The identification of risk factors for perioperative atrial arrhythmias is crucial in order to direct prophylactic measures to the appropriate patients. Several different studies have consistently shown that the single best indicator for the development postoperative atrial fibrillation is advanced age (over 60 in most studies). In other studies major risk factors for postoperative AF include increased age (over 60 years), higher preoperative baseline heart rate, male sex, nonblack race, cancer staging or tumor size, extent of lung resection, history of hypertension, and congestive heart failure [1, 11, 12]. Results from a study by Amar and colleagues demonstrated that in patients receiving major thoracic operations, the incidence of postoperative AF increased with age: 4 % at younger than 50 years; 8 % from 50 to 59 years; 14 % from 60 to 69 years, and 25 % at 70 years or older [13]. In another investigation by Hollings and colleagues, age greater than 50 years was associated with a significant risk in the incidence of postoperative AF [4].

Wu and colleagues reviewed 10, 563 patients and found seven risk factors for developing intraoperative atrial fibrillation: increasing age, male sex, lung cancer, general anesthesia plus paravertebral block, open operation, resection of one or more lobes, and increased operation time [9]. Passman and colleagues sought to derive and validate a clinical prediction rule to risk-stratify patients for postoperative AF [5]. This study had 856 patients with a 17.2 % incidence of atrial fibrillation. Using logistic regression, they found that male gender, advanced age, and heart rate >72 bpm on preoperative EKG were independent predictors of postoperative atrial fibrillation. A risk score was assigned with male gender and heart rate greater than or equal to 72 beats per minute each receiving 1 point, and age 55–74 and greater than or equal to 75 years receiving 3 and 4 points, respectively. The clinical score developed was predictive of atrial fibrillation risk in both the derivation and validation models. The risk of postoperative AF ranged from 0 % (0 points) to 14 % (4 points), 21 % (5 points), and 32 % (6 points)

There is evidence that the extent of pulmonary resection is a risk factor for arrhythmia. Anatomic pulmonary resections, such as lobectomy, bilobectomy, and pneumonectomy, have been repeatedly associated with increasing relative risk of postoperative arrhythmia compared with non-anatomic and sublobar resections [3, 6, 11, 14]. Vaporciyan et al. found that increasing the volume of lung resected was associated with increased risk of AF [6]. Lobectomy, bilobectomy, and pneumonectomy were associated with progressively increasing relative risk of developing atrial fibrillation (18, 25, 30 % respectively) Using univariate analysis Onaitis found that increasing extent of operation was a predictor of postoperative atrial arrhythmia (pneumonectomy vs. lobectomy, OR 1.71, 95 % CI 1.43–2.04, p = 0.0001 and bilobectomy vs. lobectomy, OR 1.44, 95 % CI 1.16–1.80, p = 0.001) [11]. In multivariate analysis, increasing extent of operation was associated with higher rates of atrial fibrillation (any type pneumonectomy vs lobectomy, OR1.95 95 % CI 1.52–2.50, p = 0.0001 and bilobectomy versus lobectomy OR 1.69 95 % CI 1.31–2.18 p = 0.0001) Ciriaco and colleagues found an overall rate of atrial fibrillation in patients undergoing lung resection to be 13 % [15]. Patients undergoing pneumonectomy had a rate of 33 %, lobectomy 12 %, and minor resections had a 0 % rate of atrial fibrillation. Seely et al. also found increasing incidence of atrial fibrillation with more volume resected (17.4 % after lobectomy and 22.6 % after pneumonectomy) [16].

As the interest in minimally invasive approaches to anatomic pulmonary resection has increased, some authors have suggested that utilization of video-assisted thoracic surgery (VATS) may reduce the incidence of postoperative supraventricular arrhythmias. This suggestion, however, is controversial. Villamizer et al. reported a significantly lower incidence of atrial fibrillation among 697 patients after a VATS approach compared with 382 patients after thoracotomy (16 % vs 22 %, p = 0.01) [17]. When a propensity score-matched approach was used, the difference persisted among the two groups (13 % vs. 21 %, p = 0.01). By contrast, Park and colleagues found a similar incidence of atrial fibrillation in a group of 122 patients undergoing VATS lobectomy when compared to a group of 122 patients, age and gender matched, undergoing thoracotomy [18]. Atrial fibrillation occurred in 12 % of patients (15/122) undergoing VATS and 16 % (20/122) undergoing thoracotomy (p = 0.36). Whitson and colleagues reported similar results in a systematic review of the existing literature of VATS versus thoracotomy for lobectomy in lung cancer patients [19]. The mean rate of postoperative atrial fibrillation in 1,095 VATS patients was 5.2 % (95 % CI 2.0–8.4) versus 9 % (95 % CI 2.1–15.8) in 294 patients after thoracotomy (p = 0.33). Hollings and colleagues retrospectively reviewed 360 patients who underwent lobectomy and found that AF occurred in 15 of 54 patients (27 %) undergoing VATS versus 39 of 306 patients (16 %) undergoing thoracotomy [4]. This was not statistically significant (P = 0.054). Due to discordant data, the type of surgery cannot be used as a predictor for atrial fibrillation until further studies are done.

Table 10.2 shows the results of the studies examining the efficacy of different pharmacologic strategies for the prevention of postoperative atrial fibrillation. Two systematic reviews and one guideline paper have shown that calcium-channel blockers and beta blockers are effective in reducing postoperative supraventricular arrhythmias. Due to their potential adverse effects, their use should be individualized [24–26].