Atrial Fibrillation: Current Evidence and Management Strategies During the Perioperative Period

Kunal Karamchandani, MD, FCCP; Ashish K. Khanna, MD, FCCP, FCCM; Somnath Bose, MD; Rohesh J. Fernando, MD, FASE; Allan J. Walkey, MD, MSc


Anesth Analg. 2019;130(1):2-13. 

In This Article


AF is the most common perioperative arrhythmia with potentially increasing incidence as progressively older patients present for surgery. POAF can develop both de novo and in patients with a history of AF. Avoiding perioperative triggers and optimizing patient-related factors are currently the mainstay of POAF prevention and further research is needed to better identify the impact of such strategies. Intraoperative prevention follows the same general goals in minimizing potential triggers such as hypotension, sympathetic stimulation, hypoxia/hypercarbia, and metabolic abnormalities. The potential impact of intraoperative anesthetic agents such as ketamine, glycopyrrolate, and desflurane also needs further evaluation. Because the natural history of AF progresses from paroxysmal to persistent to permanent subtypes, preventing paroxysmal AF in the perioperative period may avoid eventual progression to more dangerous forms and have considerable long-term health consequences. Because of surgical stimulation, bleeding, swings in vital signs, and fluctuating volume levels, management of AF can be challenging, and the use of intraoperative TEE and transthoracic ultrasound may rule out dangerous causes such as PE or MI and allow for early, aggressive treatment. Although previously considered a benign and self-limiting entity, POAF worsens postoperative outcomes, can be a harbinger of stroke and severe disability, and increases the risk of postoperative morbidity and mortality. Postoperative continuation of rate-control therapy initiated during the perioperative period is currently recommended even for paroxysmal AF, and further study is needed to validate that approach. Because of the heightened risk of perioperative stroke, prophylaxis should be discussed between anesthesiologist, intensivist, surgeon, and cardiologist with a focus on the risk-benefit profile of such interventions.