Rationale and management of perioperative atrial fibrillation

Atrial fibrillation is the most common clinically relevant arrhythmia. Anesthesiologists will be faced with atrial fibrillation of new or undetermined onset at their preoperative evaluation of patients as well as during intra- and post operative care. Because of fast electrophysical and structural remodeling, atrial fibrillation tends to persist and reoccur after successful conversion with increasing time of duration. Therefore, atrial fibrillation with an onset of less than 48 hours should be attempt to convert as soon as diagnostic work up has been made and possible causes have been corrected. New developments of electrophysiological and pharmacological treatment have improved the short term success rate of cardioversion. Further developments might give even more specific treatment options for the individual patient. In contrast, for treatment of chronic atrial fibrillation rate control therapy and thromboembolic prophylaxes seems to be more advisable with a lower risk of drug side effects and stroke. Anticoagulation should be initiated not later than 48 hours after the onset of atrial fibrillation. Finally, the development of implantable devices for the treatment of atrial fibrillation seem to be a promising therapeutic option for patients in end-stage heart diseases.