Atrial Fibrillation in the Perioperative Period of Liver Transplantation: An Integrative Review

Cardoso, Rayanne Meirelly Vasconcelos; Fonseca Neto, Olival Cirilo Lucena da

doi:10.53855/bjt.v27i1.601_ENG

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Brazilian Journal of Transplantation

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REVIEW ARTICLE • Braz. J. Transplant. 27 • 2024 • https://doi.org/10.53855/bjt.v27i1.601_ENG copy

Atrial Fibrillation in the Perioperative Period of Liver Transplantation: An Integrative Review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To review the development of atrial fibrillation (AF) during the perioperative period (intraoperative and postoperative) in liver transplant recipients.

Methods:

This integrative review sought to analyze the emergence of AF in the perioperative period of liver transplantation and its associated factors. The following databases were used: PubMed, MEDLINE, SciELO, and Scopus. The descriptors were interchanged using the boolean operator “AND”, with a time restriction of 10 years, in English and Portuguese. Initially, 305 articles were found, of which nine met the proposed objective after analysis.

Results:

In this review, nine articles were selected, categorized according to the onset of AF concerning liver transplant surgery: three concerning the onset of AF in the intraoperative period and six in the postoperative period. During the intraoperative period, cases of AF had a higher incidence after reperfusion of the liver graft. In addition, the group with AF had a higher incidence of liver failure, a higher model for end-stage liver disease (MELD) scores, higher serum total bilirubin concentrations, and increased international normalized ratio (INR) values. AF in the postoperative period was associated with older patients, higher MELD scores, and renal dysfunction. Hospital stay was prolonged, and the risk of mortality was increased in patients with postoperative AF.

Conclusion:

The appearance of AF in the perioperative period of liver transplantation suggests a correlation with patients with higher MELD scores, advanced age, and instability during surgery and may indicate a poor prognosis for the patient.

Descriptors
Atrial Fibrillation; Liver Transplantation; Intraoperative Period; Postoperative Period

Reference/ country	Year of publication	Type ofStudy	Studyobjective	Sample size	Incidence of AF	Main results
Prakash et al.⁸8 Prakash K, Karna ST, Pandey CK. Atrial fibrillation during anhepatic phase liver transplantation: now what? J Anaesthesiol Clin Pharmacol 2019; 35(2): 269-71. https://doi.org/10.4103/joacp.JOACP_234_17 https://doi.org/10.4103/joacp.JOACP_234_... India	2019	Case report	Report the occurrence of SVT and AF during the anhepatic phase of living donor LTx and describe its management.	1	-	New-onset SVT or AF may occur in the anhepatic phase of LTx. Factors attributed to the development of AF during LTx include alcoholism, hypomagnesemia, preexisting cardiac conditions, massive blood loss, and acid-base and electrolyte imbalances. Although AF may be present preoperatively, it has also been described after reperfusion.
Li et al.⁹9 Li X, Wang X, Guan Z. New onset atrial fibrillation during orthotopic liver transplantation induced by iced saline injection for transpulmonary thermodilution: a case report. J Int Med Res 2022; 50(10): 03000605221132711. https://doi.org/10.1177/03000605221132711 https://doi.org/10.1177/0300060522113271... China	2022	Case report	To describe the case of a patient who presented with new-onset AF during orthotopic liver transplantation that may have been induced by injection of ice-cold saline to measure TPTD.	1	-	AF occurs during the dissection of the recipient’s liver. The incidence of AF was due to the infusion of cold saline solution to measure TPTD during orthotopic liver transplantation. The onset of AF during LTx can be self-limited, often lasting between 1 hour and 1 week.
Moon et al.¹⁰10 Moon Y-J, Kwon H-M, Park Y-S, Kim S-H, Hwang G-S. Brief episodes of newly developed intraoperative atrial fibrillation predicts worse outcomes in adult liver transplantation. Transplant Proc 2018; 50(4): 1142-6. https://doi.org/10.1016/j.transproceed.2018.01.039 https://doi.org/10.1016/j.transproceed.2... South Korea	2018	Retrospective cohort study	To describe the occurrence of newly developed IOAF during LTx and evaluate patient outcomes concerning the duration of AF.	1,059	1.20%	Higher MELD scores and fulminant liver failure may contribute to developing IOAF.

Moon et al.¹⁰10 Moon Y-J, Kwon H-M, Park Y-S, Kim S-H, Hwang G-S. Brief episodes of newly developed intraoperative atrial fibrillation predicts worse outcomes in adult liver transplantation. Transplant Proc 2018; 50(4): 1142-6. https://doi.org/10.1016/j.transproceed.2018.01.039 https://doi.org/10.1016/j.transproceed.2...	Age	MELD	INR	Serum bilirubin
Patients with IOAF	45.4	31.5	2.8	34.7
Patients without IOAF	50.6	18.8	1.7	2.8

Reference/ country	Year of publication	Type of Study	Studyobjective	Sample size	Incidence of AF	Mainresults
Xia et al.⁵5 Xia VW, Worapot A, Huang S, Dhillon A, Gudzenko V, Backon A, et al. Postoperative atrial fibrillation in liver transplantation. Am J Transplant 2015; 15(3): 687-94. https://doi.org/10.1111/ajt.13034 https://doi.org/10.1111/ajt.13034... USA	2015	Retrospective cohort study	To investigate the incidence, impact and risk factors of POAF in patients with LTx.	1,387	7.4%	Patients with POAF were significantly older, with higher MELD scores and baseline creatinine levels. A history of AF before LTx and the need for a pre-transplant vasopressor was significantly associated with the development of POAF after LTx. Hospital stays were significantly more extended in patients who developed POAF. The incidence of acute kidney injury in the POAF group was 24.3%, considerably higher than that in the non-POAF group (11.8%).
Nicolau-Raducu et al.¹¹11 Nicolau-Raducu R, Gitman M, Ganier D, Loss GE, Cohen AJ, Patel H, et al. Adverse cardiac events after orthotopic liver transplantation: a cross-sectional study in 389 consecutive patients. Liver Transpl 2015; 21(1): 13-21. https://doi.org/10.1002/lt.23997 https://doi.org/10.1002/lt.23997... USA	2015	Retrospective cohort study	To investigate the role of reported predictor variables on the incidence of early and late cardiac morbidity and mortality in a high-risk group of liver transplant recipients.	389	2.6%	During the initial year after LTx, cardiovascular morbidity and mortality rates of 15.2 and 2.8%, respectively, were observed. Among patients crossing the 1st year, morbidity and mortality rates were 3.9 and 2%, with cardiovascular etiology being the third cause of death.
Koshy et al.⁶6 Koshy AN, Enyati A, Weinberg L, Han H-C, Horrigan M, Gow P, et al. Postoperative atrial fibrillation and long-term risk of stroke in patients undergoing liver transplantation. Stroke 2021; 52(1): 111-20. https://doi.org/10.1161/STROKEAHA.120.031454 https://doi.org/10.1161/STROKEAHA.120.03... Australia	2021	Retrospective cohort study	To evaluate whether POAF was associated with the risk of stroke and systemic embolism in an unselected population of patients undergoing LTx	461	10.2%	POAF after LTx is common and is associated with an eightfold increased risk of thromboembolic events, and the use of the CHA₂DS₂-VASc score may facilitate adequate risk stratification of these patients.
Molinari, Michele et al.¹⁴14 Molinari M, Sood P, Samra PB, Tevar A, Ganoza A, Jonassaint N, et al. Atrial fibrillation in renal or liver transplant recipients: a systematic review and meta-analysis. Transplant Rev 2019; 33(1) 29-38. https://doi.org/10.1016/j.trre.2018.07.003 https://doi.org/10.1016/j.trre.2018.07.0... USA	2019	Meta-analysis	To evaluate whether the presence of AF in kidney and liver transplant recipients was associated with inferior patient and graft survival.	2,239	6.8%	In the presence of AF, the risk of mortality increased by 2.3 for LTx recipients. The risk of graft loss showed no statistically significant difference after LTx, probably due to the small number of patients with LTx and AF.
Rivas et al.¹²12 Rivas E, Sasaki K, Liang C, Wang J, Quintini C, Maheshwari K, et al. New-onset atrial fibrillation in patients undergoing liver transplantation: retrospective analysis of risk factors and outcomes. J Cardiothorac Vasc Anesth 2022; 36(11): 4100-7. https://doi.org/10.1053/j.jvca.2022.07.013 https://doi.org/10.1053/j.jvca.2022.07.0... USA	2022	Retrospective cohort study	To identify predictors of new-onset POAF during the first 90 days after LTx and evaluate the association between POAF and in-hospital and 1-year mortality.	857	10.4%	Patients who had new-onset AF were older, more likely to be white, have a higher MELD score, and more likely to have a history of renal dysfunction requiring dialysis, coronary artery disease, hypertension, chronic obstructive pulmonary disease, ascites, hepatorenal syndrome and pulmonary hypertension.
Rachwan et al.¹³13 Rachwan RJ, Kutkut I, Hathaway TJ, Timsina LR, Kubal CA, Lacerda MA, et al. Postoperative atrial fibrillation and flutter in liver transplantation: an important predictor of early and late morbidity and mortality. Liver Transpl 2020; 26(1): 34-44. https://doi.org/10.1002/lt.25631 https://doi.org/10.1002/lt.25631... USA	2020	Retrospective cohort study	Determine the incidence of POAF, identify associated risk factors and evaluate outcomes in FTx.	1,011	10%	The incidence of POAF was significantly higher in patients with non-alcoholic fatty liver disease. A higher MELD score and age over 50 were also factors associated with an increased incidence of POAF.

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[1] * Corresponding author: rayannemeirelly16@gmail.com