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CLINICAL RESEARCH: CLINICAL TRIAL

Impact of Epicardial Anterior Fat Pad Retention on Postcardiothoracic Surgery Atrial Fibrillation Incidence

The AFIST-III Study

C. Michael White, PharmD^_*,,, Stephen Sander, PharmD^,, Craig I. Coleman, PharmD^,, Robert Gallagher, MD, Hiroyoshi Takata, MD, Chester Humphrey, MD, Nickole Henyan, PharmD^,, Effie L. Gillespie, PharmD^, and Jeffrey Kluger, MD^_*,||,_*

^_* Division of Cardiology, Hartford Hospital, Hartford, Connecticut
Division of Surgery, Hartford Hospital, Hartford, Connecticut
Division of Drug Information, Hartford Hospital, Hartford, Connecticut
University of Connecticut School of Pharmacy, Storrs, Connecticut
^|| University of Connecticut School of Medicine, Farmington, Connecticut.

Manuscript received July 24, 2006; revised manuscript received August 29, 2006, accepted September 11, 2006.

^_* Reprint requests and correspondence: Dr. Jeffrey Kluger, Heart Rhythm Service, Hartford Hospital, 80 Seymour Street, Suite 1001, Hartford, Connecticut 06102-5037. (Email: jkluger{at}harthosp.org).

OBJECTIVES: We conducted a randomized, blinded, controlled study evaluating the impact of anterior fat pad (AFP) maintenance on postoperative atrial fibrillation (POAF) incidence.

BACKGROUND: Drugs with antiadrenergic effects reduce POAF. Because the epicardial AFP is parasympathetically innervated, its routine excision during coronary artery bypass grafting (CABG) might precipitate autonomic imbalance and induce POAF.

METHODS: Patients (n = 180, mean age = 66 ± 10 years, 80% men, 5% with previous atrial fibrillation) undergoing CABG surgery were randomized to either AFP maintenance or AFP removal. Routine prophylaxis against POAF with beta-blockers (85%) and amiodarone (28%) was allowed on the basis of caregivers’ discretion. The development of POAF, total hospital costs, and heart rate variability was compared between groups.

RESULTS: Anterior fat pad maintenance did not reduce POAF incidence (34.8% vs. 35.2%, p = 0.950) or total hospital costs (data as medians with 25%, 75% percentiles: $22,940 [$17,629, $29,274] vs. $23,866 [$18,602, $30,370], p = 0.647) but was associated with higher heart rate variability (SD of normal-to-normal RR intervals [SDNN]: 31.7 ± 24.6 vs. 22.7 ± 8.3, p = 0.05 and SD of all 5-min mean RR intervals [SDANN 5]: 17.1 ± 11.9 vs. 10.1 ± 5.5, p = 0.003) than AFP removal.

CONCLUSIONS: Maintaining the AFP prevents attenuation of parasympathetic tone after CABG but does not reduce POAF or total hospital costs in any appreciable way.

Abbreviations and Acronyms   AFP = anterior fat pad   CABG = coronary artery bypass graft (surgery)   CI = confidence interval   HRV = heart rate variability   OR = odds ratio   POAF = postoperative atrial fibrillation

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