Atrial Arrhythmias Following Pulmonary Thromboendarterectomy: A Comprehensive Review Of Current Literature




Atrial arrhythmias, postoperative atrial fibrillation, chronic thromboembolic pulmonary hypertension, pulmonary thromboendarterectomy, narrative review


Chronic thromboembolic pulmonary hypertension (CTEPH) presents as a progressive vascular condition arising from previous episodes of acute pulmonary embolism, contributing to the development of pulmonary hypertension (PH). Pulmonary thromboendarterectomy (PTE) is the gold-standard surgical treatment for CTEPH; however, it may be associated with postoperative sequelae, including atrial arrhythmias (AAs). This comprehensive literature review explores the potential mechanisms for PTE-induced AAs with emphasis on the role of PH-related atrial remodelling and the predisposing factors. The identified preoperative predictors for AAs include advanced age, male gender, elevated resting heart rate, previous AAs, and baseline elevated right atrial pressure. Furthermore, we explore the available data on the association between post-PTE pericardial effusions and the development of AAs. Lastly, we briefly discuss the emerging role of radiomic analysis of epicardial adipose tissue as an imaging biomarker for predicting AAs.


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Simonneau G, Montani D, Celermajer DS, Denton CP, Gatzoulis MA, Krowka M, et al. Haemodynamic definitions and updated clinical classification of pulmonary hypertension. European Respiratory Journal [Internet]. 2019 Jan 1 [cited 2023 Sep 21];53(1). Available from: /53/1/1801913

Madani MM. Surgical Treatment of Chronic Thromboembolic Pulmonary Hypertension: Pulmonary Thromboendarterectomy. Methodist Debakey Cardiovasc J. 2016;12(4):213–8.

Amsallem M, Guihaire J, Ataam JA, Lamrani L, Boulate D, Mussot S, et al. Impact of the initiation of balloon pulmonary angioplasty program on referral of patients with chronic thromboembolic pulmonary hypertension to surgery. The Journal of Heart and Lung Transplantation. 2018 Sep 1;37(9):1102–10.

Fedullo P, Kerr KM, Kim NH, Auger WR. Chronic thromboembolic pulmonary hypertension. Am J Respir Crit Care Med. 2011 Jun 15;183(12):1605–13.

Lang IM, Madani M. Update on Chronic Thromboembolic Pulmonary Hypertension. Circulation. 2014 Aug 5;130(6):508–18.

Jamieson SW, Auger WR, Fedullo PF, Channick RN, Kriett JM, Tarazi RY, et al. Experience and results with 150 pulmonary thromboendarterectomy operations over a 29-month period. The Journal of Thoracic and Cardiovascular Surgery. 1993 Jul 1;106(1):116 –27.

Deng L, Quan R, Yang Y, Yang Z, Tian H, Li S, et al. Characteristics and long-term survival of patients with chronic thromboembolic pulmonary hypertension in China. Respirology. 2021;26(2):196 –203.

Jenkins D. Pulmonary endarterectomy: the potentially curative treatment for patients with chronic thromboembolic pulmonary hypertension. European Respiratory Review. 2015 Jun 1;24(136):263–71.

Sadeghi HM, Kimura BJ, Raisinghani A, Blanchard DG, Mahmud E, Fedullo PF, et al. Does lowering pulmonary arterial pressure eliminate severe functional tricuspid regurgitation? Insights from pulmonary thromboendarterectomy. J Am Coll Cardiol. 2004 Jul 7;44(1):126–32.

Fernandes TM, Auger WR, Fedullo PF, Kim NH, Poch DS, Madani MM, et al. “Baseline Body Mass Index Does Not Significantly Affect Outcomes after Pulmonary Thromboendarterectomy.” Ann Thorac Surg. 2014 Nov;98(5):1776–81.

Kamenskaya O, Klinkova A, Loginova I, Chernyavskiy A, Edemskiy A, Lomivorotov VV, et al. Determinants of Health-Related Quality of Life 1 Year after Pulmonary Thromboendarterectomy. Ann Vasc Surg. 2018 Aug;51:254–61.

Farasat S, Papamatheakis DG, Poch DS, Higgins J, Pretorius VG, Madani MM, et al. Atrial arrhythmias after pulmonary thromboendarterectomy. J Card Surg. 2019 May;34(5):312–7.

Havranek S, Fingrova Z, Ambroz D, Jansa P, Kuchar J, Dusik M, et al. Atrial fibrillation and atrial tachycardia in patients with chronic thromboembolic pulmonary hypertension treated with pulmonary endarterectomy. Eur Heart J Suppl. 2020 Jul;22(Suppl F):F30–7.

Liu Z, Zhen Y, Lin F, Zheng X, Liu X, Sun G, et al. Resting heart rate as a preoperative predictor of postoperative atrial fibrillation after pulmonary thromboendarterectomy. J Card Surg. 2022 Jun;37(6):1644–50.

Liu Z, Deng Y, Wang X, Liu X, Zheng X, Sun G, et al. Radiomics signature of epicardial adipose tissue for predicting postoperative atrial fibrillation after pulmonary endarterectomy. Frontiers in Cardiovascular Medicine [Internet]. 2023 [cited 2023 Sep 23];9. Available from: articles/10.3389/fcvm.2022.1046931

Pietra GG, Capron F, Stewart S, Leone O, Humbert M, Robbins IM, et al. Pathologic assessment of vasculopathies in pulmonary hypertension. J Am Coll Cardiol. 2004 Jun 16;43(12 Suppl S):25S-32S.

Medi C, Kalman JM, Ling LH, Teh AW, Lee G, Lee G, et al. Atrial electrical and structural remodeling associated with longstanding pulmonary hypertension and right ventricular hypertrophy in humans. J Cardiovasc Electrophysiol. 2012 Jun;23(6):614–20.

Folino AF, Bobbo F, Schiraldi C, Tona F, Romano S, Buja G, et al. Ventricular arrhythmias and autonomic profile in patients with primary pulmonary hypertension. Lung. 2003;181(6):321–8.

Schrier RW, Bansal S. Pulmonary hypertension, right ventricular failure, and kidney: different from left ventricular failure? Clin J Am Soc Nephrol. 2008 Sep;3(5):1232–7.

Olsson KM, Nickel NP, Tongers J, Hoeper MM. Atrial flutter and fibrillation in patients with pulmonary hypertension. Int J Cardiol. 2013 Sep 1;167(5):2300–5.

Adams DC, Heyer EJ, Simon AE, Delphin E, Rose EA, Oz MC, et al. Incidence of atrial fibrillation after mild or moderate hypothermic cardiopulmonary bypass. Crit Care Med. 2000 Feb;28(2):309–11.

Hashemzadeh K, Dehdilani M, Dehdilani M. Postoperative Atrial Fibrillation following Open Cardiac Surgery: Predisposing Factors and Complications. J Cardiovasc Thorac Res. 2013;5(3):101–7.

Sun LS, Adams DC, Delphin E, Graham J, Meltzer E, Rose EA, et al. Sympathetic response during cardiopulmonary bypass: Mild versus moderate hypothermia. Critical Care Medicine. 1997 Dec;25(12):1990.

Tokunaga S, Imaizumi T, Fukae K, Nakashima A, Hisahara M, Tominaga R, et al. Effects of hypothermia during cardiopulmonary bypass and circulatory arrest on sympathetic nerve activity in rabbits. Cardiovascular Research. 1996 May 1;31(5):769–76.

Kalman JM, Munawar M, Howes LG, Louis WJ, Buxton BF, Gutteridge G, et al. Atrial fibrillation after coronary artery bypass grafting is associated with sympathetic activation. Ann Thorac Surg. 1995 Dec;60(6):1709–15.

Carnagarin R, Kiuchi MG, Ho JK, Matthews VB, Schlaich MP. Sympathetic Nervous System Activation and Its Modulation: Role in Atrial Fibrillation. Frontiers in Neuroscience [Internet]. 2019 [cited 2023 Sep 22];12. Available from: https://www.

Zhang M, Bautista A, Papamatheakis DG, Poch DS, Kerr KM, Kim NH, et al. Pericardial Effusion After Pulmonary Thromboendarterectomy. In: TP82 TP082 LET IT BE - CLINICAL ADVANCES IN PULMONARY VASCULAR DISEASE: PAH AND BEYOND [Internet]. American Thoracic Society; 2021 [cited 2023 Oct 6]. p. A3586–A3586. Available from: https://www.atsjournals. org/doi/10.1164/ajrccm-conference.2021.203.1_MeetingAb-stracts.A3586

Willner DA, Goyal A, Grigorova Y, Kiel J. Pericardial Effusion. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Oct 5]. Available from: http://www.ncbi.nlm.

Bartlett M, Drcar T. PHPN: Post-Pulmonary Endarterectomy: What to Expect During the First Year and How to Handle the Unexpected. Advances in Pulmonary Hypertension. 2014 Jan 1;12(4):206 –7.

Song W, Zhu J, Zhong Z, Song Y, Liu S. Long-term outcome prediction for chronic thromboembolic pulmonary hypertension after pulmonary endarterectomy. Clinical Cardiology. 2022;45(12):1255–63.

Forfia P, Ferraro B, Vaidya A. Recognizing pulmonary hypertension following pulmonary thromboendarterectomy: A practical guide for clinicians. Pulm Circ. 2022 Jun 7;12(2):e12073.

Dobrev D, Aguilar M, Heijman J, Guichard JB, Nattel S. Post-operative atrial fibrillation: mechanisms, manifestations and management. Nat Rev Cardiol. 2019 Jul;16(7):417–36.

Wu JHY, Marchioli R, Silletta MG, Masson S, Sellke FW, Libby P, et al. Oxidative Stress Biomarkers and Incidence of Postoperative Atrial Fibrillation in the Omega-3 Fatty Acids for Prevention of Postoperative Atrial Fibrillation (OPERA) Trial. J Am Heart Assoc. 2015 May 20;4(5):e001886.

Gozdek M, Pawliszak W, Hagner W, Zalewski P, Kowalewski J, Paparella D, et al. Systematic review and meta-analysis of randomized controlled trials assessing safety and efficacy of posterior pericardial drainage in patients undergoing heart surgery. J Thorac Cardiovasc Surg. 2017 Apr;153(4):865-875.e12.

Youn JY, Zhang J, Zhang Y, Chen H, Liu D, Ping P, et al. Oxidative Stress in Atrial Fibrillation: An Emerging Role of NADPH Oxidase. J Mol Cell Cardiol. 2013 Sep;62:72–9.

Fuller JA, Adams GG, Buxton B. Atrial fibrillation after coronary artery bypass grafting. Is it a disorder of the elderly? J Thorac Cardiovasc Surg. 1989 Jun;97(6):821–5.

Goulden CJ, Hagana A, Ulucay E, Zaman S, Ahmed A, Harky A. Optimising risk factors for atrial fibrillation post-cardiac surgery. Perfusion. 2022 Oct;37(7):675–83.

Bhave P, Passman R. Age as a Risk factor for Atrial Fibrillation and Flutter after Coronary Artery Bypass Grafting. J Atr Fibrillation. 2012 Feb 2;4(5):482.

Mariscalco G, Engström KG, Ferrarese S, Cozzi G, Bruno VD, Sessa F, et al. Relationship between atrial histopathology and atrial fibrillation after coronary bypass surgery. J Thorac Cardiovasc Surg. 2006 Jun;131(6):1364–72.

Kottkamp H. Human atrial fibrillation substrate: towards a specific fibrotic atrial cardiomyopathy. Eur Heart J. 2013 Sep;34(35):2731–8.

Verdecchia P, Angeli F, Reboldi G. Hypertension and Atrial Fibrillation. Circulation Research. 2018 Jan 19;122(2):352–68.

Caraballo C, Desai NR, Mulder H, Alhanti B, Wilson FP, Fiuzat M, et al. Clinical Implications of the New York Heart Association Classification. Journal of the American Heart Association. 2019 Dec 3;8(23):e014240.

Anter E, Jessup M, Callans DJ. Atrial Fibrillation and Heart Failure. Circulation. 2009 May 12;119(18):2516–25.

Li D, Fareh S, Leung TK, Nattel S. Promotion of Atrial Fibrillation by Heart Failure in Dogs. Circulation. 1999 Jul 6;100(1):87–95.

Babapoor-Farrokhran S, Gill D, Alzubi J, Mainigi SK. Atrial fibrillation: the role of hypoxia-inducible factor-1-regulated cytokines. Mol Cell Biochem. 2021 Jun;476(6):2283–93.

Yang M, Cao Q, Xu Z, Ge Y, Li S, Yan F, et al. Development and Validation of a Machine Learning-Based Radiomics Model on Cardiac Computed Tomography of Epicardial Adipose Tissue in Predicting Characteristics and Recurrence of Atrial Fibrillation. Frontiers in Cardiovascular Medicine [Internet]. 2022 [cited 2023 Sep 23];9. Available from:

Petraglia L, Conte M, Comentale G, Cabaro S, Campana P, Russo C, et al. Epicardial Adipose Tissue and Postoperative Atrial Fibrillation. Frontiers in Cardiovascular Medicine [Internet]. 2022 [cited 2023 Sep 23];9. Available from:

Zhao J, Zhang Y, Yin Z, Zhu Y, Xin F, Zhang H, et al. Impact of proinflammatory epicardial adipose tissue and differentially enhanced autonomic remodeling on human atrial fibrillation. The Journal of Thoracic and Cardiovascular Surgery. 2023 Apr 1;165(4):e158–74.

Ciuffo L, Nguyen H, Marques MD, Aronis KN, Sivasambu B, de Vasconcelos HD, et al. Periatrial Fat Quality Predicts Atrial Fibrillation Ablation Outcome. Circulation: Cardiovascular Imaging. 2019 Jun;12(6):e008764.

Maeda M, Oba K, Yamaguchi S, Arasaki O, Sata M, Masuzaki H, et al. Usefulness of Epicardial Adipose Tissue Volume to Predict Recurrent Atrial Fibrillation After Radiofrequency Catheter Ablation. The American Journal of Cardiology. 2018 Nov 15;122(10):1694–700.

van Rosendael AR, Smit JM, El’Mahdiui M, van Rosendael PJ, Leung M, Delgado V, et al. Association between left atrial epicardial fat, left atrial volume, and the severity of atrial fibrillation. EP Europace. 2022 Aug 3;24(8):1223–8.

Yang M, Bao W, Xu Z, Qin L, Zhang N, Yan F, et al. Association between epicardial adipose tissue and recurrence of atrial fibrillation after ablation: a propensity score-matched analysis. Int J Cardiovasc Imaging. 2022 Aug 1;38(8):1865–72.




How to Cite

Elsebaie A, Enriquez VRB, Baranchuk A, Nahin MA, El-Diasty M. Atrial Arrhythmias Following Pulmonary Thromboendarterectomy: A Comprehensive Review Of Current Literature. Rev Port Cir Cardiotorac Vasc [Internet]. 2024 May 13 [cited 2024 May 21];31(1):41-6. Available from:



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