Prophylaxis and Management of Atrial Fibrillation Associated With General Thoracic Surgery

Patients taking
-blockers before GTS should have
-blockade continued (at reduced dose if epidural analgesia is used) in the postoperative period. (B, Class I)

Diltiazem prophylaxis is reasonable in most patients undergoing major pulmonary resection who are not taking a
-blocker preoperatively. As with
-blockers, hypotension may develop in some patients receiving diltiazem prophylaxis, and dose reduction or other pressure-elevating therapies may be required. (B, Class IIa)

Amiodarone prophylaxis is reasonable to reduce the incidence of atrial fibrillation after GTS (excluding pneumonectomy), according to strict dosing regimens. For patients undergoing pulmonary lobectomy, the recommended dose is 1,050 mg by continuous infusion over the first 24 hours after surgery (43.75 mg/h), followed by 400 mg orally twice daily for 6 days. For patients undergoing esophagectomy, the recommended dose is continuous intravenous (IV) infusion at a rate of 43.75 mg/h (1,050 mg daily) for 4 days. (B, Class IIa)

Amiodarone is not recommended, outside of clinical studies, for patients undergoing pneumonectomy, until additional data addressing its potential toxicity in this setting are available. (B, Class III)

Magnesium supplementation is reasonable to augment the prophylactic effects of other medications. (B, Class IIa)

It may be reasonable to initiate new
-blockers for prophylaxis against postoperative AF after GTS, but their use is more limited by side effects than diltiazem and thus less broadly applicable. (B, Class IIb)

Flecainide is not recommended for prophylaxis of postoperative atrial fibrillation after GTS. (B, Class III)

Digitalis should not be used as a prophylactic agent against atrial fibrillation after GTS. (A, Class III)