Development and validation of a novel predicting nomogram for new-onset postoperative atrial fibrillation following isolated aortic valve replacement_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LI Rui ^1,2 , LIANG Hanqing ³ ,  HAN Jinsong ²

1. General Hospital of Northern Theater Command, The Graduate Training Base of Jinzhou Medical University, Shenyang, 110016, P. R. China;
2. Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang, 110016, P. R. China;
3. Department of Cardiothoracic Surgery, Xuzhou Hospital, Xuzhou Medical University, Xuzhou, 221000, Jiangsu, P. R. China;

Corresponding author：

HAN Jinsong, Email: hanjs0216@sina.com

Keywords：

Isolated aortic valve replacement; nomogram; postoperative atrial fibrillation

DOI：

10.7507/1007-4848.202308040

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Objective To establish and validate a nomogram model for predicting the risk of new-onset postoperative atrial fibrillation (POAF) after isolated aortic valve replacement (AVR). Methods The clinical data of patients without atrial fibrillation (AF) who underwent isolated AVR in the General Hospital of the Northern Theater of the Chinese People's Liberation Army from June 2020 to June 2022 were retrospectively collected. Patients with AVR were divided into a POAF group and a non-POAF group according to whether POAF occurred within 7 days after surgery. The preoperative baseline data, preoperative blood indexes, preoperative color Doppler echocardiography and the heart rate variability (HRV) in 7-days Holter monitoring before surgery were analyzed. Logistic regression was used to analyze the preoperative risk factors for POAF and R language was used to construct a nomogram to predict POAF. The results were compared with the established AF model (POAF-AF score). Results A total of 191 patients were enrolled in this study, and 66 (34.55%) of them developed POAF within 7 days after the surgery. The age of the patients in the POAF group was 60.97±8.41 years and 16 (24%) were female, while the age of the patients in the non-POAF group was 54.65±11.85 years and 59 (47%) were female. Univariate and multivariate logistic regression analysis showed that age, sex, drinking history, chronic obstructive pulmonary disease, platelet accumulation and high frequency power were independently associated with POAF after the AVR. The nomogram of POAF was constructed by combining the above independent risk factors. We predicted the area under ROC curve (AUC =0.812) in the nomogram of POAF after simple aortic valve replacement. The model was internally verified by a 10-fold cross-validation resampling (AUC=0.757, Kappa=0.438). Compared with the POAF-AF score, the nomogram had a superior discrimination performance. Conclusion Age, sex, drinking history, chronic obstructive pulmonary disease, plateletocrit, and high frequency power are independent predictors for POAF after isolated AVR. The nomogram can be used as a practical tool to help clinicians predict the probability of individual POAF occurrence and take necessary preventive measures.

1.	Aranki SF, Shaw DP, Adams DH, et al. Predictors of atrial fibrillation after coronary artery surgery. Current trends and impact on hospital resources. Circulation, 1996, 94(3): 390-397.
2.	Chen LY, Chung MK, Allen LA, et al. Atrial fibrillation burden: Moving beyond atrial fibrillation as a binary entity: A scientific statement from the American Heart Association. Circulation, 2018, 137(20): e623-e644.
3.	Hogue CW, Hyder ML. Atrial fibrillation after cardiac operation: Risks, mechanisms, and treatment. Ann Thorac Surg, 2000, 69(1): 300-306.
4.	Turan A, Duncan A, Leung S, et al. Dexmedetomidine for reduction of atrial fibrillation and delirium after cardiac surgery (DECADE): A randomised placebo-controlled trial. Lancet, 2020, 396(10245): 177-185.
5.	Peretto G, Durante A, Limite LR, et al. Postoperative arrhythmias after cardiac surgery: Incidence, risk factors, and therapeutic management. Cardiol Res Pract, 2014, 2014: 615987.
6.	Iliescu AC, Salaru DL, Achitei I, et al. Postoperative atrial fibrillation prediction following isolated surgical aortic valve replacement. Anatol J Cardiol, 2018, 19(6): 394-400.
7.	Kalra R, Patel N, Doshi R, et al. Evaluation of the incidence of new-onset atrial fibrillation after aortic valve replacement. JAMA Intern Med, 2019, 179(8): 1122-1130.
8.	Jorgensen TH, Thygesen JB, Thyregod HG, et al. New-onset atrial fibrillation after surgical aortic valve replacement and transcatheter aortic valve implantation: A concise review. J Invasive Cardiol, 2015, 27(1): 41-47.
9.	Lewis T, Drury A and Bulger H. Observations upon atrial flutter and fibrillation. Ⅵ. Refractory period and rate of propagation in the auricle: Their relation to block in the auricular walls and to flutter. Heart, 1921, 8: 84-134.
10.	Morillo CA, Klein GJ, Jones DL, et al. Chronic rapid atrial pacing. Structural, functional, and electrophysiological characteristics of a new model of sustained atrial fibrillation. Circulation, 1995, 91(5): 1588-1595.
11.	Banach M, Rysz J, Drozdz JA, et al. Risk factors of atrial fibrillation following coronary artery bypass grafting: A preliminary report. Circ J, 2006, 70(4): 438-441.
12.	Stamou SC, Dangas G, Hill PC, et al. Atrial fibrillation after beating heart surgery. Am J Cardiol, 2000, 86(1): 64-67.
13.	Ascione R, Caputo M, Calori G, et al. Predictors of atrial fibrillation after conventional and beating heart coronary surgery: A prospective, randomized study. Circulation, 2000, 102(13): 1530-1535.
14.	Cameron MJ, Tran DTT, Abboud J, et al. Prospective external validation of three preoperative risk scores for prediction of new onset atrial fibrillation after cardiac surgery. Anesth Analg, 2018, 126(1): 33-38.
15.	Gong J, Wei Y, Zhang Q, et al. Nomogram predicts atrial fibrillation after coronary artery bypass grafting. BMC Cardiovasc Disord, 2022, 22(1): 388.
16.	Fan K, Chen L, Liu F, et al. Predicting new-onset postoperative atrial fibrillation following isolated coronary artery bypass grafting: Development and Validation of a Novel Nomogram. Int J Gen Med, 2022, 15: 937-948.
17.	Funk M, Richards S B, Desjardins J, et al. Incidence, timing, symptoms, and risk factors for atrial fibrillation after cardiac surgery. Am J Crit Care, 2003, 12(5): 424-435.
18.	Lee SH, Kang DR, Uhm JS, et al. New-onset atrial fibrillation predicts long-term newly developed atrial fibrillation after coronary artery bypass graft. Am Heart J, 2014, 167(4): 593-600.
19.	Banach M, Goch A, Misztal M, et al. Predictors of paroxysmal atrial fibrillation in patients undergoing aortic valve replacement. J Thorac Cardiovasc Surg, 2007, 134(6): 1569-1576.
20.	Maesen B, Nijs J, Maessen J, et al. Post-operative atrial fibrillation: A maze of mechanisms. Europace, 2012, 14(2): 159-174.
21.	Banach M, Kourliouros A, Reinhart KM, et al. Postoperative atrial fibrillation: What do we really know? Curr Vasc Pharmacol, 2010, 8(4): 553-572.
22.	Goudis CA. Chronic obstructive pulmonary disease and atrial fibrillation: An unknown relationship. J Cardiol, 2017, 69(5): 699-705.
23.	Khan AA, Lip GYH, Shantsila A. Heart rate variability in atrial fibrillation: The balance between sympathetic and parasympathetic nervous system. Eur J Clin Invest, 2019, 49(11): e13174.
24.	Ye J, Wu M, He L, et al. Glutathione-s-transferase p 1 gene promoter methylation in cell-free DNA as a diagnostic and prognostic tool for prostate cancer: A systematic review and meta-analysis. Int J Endocrinol, 2023, 2023: 7279243.
25.	Xi Y, Cheng J. Dysfunction of the autonomic nervous system in atrial fibrillation. J Thorac Dis, 2015, 7(2): 193-198.
26.	Axtell AL, Moonsamy P, Melnitchouk S, et al. Preoperative predictors of new-onset prolonged atrial fibrillation after surgical aortic valve replacement. J Thorac Cardiovasc Surg, 2020, 159(4): 1407-1414.
27.	Alam M, Lee VV, Elayda MA, et al. Association of gender with morbidity and mortality after isolated coronary artery bypass grafting. A propensity score matched analysis. Int J Cardiol, 2013, 167(1): 180-184.
28.	Filardo G, Ailawadi G, Pollock BD, et al. Postoperative atrial fibrillation: Sex-specific characteristics and effect on survival. J Thorac Cardiovasc Surg, 2020, 159(4): 1419-1425.
29.	Biddinger KJ, Emdin CA, Haas ME, et al. Association of habitual alcohol intake with risk of cardiovascular disease. JAMA Netw Open, 2022, 5(3): e223849.
30.	Jiang H, Mei X, Jiang Y, et al. Alcohol consumption and atrial fibrillation risk: An updated dose-response meta-analysis of over 10 million participants. Front Cardiovasc Med, 2022, 9: 979982.
31.	Cha MJ, Oh GC, Lee H, et al. Alcohol consumption and risk of atrial fibrillation in asymptomatic healthy adults. Heart Rhythm, 2020, 17(12): 2086-2092.
32.	Arslan AK, Erdil N, Guldogan E, et al. Prediction of postcoronary artery bypass grafting atrial fibrillation: POAFRiskScore tool. Thorac Cardiovasc Surg, 2023, 71(4): 282-290.
33.	Guzelburc O, Zengin A, Karatas MB, et al. Relationship between platelet mass index and postoperative atrial fibrillation after elective coronary artery bypass surgery: A retrospective study. Herz, 2023, 48(4): 309-315.

1. Aranki SF, Shaw DP, Adams DH, et al. Predictors of atrial fibrillation after coronary artery surgery. Current trends and impact on hospital resources. Circulation, 1996, 94(3): 390-397.
2. Chen LY, Chung MK, Allen LA, et al. Atrial fibrillation burden: Moving beyond atrial fibrillation as a binary entity: A scientific statement from the American Heart Association. Circulation, 2018, 137(20): e623-e644.
3. Hogue CW, Hyder ML. Atrial fibrillation after cardiac operation: Risks, mechanisms, and treatment. Ann Thorac Surg, 2000, 69(1): 300-306.
4. Turan A, Duncan A, Leung S, et al. Dexmedetomidine for reduction of atrial fibrillation and delirium after cardiac surgery (DECADE): A randomised placebo-controlled trial. Lancet, 2020, 396(10245): 177-185.
5. Peretto G, Durante A, Limite LR, et al. Postoperative arrhythmias after cardiac surgery: Incidence, risk factors, and therapeutic management. Cardiol Res Pract, 2014, 2014: 615987.
6. Iliescu AC, Salaru DL, Achitei I, et al. Postoperative atrial fibrillation prediction following isolated surgical aortic valve replacement. Anatol J Cardiol, 2018, 19(6): 394-400.
7. Kalra R, Patel N, Doshi R, et al. Evaluation of the incidence of new-onset atrial fibrillation after aortic valve replacement. JAMA Intern Med, 2019, 179(8): 1122-1130.
8. Jorgensen TH, Thygesen JB, Thyregod HG, et al. New-onset atrial fibrillation after surgical aortic valve replacement and transcatheter aortic valve implantation: A concise review. J Invasive Cardiol, 2015, 27(1): 41-47.
9. Lewis T, Drury A and Bulger H. Observations upon atrial flutter and fibrillation. Ⅵ. Refractory period and rate of propagation in the auricle: Their relation to block in the auricular walls and to flutter. Heart, 1921, 8: 84-134.
10. Morillo CA, Klein GJ, Jones DL, et al. Chronic rapid atrial pacing. Structural, functional, and electrophysiological characteristics of a new model of sustained atrial fibrillation. Circulation, 1995, 91(5): 1588-1595.
11. Banach M, Rysz J, Drozdz JA, et al. Risk factors of atrial fibrillation following coronary artery bypass grafting: A preliminary report. Circ J, 2006, 70(4): 438-441.
12. Stamou SC, Dangas G, Hill PC, et al. Atrial fibrillation after beating heart surgery. Am J Cardiol, 2000, 86(1): 64-67.
13. Ascione R, Caputo M, Calori G, et al. Predictors of atrial fibrillation after conventional and beating heart coronary surgery: A prospective, randomized study. Circulation, 2000, 102(13): 1530-1535.
14. Cameron MJ, Tran DTT, Abboud J, et al. Prospective external validation of three preoperative risk scores for prediction of new onset atrial fibrillation after cardiac surgery. Anesth Analg, 2018, 126(1): 33-38.
15. Gong J, Wei Y, Zhang Q, et al. Nomogram predicts atrial fibrillation after coronary artery bypass grafting. BMC Cardiovasc Disord, 2022, 22(1): 388.
16. Fan K, Chen L, Liu F, et al. Predicting new-onset postoperative atrial fibrillation following isolated coronary artery bypass grafting: Development and Validation of a Novel Nomogram. Int J Gen Med, 2022, 15: 937-948.
17. Funk M, Richards S B, Desjardins J, et al. Incidence, timing, symptoms, and risk factors for atrial fibrillation after cardiac surgery. Am J Crit Care, 2003, 12(5): 424-435.
18. Lee SH, Kang DR, Uhm JS, et al. New-onset atrial fibrillation predicts long-term newly developed atrial fibrillation after coronary artery bypass graft. Am Heart J, 2014, 167(4): 593-600.
19. Banach M, Goch A, Misztal M, et al. Predictors of paroxysmal atrial fibrillation in patients undergoing aortic valve replacement. J Thorac Cardiovasc Surg, 2007, 134(6): 1569-1576.
20. Maesen B, Nijs J, Maessen J, et al. Post-operative atrial fibrillation: A maze of mechanisms. Europace, 2012, 14(2): 159-174.
21. Banach M, Kourliouros A, Reinhart KM, et al. Postoperative atrial fibrillation: What do we really know? Curr Vasc Pharmacol, 2010, 8(4): 553-572.
22. Goudis CA. Chronic obstructive pulmonary disease and atrial fibrillation: An unknown relationship. J Cardiol, 2017, 69(5): 699-705.
23. Khan AA, Lip GYH, Shantsila A. Heart rate variability in atrial fibrillation: The balance between sympathetic and parasympathetic nervous system. Eur J Clin Invest, 2019, 49(11): e13174.
24. Ye J, Wu M, He L, et al. Glutathione-s-transferase p 1 gene promoter methylation in cell-free DNA as a diagnostic and prognostic tool for prostate cancer: A systematic review and meta-analysis. Int J Endocrinol, 2023, 2023: 7279243.
25. Xi Y, Cheng J. Dysfunction of the autonomic nervous system in atrial fibrillation. J Thorac Dis, 2015, 7(2): 193-198.
26. Axtell AL, Moonsamy P, Melnitchouk S, et al. Preoperative predictors of new-onset prolonged atrial fibrillation after surgical aortic valve replacement. J Thorac Cardiovasc Surg, 2020, 159(4): 1407-1414.
27. Alam M, Lee VV, Elayda MA, et al. Association of gender with morbidity and mortality after isolated coronary artery bypass grafting. A propensity score matched analysis. Int J Cardiol, 2013, 167(1): 180-184.
28. Filardo G, Ailawadi G, Pollock BD, et al. Postoperative atrial fibrillation: Sex-specific characteristics and effect on survival. J Thorac Cardiovasc Surg, 2020, 159(4): 1419-1425.
29. Biddinger KJ, Emdin CA, Haas ME, et al. Association of habitual alcohol intake with risk of cardiovascular disease. JAMA Netw Open, 2022, 5(3): e223849.
30. Jiang H, Mei X, Jiang Y, et al. Alcohol consumption and atrial fibrillation risk: An updated dose-response meta-analysis of over 10 million participants. Front Cardiovasc Med, 2022, 9: 979982.
31. Cha MJ, Oh GC, Lee H, et al. Alcohol consumption and risk of atrial fibrillation in asymptomatic healthy adults. Heart Rhythm, 2020, 17(12): 2086-2092.
32. Arslan AK, Erdil N, Guldogan E, et al. Prediction of postcoronary artery bypass grafting atrial fibrillation: POAFRiskScore tool. Thorac Cardiovasc Surg, 2023, 71(4): 282-290.
33. Guzelburc O, Zengin A, Karatas MB, et al. Relationship between platelet mass index and postoperative atrial fibrillation after elective coronary artery bypass surgery: A retrospective study. Herz, 2023, 48(4): 309-315.

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