Adverse Events After Prolapse Surgery in Patients with Atrial Fibrillation

Objectives: To examine whether pre-operative diagnosis of atrial fibrillation (AF) in older women increases the risk of adverse outcomes within 8 weeks after pelvic organ prolapse (POP) surgery. We hypothesized that older patients with AF are more likely to experience perioperative adverse events (AEs) compared to those without AF.

Methods: This is a secondary analysis of a retrospective study examining perioperative AEs in women aged ≥61 years undergoing major POP surgery at a large academic center. We identified 80 patients with a preoperative diagnosis of AF and created a 1:3 matched cohort of patients without AF using age and Charlson Comorbidity Index (CCI) score. The primary outcome was perioperative AEs that occurred within 8 weeks of surgery including the following: intraoperative complications (conversion to open, bladder, ureteral, bowel injury, or estimated blood loss (EBL)≥500) and postoperative AEs (transfusion, return to operating room, readmission, emergency room evaluation, discharge to skilled nursing facility, cardiac complication, venous thromboembolism, hematoma, wound dehiscence, ileus/small bowel obstruction, surgical site infection, urinary tract infection, and other complications). AEs were analyzed as a composite variable as well as individually. Demographic and clinical variables were compared between patients with and without AF using T-test (Mann-Whitney U) and chi-square (Fisher’s exact) analyses as appropriate. Perioperative AEs were compared between the two groups in a similar fashion, and multivariable logistic regression was performed to examine the association between composite AEs and AF, controlling for any clinical variables with p< 0.05 on univariate analysis.

Results: In the matched cohort of 80 women with AF and 240 without AF, patients were on average 74.5 years (standard deviation (SD) 6.1) with a body mass index of 28.0kg/m2 (SD 5.0) and were predominantly White (95.6%). Patients with AF were more likely to be on an anticoagulant preoperatively (63.8% vs. 7.6%, p< 0.01) and have had a prior hysterectomy (52.5% vs. 36.7%, p=0.01). There were no differences in concomitant hysterectomy or incontinence procedure, length of surgery time, or EBL between patients with and without AF.

Composite perioperative AEs did not differ between the two groups, although surgical site infection was higher in the AF group (5.0% vs 0.8%, p=0.04). On multivariable analyses controlling for preoperative anticoagulant use and prior hysterectomy, there remained no association between composite AEs and AF. However, preoperative anticoagulant use was associated with a 2.14 higher adjusted odds of adverse events (95% CI 1.02– 4.46).

Conclusions: Pre-existing AF did not increase overall likelihood of perioperative AEs within 8 weeks of major POP surgery, except for surgical site infection. However, preoperative anticoagulant use was associated with a greater odds of perioperative AEs. Clinicians should consider optimizing perioperative management (specifically patient counseling on potential for adverse events and postoperative care planning) for patients using preoperative anticoagulation.