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Acute bypass graft occlusion (check the ECG)

SVT in a cardiac surgery patient

Patrick Murray

Supraventricular tachycardia (SVT) in a cardiac surgery patient

Also known as:

  • SVT, which incorporates supraventricular arrhythmias (SVA)
  • Paroxysmal SVT, a subset of SVTs commonly used to describe those with a sudden or paroxysmal onset, such as AV nodal re-entrant tachycardias (AVNRT), AV re-entrant tachycardias (AVRT), and atrial tachycardias
  • Atrial arrhythmias: this includes atrial fibrillation, atrial flutter, and atrial tachycardia.

Related condtions:

  • Atrial fibrillation
  • Atrial flutter (macro-re-entrant tachycardia)
  • AV nodal re-entrant tachycardia (AVNRT)
  • AV re-entrant tachycardia (AVRT) (eg, Wolff-Parkinson-White syndrome [WPW] and accessory pathways)
  • Junctional tachycardias
  • Atrial tachycardias, including focal atrial tachycardia, multifocal atrial tachycardia

1. Description of the problem

This topic deals predominantly with atrial fibrillation (AF) and atrial flutter (AFlutter), the two most common SVTs occurring during cardiac surgery. For a comprehensive review of other SVT subtypes and their clinical features, see the chapter “SVT (non-cardiac surgery).”

SVTs, in particular AF, have a significant impact on mortality and morbidity, by increasing stroke and thromboembolic risk, increasing progression to ventricular arrhythmias, precipitating hemodynamic instability, as well as increasing hospital stay and increasing risks from iatrogenic interventions (anticoagulation, pacemakers, arrhythmic drugs).

SVT occurring in the setting of cardiac surgery requires several key considerations:

1. Preoperative assessment: how to manage patients with a history of SVT, how to manage patients taking oral anticoagulation, and what predisposing factors are associated with development of SVT

2. Perioperative period: how to prevent de novo or recurrent SVTs from occurring

3. Postoperative period: which SVTs tend to occur depending on the type of cardiac surgery

AF is the most common SVT occurring in the perioperative period for cardiac surgery, and it occurs in an estimated 30% of patients undergoing coronary artery bypass grafting (CABG), 40% of those undergoing valvular surgery, and 50-55% of patients having combined procedures.

Furthermore, the mechanisms of onset of SVT, as well as the type of cardiac surgery, also require individual consideration, as patients with congenital heart disease undergoing Senning or Mustard repairs will have different comorbidities than patients with degenerative valvular disease, those with ischemic heart disease, or those requiring orthotopic cardiac transplantation.

Patients with surgically repaired congenital heart disease may experience tachyarrhythmias/SVTs as a result of hemodynamic disturbances, and thus an extensive evaluation of residual shunts/intracardiac pressures is often warranted sooner than for those with SVTs and acquired heart disease.

Atrial tachycardias are common after mitral valve surgery, occurring in the early postoperative period (due to transient ischemia, pericarditis, type of surgical approach) as well as in the late postoperative period (multifactorial – aging, myocardial remodeling).