New-Onset Atrial Fibrillation in Patients Undergoing Liver Transplantation: Retrospective Analysis of Risk Factors and Outcomes


      The authors aimed to identify predictors of new-onset postoperative atrial fibrillation (POAF) during the initial 90 days following liver transplantation, and to assess the association between POAF in-hospital and 1-year mortality.


      A retrospective cohort study.


      At a university hospital between 2005 and 2017.


      Adults without a history of preoperative atrial fibrillation who underwent orthotopicliver transplantation.

      Measurement and Main Results

      The authors assessed the univariate association between new-onset of POAF in the postoperative period and each potential factor through a logistic regression model. Moreover, they explored predictors for POAF through stepwise selection. Finally, the authors assessed the relationship between POAF and in-hospital and 1-year mortality using logistic regression models, and whether the duration of atrial fibrillation was associated with in-hospital and 1-year mortality. Among 857 patients, 89 (10.4%) developed POAF. Using only preoperative variables, pulmonary hypertension, age, Model for End-Stage Liver Disease (MELD) score, and White race were identified as the most important predictors. Model discrimination was 0.75 (95% CI: 0.69-0.80), and incorporating intraoperative variables was 0.77 (95% CI: 0.72-0.82). In-hospital mortality was observed in 7.2% (6/83) of patients with new-onset of POAF, and in 2.8% (22/768) without, with confounder-adjusted odds ratio (OR) 1.00 (97.5% CI: 0.29,3.45; p = 0.996). One-year mortality was 22.4% (20/89) in patients who developed POAF and 8.3% (64/768) in patients who did not, confounder-adjusted OR 2.64 (97.5% CI: 1.35-5.16; p = 0.001). The duration of POAF did not affect long-term postoperative mortality.


      Preoperative, mostly unmodifiable comorbidities are important risk factors for new-onset POAF after liver transplantation. The POAF was not associated with in-hospital mortality, but with increased 1-year mortality. Once developed, the duration of POAF did not affect long-term mortality after a liver transplant.


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      1. Organ Procurement and Transplantation Network. OPTN/SRTR 2019 annual data report: Liver. Available at: Accessed.

        • VanWagner LB
        • Serper M
        • Kang R
        • et al.
        Factors associated with major adverse cardiovascular events after liver transplantation among a national sample.
        Am J Transplant. 2016; 16: 2684-2694
        • VanWagner LB
        • Harinstein ME
        • Runo JR
        • et al.
        Multidisciplinary approach to cardiac and pulmonary vascular disease risk assessment in liver transplantation: An evaluation of the evidence and consensus recommendations.
        Am J Transplant. 2018; 18: 30-42
        • VanWagner LB
        • Ning H
        • Whitsett M
        • et al.
        A point-based prediction model for cardiovascular risk in orthotopic liver transplantation: The CAR-OLT score.
        Hepatology. 2017; 66: 1968-1979
        • Koshy AN
        • Gow PJ
        • Han HC
        • et al.
        Cardiovascular mortality following liver transplantation: Predictors and temporal trends over 30 years.
        Eur Heart J Qual Care Clin. 2020; 6: 243-253
        • Appleton CP
        • Hurst RT
        • Lee KS
        • et al.
        Long-term cardiovascular risk in the orthotopic liver transplant population.
        Liver Transpl. 2006; 12: 352-355
        • Schnabel RB
        • Yin X
        • Larson MG
        • et al.
        Fifty-year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the community renate.
        Lancet. 2015; 386: 154-162
        • Walsh SR
        • Tang T
        • Wijewardena C
        • et al.
        Postoperative arrhythmias in general surgical patients.
        Ann R Coll Surg Engl. 2007; 89: 91-95
        • Kanji S
        • Williamson DR
        • Yaghchi BM
        • et al.
        Epidemiology and management of atrial fibrillation in medical and noncardiac surgical adult intensive care unit patients.
        J Crit Care. 2012; 27 (326.e1-8)
        • Alonso-Coello P
        • Cook D
        • Xu SC
        • et al.
        Predictors, prognosis, and management of new clinically important atrial fibrillation after noncardiac surgery: A prospective cohort study.
        Anesth Analg. 2017; 125: 162-169
        • Son YG
        • Lee H
        • Oh SY
        • et al.
        Risk factors for intensive care unit readmission after liver transplantation: A retrospective cohort study.
        Ann Transplant. 2018; 23: 767-774
        • Piccini JP
        • Hammill BG
        • Sinner MF
        • et al.
        Incidence and prevalence of atrial fibrillation and associated mortality among medicare beneficiaries: 1993-2007.
        Circ Cardiovasc Qual Outcomes. 2012; 5: 85-93
        • Chokesuwattanaskul R
        • Thongprayoon C
        • Bathini T
        • et al.
        Liver transplantation and atrial fibrillation: A meta-analysis.
        World J Hepatol. 2018; 10: 761-771
        • Huang WA
        • Dunipace EA
        • Sorg JM
        • et al.
        Liver disease as a predictor of new-onset atrial fibrillation.
        J Am Heart Assoc. 2018; 7e008703
        • Bargehr J
        • Trejo-Gutierrez JF
        • Rosser BG
        • et al.
        Liver transplantation in patients with atrial fibrillation.
        Transplant Proc. 2013; 45: 2302-2306
        • Vannucci A
        • Rathor R
        • Vachharajani N
        • et al.
        Atrial fibrillation in patients undergoing liver transplantation - A single-center experience.
        Transplant Proc. 2014; 46: 1432-1437
        • Moon YJ
        • Kwon HM
        • Park YS
        • et al.
        Brief episodes of newly developed intraoperative atrial fibrillation predicts worse outcomes in adult liver transplantation.
        Transplant Proc. 2018; 50: 1142-1146
        • Molinari M
        • Sood P
        • Samra PB
        • et al.
        Atrial fibrillation in renal or liver transplant recipients: A systematic review and meta-analysis.
        Transplant Rev. 2019; 33: 29-38
        • Dutkowski P
        • Linecker M
        • Deoliveira ML
        • et al.
        Challenges to liver transplantation and strategies to improve outcomes.
        Gastroenterology. 2015; 148: 307-323
        • Koshy AN
        • Enyati A
        • Weinberg L
        • et al.
        Postoperative atrial fibrillation and long-term risk of stroke in patients undergoing liver transplantation.
        Stroke. 2021; 52: 111-120
        • Rachwan RJ
        • Kutkut I
        • Hathaway TJ
        • et al.
        Postoperative atrial fibrillation and flutter in liver transplantation: An important predictor of early and late morbidity and mortality.
        Liver Transplant. 2020; 26: 34-44
        • Xia VW
        • Worapot A
        • Huang S
        • et al.
        Postoperative atrial fibrillation in liver transplantation.
        Am J Transplant. 2015; 15: 687-694
        • Dogan U
        • Yaprak M
        • Dogan EA
        • et al.
        Cardiac and neurologic complications in the late period after liver transplantation: A retrospective analysis of 4 years.
        Transplant Proc. 2019; 51: 1153-1156
        • Peduzzi P
        • Concato J
        • Kemper E
        • et al.
        A simulation study of the number of events per variable in logistic regression analysis.
        J Clin Epidemiol. 1996; 49: 1373-1379
        • Duceppe E
        • Parlow J
        • MacDonald P
        • et al.
        Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery.
        Can J Cardiol. 2017; 33: 17-32
        • Fernando SM
        • Mathew R
        • Hibbert B
        • et al.
        New-onset atrial fibrillation and associated outcomes and resource use among critically ill adults - a multicenter retrospective cohort study.
        Crit. Care Critical Care. 2020; 24: 15
        • Izzy M
        • VanWagner LB
        • Lin G
        • et al.
        Redefining cirrhotic cardiomyopathy for the modern era.
        Hepatology. 2020; 71: 334-345
        • Flores A
        • Asrani SK.
        The donor risk index: A decade of experience.
        Liver Transplant. 2017; 23: 1216-1225