Postoperative Atrial Fibrillation– A Hypothetical Case

Two days have passed since a female patient underwent coronary artery bypass graft (CABG) surgery. As this patient reflects on how she should have taken better care of her body, her concentration is broken when she notices that her heart rhythm on the ECG monitor is no longer making that nice beep…..beep….beep sound. The nurse immediately notifies the patient’s cardiologist and he informs his patient that she has developed postoperative atrial fibrillation. Unfortunately, this will now delay her discharge from the hospital by a few days. Her cardiologist tells her that it is important to monitor the progression of the atrial fibrillation and the potential complications that may arise, such as hemodynamic instability (blood pressure changes and/or diminished cardiac output), stroke, and even death. The patient becomes slightly angry because this will prevent her from getting back to a normal life and routine in a timely fashion. Twenty-four hours pass and the atrial fibrillation has not spontaneously corrected itself. Her cardiologist then prescribes a commonly used antiarrhythmic drug. Her cardiologist explains that it takes time for this drug to build up to the correct therapeutic level to treat her atrial fibrillation. In addition, he tells her that as a precaution, he may also prescribe an anticoagulant. Forty-eight hours have passed and the patient’s cardiologist is concerned that the atrial fibrillation has not been corrected with the drugs that have been prescribed for her. He recommends that they perform external electrocardioversion to return her heart to a normal sinus rhythm. External electrical cardioversion will subject the patient to a large amount of electrical energy (100- 360 joules). A joule (J) is a way to measure electrical energy in the International System of Units (SI), much like Celsius is used to measure temperature.  As a comparison, 1J is equal to 1 watt/second. That is, a 100W light bulb uses 100J of electrical energy every second. The electrical energy needed to successfully cardiovert the patient is significant. Her cardiologist informs her that she will need to be sedated in order to perform the procedure and that an anesthesiologist will administer and monitor her sedation. After she is completely sedated, the patient is shocked 1 to 3 times with approximately 100- 360J of energy. After the procedure, the patient awakens from sedation with burn marks on her chest and she is experiencing some pain and discomfort. However, she is relieved when her cardiologist informs her that her heart rhythm has returned to normal. When the patient is finally discharged from the hospital, she thinks back on the long drawn-out process of administering the antiarrhythmic drugs, her anxiety of constantly waiting, being placed under anesthesia, and the burns she received on her chest…she wonders why no one has come up with a better solution for alleviating postoperative atrial fibrillation.