactions, and severe left ventricular dysfunction (ejection fraction less than 40 percent). [121 ] , [137 ] Prophylactic correction of hypoxemia, acidosis, hypokalemia, and hypomagnesemia is particularly important in the immediate postoperative period. Development of ventricular arrhythmias should prompt evaluation for ongoing myocardial ischemia. [121 ] , [136 ] , [138 ]

Immediate cardioversion followed by resuscitation and antiarrhythmic therapy is essential for sustained ventricular tachycardia and ventricular fibrillation. Once the patient is resuscitated, a cause for the event should be sought and corrected if possible (e.g., hypoxemia, hypercarbic, etc.). Because these arrhythmias are lethal, electrophysiologic testing is necessary to determine effectiveness of specific drugs in individual patients. This should be done before hospital discharge, and occasional patients may require an implanted automatic internal cardiac defibrillator prior to hospital discharge. [137 ] Sustained ventricular tachycardia and fibrillation have an associated mortality up to 44 percent that can be substantially reduced by aggressive therapy. [121 ] , [136 ] ? [137 ]

CONDUCTION DISTURBANCES
Transient conduction disturbances after open cardiac surgery are very common, and most do not require treatment other than transient pacing via temporary pacing wires. [139 ] The incidence of permanent disturbances varies widely but is as high as 34?55 percent in subsets of patients with coronary arterial disease. [140 ] ? [142 ] Hemiblock and bundle branch blocks are rarely symptomatic, but atrioventricular block and sinus node dysfunction that occur in 0.5?4 percent of patients usually require a pacemaker. [121 ] , [140 ] Possible contributing factors to the development of postoperative conduction disturbances include the severity of coronary arterial disease, particularly of septal vessels, duration of aortic cross-clamping and cardiopulmonary bypass, method of cardioplegia, depth of myocardial hypothermia, patient age, and specific operation. [121 ] , [140 ] ? [142 ] Persistence of sinus node dysfunction or atrioventricular block beyond 4 or 5 days is an indication for a permanent pacemaker. [121 ] Other indications for permanent pacemakers are presented in Chapters 25 and 27.

 

[Marge]

Bill, thanks for the article. Very useful & interesting. I know there is nothing much I can do about this, whatever happens will happen, and if it does they will treat it, but I like to know as much as possible.

I guess my worst "predisposing factor" (for ventricular arrythmias rather than A-fib) is my "severe left ventricular dysfunction (ejection fraction less than 40 percent)." Oh goodie, JUST WHAT I NEED, something else to fret about! LOL. I do see, however, why my surgeon said he would not want to wait around & see if my EF, now somewhere between 30 and 35, dropped below 30!