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The prediction of atrial fibrillation following coronary artery bypass graftingGibson, Patrick H. January 2010 (has links)
Atrial fibrillation (AF) is one of the most frequent complications following coronary artery bypass grafting (CABG), occurring in up to 40% of patients. This thesis investigates the utility of non-invasive markers of left ventricular filling pressure in predicting AF in this setting, and assesses a novel marker of inflammation in the same role. Given the haemodynamic changes occurring peri-operatively it was hypothesised that acute changes in left ventricular filling pressure (LVFP), and resulting atrial stretch, might predispose to post-operative AF. Levels of the natriuretic peptides, BNP and NT-proBNP, were measured pre-operatively in 275 patients undergoing non-emergency CABG, and detailed echocardiographic examination performed. The natriuretic peptides were higher in patients who developed AF, and both were independently predictive of post-operative AF in multivariable analysis. However, their clinical utility appears modest in this role. The only significant echocardiographic predictors of AF were the transmitral E to A-wave ratio and the early mitral annulus velocity. None of the echocardiographic parameters remained independently predictive in multivariable analysis. The strongest echocardiographic correlate of both BNP and NT-proBNP was the left atrial volume index (LAVi), a marker of chronic LV filling pressure. Patients undergoing CABG are subject to a significant peri-operative inflammatory response. This was investigated in the same cohort by means of the neutrophil/lymphocyte (N/L) ratio. Patients who developed AF had greater pre- and post-operative N/L ratios, with no preoperative differences observed in other white blood cell parameters or C-reactive protein. In multivariate models, a greater post-operative N/L ratio was independently associated with the incidence of AF. In patients undergoing CABG, AF remains difficult to predict from pre-operative variables, although age appears to be a consistent factor. Difficulties in the prediction of AF in this setting are likely to reflect the heterogeneity of influences on the development of the arrhythmia in this setting.
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