Intravenous amiodarone for the prevention of atrial fibrillation after open heart surgery: the Amiodarone Reduction in Coronary Heart (ARCH) trial.

OBJECTIVES: This study was designed to test whether intravenous (i.v.) amiodarone would prevent atrial fibrillation and decrease hospital stay after open heart surgery. BACKGROUND: Atrial fibrillation commonly occurs after open heart procedures and is thought to be a significant determinant for prolongation of hospitalization. Oral amiodarone given preoperatively appears to reduce the incidence of atrial fibrillation. This study was designed to test whether the more rapid-acting i.v. formulation of amiodarone given postoperatively would reduce the incidence of atrial fibrillation. METHODS: Three hundred patients undergoing standard open heart surgery were randomized in a double-blind fashion to i.v. amiodarone (1 g/day for 2 days) versus placebo immediately after open heart surgery. The primary end points of the trial were incidence of atrial fibrillation and length of hospital stay. Baseline clinical variables and mortality and morbidity data were collected. RESULTS: Atrial fibrillation occurred in 67/142 (47%) patients on placebo versus 56/158 (35%) on amiodarone (p = 0.01). Length of hospital stay for the placebo group was 8.2 +/- 6.2 days, and 7.6 +/- 5.9 days for the amiodarone group (p = 0.34). No differences were noted in baseline variables, morbidity or mortality. CONCLUSIONS: Low-dose i.v. amiodarone was safe and effective in reducing the incidence of atrial fibrillation after heart surgery, but did not significantly alter length of hospital stay.     

Amiodarone vs. sotalol as prophylaxis against atrial fibrillation/flutter after heart surgery: a meta-analysis

BACKGROUND: The incidence of supraventricular arrhythmias remains high following open-heart surgery. The most common of these arrhythmias are atrial fibrillation and flutter (AFF), for which treatment is not well defined. Recent studies have focused on prophylactically treating patients in an attempt to reduce postoperative AFF. Several studies have shown that sotalol and amiodarone are both effective in reducing AFF following heart surgery. However, no studies have been done comparing both drugs. METHODS: A meta-analysis was done to compare the efficacy of sotalol and amiodarone after bypass graft surgery. Randomized controlled trials were included if patients were clearly monitored, and the incidence of AFF was noted. Ten studies were included in the final analysis. RESULTS: Both amiodarone and sotalol were more effective than placebo treatment in reducing the incidence of postoperative AFF. However, when the data were pooled, no differences were noted between amiodarone and sotalol for efficacy (sotalol, - 21.5%; 95% confidence interval [CI], - 28.3 to - 14.6; amiodarone, - 14.1%; CI, - 20.1 to - 8.1), length of stay (sotalol, - 0.13 d; CI, - 0.33 to 0.07 d; amiodarone, - 0.18; CI, - 0.38 to 0.02 d), or adverse drug reactions causing drug termination (sotalol, 9.7%; CI, 0.086 to 19.3; amiodarone, 1.95%; CI, - 0.48 to 4.38). CONCLUSIONS: This data would suggest that either drug could be used in a prophylactic regimen to reduce the incidence of AFF following heart surgery.     

Esmolol versus diltiazem in the treatment of postoperative atrial fibrillation/atrial flutter after open heart surgery

BACKGROUND: Supraventricular tachyarrhythmias are common after open heart surgery. Possible causative factors for these arrhythmias include operative trauma, atrial ischemia, electrolyte imbalances, pericardial irritation, and excess catecholamines. Two agents commonly used to control ventricular rate in atrial fibrillation or atrial flutter (AF/AFL) are beta-blockers and calcium channel blockers. METHODS AND RESULTS: This randomized study was designed to compare the safety and efficacy of intravenous diltiazem versus intravenous esmolol in patients with postoperative AF/AFL after coronary bypass surgery and/or valve replacement surgery. A comparative cost analysis was also performed. Thirty patients received either esmolol (n = 15) or diltiazem (n = 15) for AF/AFL. During the first 6 hours of treatment, 66.6% of esmolol-treated patients converted to sinus rhythm compared with 13.3% of the diltiazem-treated patients (P <.05). At 24 hours, 66.6% of the diltiazem group converted to SR compared with 80% of the esmolol group (not significant). Drug-induced side effects, time to rate control (<90 beats/min), number of patients requiring cardioversion, and length of hospitalization were similar for the two groups. The drug cost/successfully treated patient for esmolol versus diltiazem was $254 versus $437 at 6 hours and $529 versus $262 at 24 hours. CONCLUSIONS: Although this is a small study, it suggests that esmolol is more effective in converting patients to normal sinus rhythm than diltiazem during the initial dosing period. No differences in conversion rates were observed between the two groups after 24 hours. Additional studies are needed to confirm whether esmolol is the initial drug of choice in patients with postoperative AF/AFL after coronary bypass surgery.     

Efficacy of landiolol hydrochloride for atrial fibrillation after open heart surgery

It is important to establish effective treatment for postoperative atrial fibrillation (AF), the most common complication after cardiac surgery. We evaluated the efficacy and safety of landiolol hydrochloride for rhythm conversion in patients with postoperative AF. Among 134 patients who developed new-onset AF after open heart surgery between 2007 and 2009, 69 patients who received landiolol hydrochloride for treatment of postoperative AF were enrolled. The AF conversion rate, the percentage of patients with 20 % reduction of the ventricular rate, and the factors related to successful treatment were evaluated. Then, the landiolol group was compared with 65 patients who had postoperative AF and did not receive landiolol hydrochloride. Landiolol hydrochloride was the first-line treatment in 46 patients and the only therapy in 26 patients. Reversion to sinus rhythm was achieved in 51 patients, while the conversion rate in patients without landiolol hydrochloride was only 56.8 % (p < 0.05). A 20 % reduction of the ventricular rate was achieved more frequently in the landiolol group. Although landiolol hydrochloride was highly effective in patients who had undergone off-pump coronary artery bypass grafting, patients with cardiopulmonary bypass did not respond as well. The heart rate was reduced from 130 ± 26 to 81 ± 12 (p < 0.05) after landiolol administration, while blood pressure did not decrease significantly. Landiolol hydrochloride was effective for conversion of postoperative AF. This ultra-short-acting β-blocker is a safe first-line treatment for postoperative AF after open heart surgery, and is most effective in patients who have undergone off-pump coronary artery bypass grafting.     

Preoperative atrial fibrillation and long-term survival after open heart surgery in a rural tertiary heart institute

Background

Preoperative atrial fibrillation (AF) is associated with increased morbidity and mortality after open heart surgery. However, the impact of preoperative AF on long-term survival after open heart surgery has not been widely examined in rural populations. Patients from rural regions are less likely to receive treatment for cardiac conditions and to have adequate medical insurance coverage.

Objective

To examine the influence of preoperative AF on long-term survival following open heart surgery in rural eastern North Carolina.

Methods

Long-term survival was compared in patients with and without preoperative AF after coronary artery bypass grafting (CABG) and CABG plus valve (CABG + V) surgery between 2002 and 2011. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model.

Results

The study population consisted of 5438 patients. A total of 263 (5%) patients had preoperative AF. Preoperative AF was an independent predictor of long-term survival (open heart surgery: adjusted HR = 1.6, 95% CI = 1.3–2.0; CABG: adjusted HR = 1.6, 95% CI = 1.3–2.1; CABG + V: adjusted HR = 1.6, 95% CI = 1.1–2.3).

Conclusion

Preoperative AF is an important predictor of long-term survival after open heart surgery in this rural population.     

Canadian Cardiovascular Society atrial fibrillation guidelines 2010: prevention and treatment of atrial fibrillation following cardiac surgery

Postoperative atrial fibrillation and atrial flutter (POAF) are the most common complications of cardiac surgery that require intervention or prolong intensive care unit and total hospital stay. For some patients, these tachyarrhythmias have important consequences including patient discomfort/anxiety, hemodynamic deterioration, cognitive impairment, thromboembolic events including stroke, exposure to the risks of antiarrhythmic treatments, longer hospital stay, and increased health care costs. We conclude that prevention of POAF is a worthwhile exercise and recommend that the dominant therapy for this purpose be β-blocker therapy, especially the continuation of β-blocker therapy that is already in place. When β-blocker therapy is contraindicated, amiodarone prophylaxis is recommended. If both of these therapies are contraindicated, therapy with either intravenous magnesium or biatrial pacing is suggested. Patients at high risk of POAF may be considered for first-line amiodarone therapy, first-line sotalol therapy, or combination prophylactic therapy. The treatment of POAF may follow either a rate-control approach (with the dominant therapy being β-blocking drugs) or a rhythm-control approach. Anticoagulation should be considered if persistent POAF lasts >72 hours and at the point of hospital discharge. The ongoing need for any POAF treatment (including anticoagulation) should be reconsidered 6-12 weeks after the surgical procedure.     

Azimilide vs. placebo and sotalol for persistent atrial fibrillation: the A-COMET-II (Azimilide-CardiOversion MaintEnance Trial-II) trial.

AIMS: Treatment of atrial fibrillation remains a major clinical challenge owing to the limited efficacy and safety of anti-arrhythmic drugs, particularly in patients with structural heart disease. METHODS AND RESULTS: To evaluate the efficacy of azimilide, a new class III anti-arrhythmic drug, we studied 658 patients with symptomatic persistent atrial fibrillation, adequate anticoagulant therapy, and planned electrical cardioversion. Patients were randomized to placebo, azimilide (125 mg o.d.), or sotalol (160 mg b.i.d.). Primary efficacy analysis was based on event recurrence, which was defined as atrial fibrillation lasting>24 h, or requiring DC cardioversion. Median time to recurrence was 14 days for azimilide, 12 days for placebo, and 28 days for sotalol (P=0.0320 when comparing azimilide with placebo; P=0.0002 when comparing azimilide with sotalol). The placebo-to-azimilide hazard ratio was 1.291 (95% CI: 1.022-1.629) and the sotalol-to-azimilide hazard ratio was 0.652 (95% CI: 0.523-0.814). Adverse events causing patient withdrawal were more frequent (P<0.01) in patients on azimilide (12.3%) and on sotalol (13.9%) than on placebo (5.4%). Eight patients in the sotalol (3.5%) and 16 in the azimilide (7.6%) group interrupted the study because of QTc prolongation. Torsade de pointes was reported in five patients of the azimilide group. The percentage of patients who completed the 26 week study period without events were 19% for azimilide, 15% for placebo, and 33% for sotalol (P<0.01). Unsuccessful day 4 cardioversion, arrhythmia recurrence, and adverse events were the main causes of withdrawal from the study. CONCLUSION: This study demonstrates that the anti-arrhythmic efficacy of azimilide is slightly superior to placebo but significantly inferior to sotalol in patients with persistent AF. The modest anti-arrhythmic efficacy and high rate of torsade de pointes and marked QTc prolongation limit azimilide utilization for the treatment of AF.     

心脏直视手术下行仿改良迷宫Ⅲ术射频消融治疗心房颤动

目的 评价心脏直视下行盐水冲洗射频消融仿改良迷宫Ⅲ手术(IRFMM)治疗心脏瓣膜病合并心房颤动(房颤)的安全性及有效性.方法 回顾分析63例心脏瓣膜病合并持续性房颤病例,其中31例行瓣膜置换同期行IRFMM手术治疗房颤(治疗组),32例行瓣膜置换而未同期行IRFMM术(对照组)的治疗结果和早期随访资料.结果 治疗组18例术后立即恢复窦性心律,3例术后使用临时起搏器,于术后5 d内恢复窦性心律,7例术后由交界区心律转为窦性心律,3例仍为房颤.术后随访2～19个月,出院时90.3%(28/31)为窦性心律,随访半年以上91.3%(21/23)维持窦性心律,随访1年以上85.7%(12/14)维持窦性心律.对照组术后仅3例短暂转复为窦性心律,出院时全转为房颤.32例随访2～19个月,未转为窦性心律者,两组相比差异有统计学意义(P＜0.01).结论 使用美敦力公司Cardioblate盐水冲洗射频消融系统代替切割、冷冻施行迷宫术治疗房颤安全简便有效.     

Intravenous sotalol for the treatment of atrial fibrillation and flutter after cardiopulmonary bypass. Comparison with disopyramide and digoxin in a randomised trial

The efficacy of sotalol in treating acute atrial fibrillation and flutter after open heart surgery was compared with that of a digoxin/disopyramide combination. Forty adult patients with postoperative atrial arrhythmias were randomised into either group 1 (sotalol 1 mg/kg bolus intravenously plus 0.2 mg/kg intravenously over 12 hours) or group 2 (digoxin 0.75 mg intravenously, then two hours later disopyramide 2 mg/kg intravenous bolus and 0.4 mg/kg/h intravenously for 10 hours). In each group, 17 out of 20 patients reverted to sinus or junctional rhythm within 12 hours. The time to reversion in group 1 was significantly shorter than in group 2. Systolic blood pressure fell by greater than or equal to 20 mm Hg or to less than or equal to 90 mm Hg during drug administration in 17 out of 20 patients in group 1 (sotalol withdrawn in two) and in none out of 20 in group 2. Two patients in group 1 developed transient bradycardia (sotalol withdrawn in one). None of 17 patients in group 1 and two of 17 in group 2 relapsed temporarily into atrial fibrillation during the 12 hours of intravenous treatment. On continued oral treatment, one late relapse occurred in group 1 and five in group 2, and five patients in group 2 had disopyramide withdrawn because of anticholinergic side effects (acute urinary retention in four). Sotalol was as effective as the digoxin/disopyramide combination and acted significantly faster. Sensitivity to beta blockade in these patients may be related to high plasma catecholamine concentrations known to occur after cardiopulmonary bypass.     

胺碘酮在预防心脏瓣膜置换术后房颤中的作用

目的研究胺碘酮在预防心脏瓣膜置换术后高危患者房颤中的作用。方法常规体外循环下92例窦性心律、年龄〉50岁的瓣膜性心脏病择期行瓣膜置换术的患者,随机分为试验组（47例）和对照组（45例）。对照组术后给予常规药物和安慰剂。试验组除常规药物外,术后加用胺碘酮。两组比较瓣膜置换术后房颤的发生率。试验终点为术后第30天。结果瓣膜置换术后两组比较,试验组房颤发生率（8.5%）小于对照组（33.3%）,有统计学意义（P〈0.05）。结论胺碘酮能降低瓣膜置换术后高危患者房颤发生率,有效预防术后房颤的发生。     

Pulmonary vein antrum isolation for treatment of atrial fibrillation in patients with valvular heart disease or prior open heart surgery.

OBJECTIVES: The goal of this study was to assess the safety and efficacy of pulmonary vein antrum isolation in patients with moderate valvular heart disease or open-heart surgery and atrial fibrillation (AF). BACKGROUND: Valvular heart disease and open-heart surgery are commonly associated with AF and increase the risk of adverse events in AF patients. METHODS: A total of 391 consecutive patients who had pulmonary vein antrum isolation performed between December 2000 and December 2002 were screened. A total of 142 of these patients had clinically significant valvular disease or prior cardiac surgery. End points included AF recurrence and pulmonary vein antrum isolation complication rates. RESULTS: Patients with valvular heart disease or prior open-heart surgery were older, had larger left atria and a more advanced New York Heart Association class. They did not differ significantly with respect to gender, but had a longer history of AF. Procedure times were similar between patients with and without valvular heart disease or prior open-heart surgery. After 18 +/- 7 months in the lone AF patients, 11 +/- 5 months in patients with valvular heart disease, and 10 +/- 5 months in patients with prior open heart surgery, there was a trend toward lower recurrence of AF in patients with lone AF who enjoyed a 98% overall cure rate after up to 2 pulmonary vein antrum isolations versus 93% among patients with valvular heart disease (P = .04) and prior open heart surgery (P = .07). Complication rates were comparable between groups. CONCLUSIONS: Pulmonary vein antrum isolation is safe and effective in patients with moderate valvular heart disease and the patients who developed AF after open-heart surgery. These results have implications for our understanding of the pathophysiology of AF in patients with moderate valvular heart disease or past cardiac surgery and should be considered when discussing treatment options in these patients.     

双极射频消融心房颤动同时手术治疗器质性心脏病的临床效果

目的：探讨双极射频消融钳治疗心房颤动同期行开胸手术治疗器质性心脏病的手术方法和临床结果,提高对此类疾病的治疗水平。方法：回顾分析2009年8月～2012年5月对58例器质性心脏病并发心房颤动用双极射频消融钳治疗房颤的临床资料。结果：本组患者手术均顺利完成。射频时间16～38（24±4） min,主动脉阻断时间64～200（126±36） min,体外循环时间91～238（150±37） min;手术结束及出院时窦性心率分别为46（79%）,45（78%）例,随访3个月,6个月和12个月,窦性心率分别为41（71%）,40（69%）和42（72%）例。全组病例无手术死亡和射频相关并发症。所有患者均无需安装永久起搏器。双心房消融与单独左房消融比较无显著差异。结论：此方法可行,效果满意,但要注意把握适应证。