Management of Atrial Fibrillation in Patients Undergoing Mastoidectomy

Preoperative Anticoagulation Assessment

• The European Society of Cardiology recommends calculating the CHA₂DS₂-VASc score to determine thromboembolic risk, with patients having scores ≥2 (men) or ≥3 (women) requiring anticoagulation regardless of surgical timing 1, 3
• The CHA₂DS₂-VASc score is used to assess the risk of stroke in patients with atrial fibrillation, and is superior to older scoring systems in identifying high-risk patients 1, 3

Perioperative Anticoagulation Management

• The European Heart Society recommends continuing DOAC therapy without interruption through the perioperative period for mastoidectomy, as it is a low-to-moderate bleeding risk procedure 4, 2
• If the surgical team insists on brief interruption, hold the DOAC for 24 hours (1-2 doses) before surgery for standard renal function, then resume 6-8 hours post-procedure if hemostasis is adequate 1
• The American College of Cardiology recommends using full standard doses of DOACs unless specific dose-reduction criteria are met (advanced age with low body weight, renal impairment) 6

Rate Control During Perioperative Period

• The European Society of Cardiology recommends continuing beta-blockers throughout the perioperative period in all patients without contraindication, as withdrawal increases risk of postoperative atrial fibrillation 7, 6, 8
• Beta-blockers are recommended for rate control in patients with any ejection fraction, and alternative rate control agents (diltiazem, verapamil) can be used if LVEF >40% and beta-blockers are contraindicated 1, 7

Management of New-Onset or Worsening Atrial Fibrillation Perioperatively

• The European Heart Society recommends electrical cardioversion only if hemodynamic instability develops, and prioritizing rate control with intravenous beta-blockers (if LVEF preserved) or digoxin (any ejection fraction) for hemodynamically stable patients 1, 7, 9
• The American College of Cardiology recommends avoiding pharmacological cardioversion in the immediate perioperative period unless the patient is highly symptomatic and hemodynamically stable 7, 6

Special Considerations

• The European Society of Cardiology recommends optimizing modifiable bleeding risk factors (hypertension control, avoidance of NSAIDs, correction of anemia), but not using bleeding risk scores to withhold anticoagulation 1, 7
• The European Heart Society recommends avoiding combining anticoagulants with antiplatelet agents unless the patient has had a recent acute coronary syndrome or stent placement requiring dual antiplatelet therapy 1, 7, 6

Long-Term Management

• The European Society of Cardiology recommends continuing anticoagulation indefinitely based on CHA₂DS₂-VASc score, regardless of whether the patient remains in sinus rhythm postoperatively 1, 7, 6