Presenting a case where I'd like the group's read. 62F, no prior cardiac history, admitted for elective laparoscopic cholecystectomy — uncomplicated surgery, tolerated GA well. Developed palpitations on POD2 with rate 140s. ECG confirms AF with fast ventricular response. Structurally normal heart on echo, LA mildly dilated at 42mm, LVEF preserved at 58%.
Loaded on bisoprolol titrated to 5mg BD and added digoxin — HR settled to 110–120s at rest but rises to 150s with minimal activity. Symptomatically bothered. TSH incidentally 0.3 (repeat pending). No prior thyroid issues. TnI negative, CRP mildly elevated post-op (expected).
She's now 4 days into the arrhythmia. She's uncomfortable and wants a plan. The team is split between:
The TSH result is nagging me. I don't want to cardiovert into thyrotoxic AF that will just recur. But she is also inarguably symptomatic and low-risk anatomically. Grateful for the collective wisdom — particularly from anyone with a large post-op AF experience.
Trust your instinct on the TSH — I'd repeat with free T4 and T3 today, and also send TRAb before you commit to a strategy. If she's frankly thyrotoxic, DCCV now buys you 24–72h of sinus at best before it recurs, and you'll have anticoagulated her for nothing.
If the repeat thyroid panel is normal (transient perioperative suppression is common with steroids and stress), my preference in this exact scenario is option (b) — 3 weeks of DOAC, optimise rate control (add flecainide if structurally normal — which she is), then elective outpatient DCCV. Post-op AF at 4 days without HD compromise doesn't need to be cardioverted urgently. The evidence for TEE-DCCV in this exact window is thinner than people think.
Very happy to look at the rhythm strip if you can share it in the EP sub-channel.
Agree with Hiroshi. Also worth checking Mg — post-op patients are often 0.7-something and it materially affects rate control. Repletion is cheap and I've seen it stop the ping-ponging alone.
If she does go for cardioversion, don't forget to talk to the anaesthetist about the recent GA — 4 days post-lap chole isn't a contraindication but affects your propofol dose calculations.
Just from the anaesthetic angle — if you do end up cardioverting, we'd want a repeat FBC (post-op Hb) and clear NBM window. Not a barrier, but coordinate. Also worth double-checking she wasn't given ondansetron in theatre, which can prolong QT and matter if you're loading flecainide as Hiroshi suggests.
We audited exactly this — post-op AF within 7 days of non-cardiac surgery. About 72% spontaneously reverted within 96h once we got the electrolytes right and the pain under control. Just a data point.
Consensus emerging: confirm thyroid panel first, then favor option (b) — 3-week DOAC + optimised rate control with elective outpatient DCCV. Multiple consultants flag electrolyte optimisation (Mg) and post-op ondansetron/QT considerations. 72% spontaneous reversion cited from a 486-patient audit (Cairo).