Amiodarone versus direct current cardioversion in treatment of atrial fibrillation after cardiac surgery

Abstract

Aim:  Postoperative atrial fibrillation is common after cardiac surgery and is associated with higher rates of complications and mortality. Despite the importance of postoperative atrial fibrillation, the most effective management strategy for this common surgical complication remains uncertain. The aim of this study was to evaluate the effectiveness of amiodarone and early direct current cardioversion to restore sinus rhythm in new onset postoperative atrial fibrillation.

Material and Methods: This was a prospective, open-labeled randomized- controlled trial. A total of 50 patients who had new onset postoperative atrial fibrillation longer than 30 minutes were enrolled in the study; 26 patients were randomized to control group and 24 to amiodarone group. Patients in whom sinus rhythm did not return within 24 hours, then external electrical direct current cardioversion was performed for both groups. The primary endpoint of the study was a restoration of sinus rhythm at the 24^th hour. Secondary endpoints needed for direct current cardioversion, success rate, sinus rhythm at discharge, sinus rhythm at 30^th days and crossover rates.

Results: There was a significantly higher number of patients with sinus rhythm at the 24th hour in the amiodarone group than the control group (79.2% vs. 46.2%, p=0.022). Need for direct current cardioversion (p=0.022) and crossover ratio (p=0.021) were significantly higher in control group than amiodarone group. Direct current cardioversion success rate, normal sinus rhythm at discharge and 1^st month did not differ significantly between groups.
Conclusion: Amiodarone therapy seems effective in restoring sinus rhythm within 24 hours and decreases the need for direct current cardioversion.

Keywords:  antiarrhythmic agents; atrial fibrillation; cardiovascular surgery; post-CABG 

Keywords

• Antiarrhythmia agents,Atrial fibrillation,, Cardiovascular surgery,, post-CABG atrial fibrillation

Kalp cerrahisi sonrası gelişen atriyal fibrilasyon tedavisinde amiodarone ve doğru akım kardiyoversiyonun karşılaştırılması

Abstract

Amaç: Atriyal fibrilasyon kalp cerrahisinden sonra sık görülmektedir. Postoperatif atriyal fibrilasyon komplikasyonların ve mortalitenin artmasına neden olmaktadır. Ancak tedavisi hususunda fikir birliği yoktur. Bu çalışmanın amacı postoperatif dönemde yeni başlayan atriyal fibrilasyonu olan hastalarda amiodaron kullanımı ile erken dönemde doğru akım elektriksel kardiyoversiyonun sinüs ritmininin sağlanması üzerine olan etkilerini karşılaştırmaktır.

Gereç ve Yöntemler: Çalışma prospektif, randomize, açık kontrollü olarak tasarlanmıştır. Çalışmaya kalp cerrahisi sonrası 30 dakikadan uzun yeni başlangıçlı atriyal fibrilasyonu olan toplam 50 hasta alındı; 26 hasta kontrol grubuna; 24 hasta amiodaron grubuna randomize edildi. Her iki grupta da 24 saat içinde sinüs ritminin sağlanamadığı hastalarda doğru akım elektriksel kardiyoversiyon uygulandı. Çalışmanın birincil son noktası 24. saatte sinüs ritminin sağlanmasıydı. Çalışmanın ikincil son noktaları ise doğru akım elektriksel kardiyoversiyon oranı, başarı oranı, taburculukta sinüs ritminin varlığı, 30. günde sinüs ritminin varlığı ve grup değiştirme oranıydı.

Bulgular: Amiodaron grubunda 24. saatte sinüs ritminde olan hasta sayısı kontrol grubuna göre anlamlı olarak daha fazla saptandı (%79,2'ye karşı %46,2, p = 0.022). Doğru akım kardiyoversiyon oranı (p = 0,022) ve grup değiştirme oranı (p = 0,005) kontrol grubunda anlamlı derecede yüksekti. Taburculukta ve birinci ayda sinüs ritmi varlığı ve doğru akım kardiyoversiyon başarı oranları açısından gruplar arasında anlamlı fark saptanmadı.

Sonuç:  Amiodaron tedavisi 24 saat içinde sinüs ritmininin sağlanmasında etkin görünmekte ve doğru akım kardiyoversiyon ihtiyacını azaltmaktadır.

Keywords

• Amiodaron,atriyal fibrilasyon,kalp cerrahisi,doğru akım kardiyoversiyon

References

1. 1. Kirchhof P, Benussi S, Kotecha D et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 7: 2893-962.
2. 2. Koletsis EN, Prokakis C, Crockett JR et al. Prognostic factors of atrial fibrillation following elective coronary artery bypass grafting: the impact of quantified intraoperative myocardial ischemia. J Cardiothorac Surg 2011; 6: 127.
3. 3. Mathew JP, Fontes ML, Tudor IC et al. A multicenter risk index for atrial fibrillation after cardiac surgery. JAMA 2004; 291: 1720-29.
4. 4. Villareal RP, Hariharan R, Liu BC et al. Postoperative atrial fibrillation and mortality after coronary artery bypass surgery. J Am Coll Cardiol 2004; 43: 742-48.
5. 5. Aerra V, Kuduvalli M, Moloto AN et al. Does prophylactic sotalol and magnesium decrease the incidence of atrial fibrillation following coronary artery bypass surgery: a propensity-matched analysis. J Cardiothorac Surg 2006; 1: 6.
6. 6. Gecmen C, Güler GB, Erdoğan E et al. SYNTAX score predicts postoperative atrial fibrillation in patients undergoing on-pump isolated coronary artery bypass grafting surgery. Anatol J Cardiol 2016; 16: 655-61.
7. 7. Mithani S, Akbar MS, Johnson DJ et al. Dose dependent effect of statins on postoperative atrial fibrillation after cardiac surgery among patients treated with beta blockers. J Cardiothorac Surg 2009; 4: 61.
8. 8. Gillinov AM, Bagiella E, Moskowitz AJ et al. Rate Control versus Rhythm Control for Atrial Fibrillation after Cardiac Surgery. N Engl J Med 2016; 374: 1911-21.

9. 9. Aydın U, Yılmaz M, Duzyol C et al. Efficiency of postoperative statin treatment for preventing new-onset postoperative atrial fibrillation in patients undergoing isolated coronary artery bypass grafting: A prospective randomized study. Anatol J Cardiol 2015; 15: 491-95.
10. 10. Dunning J, Khasati N, Prendergast B. What is the optimal medical treatment for stable cardiac surgical patients who go into atrial fibrillation after their operation? Interact Cardiovasc Thorac Surg. 2004; 3: 46-51.
11. 11. VanderLugt JT, Mattioni T, Denker S et al. Efficacy and safety of ibutilide fumarate for the conversion of atrial arrhythmias after cardiac surgery. Circulation 1999; 100: 369-75.
12. 12. Cotter G, Blatt A, Kaluski E et al. Conversion of recent onset paroxysmal atrial fibrillation to normal sinus rhythm: the effect of no treatment and high-dose amiodarone. A randomized, placebo-controlled study. Eur Heart J 1999; 20: 1833-42.
13. 13. Kaireviciute D, Aidietis A, Lip GY. Atrial fibrillation following cardiac surgery: clinical features and preventative strategies. Eur Heart J 2009; 30: 410-25.
14. 14. Cameron MJ, Tran DTT, Abboud J, Newton EK, Rashidian H, Dupuis JY. Prospective external validation of three preoperative risk scores for prediction of new onset atrial fibrillation after cardiac surgery. Anesth Analg 2018; 126: 33–38.
15. 15. Di Biasi P, Scrofani R, Paje A, Cappiello E, Mangini A, Santoli C. Intravenous amiodarone vs propafenone for atrial fibrillation and flutter after cardiac operation. Eur J Cardiothorac Surg 1995; 9: 587-91.
16. 16. Bernard EO, Schmid ER, Schmidlin D, Scharf C, Candinas R, Germann R. Ibutilide versus amiodarone in atrial fibrillation: a double-blinded, randomized study. Crit Care Med 2003; 31: 1031-34.
17. 17. Larbuisson R, Venneman I, Stiels B. The efficacy and safety of intravenous propafenone versus intravenous amiodarone in the conversion of atrial fibrillation or flutter after cardiac surgery. J Cardiothorac Vasc Anesth. 1996; 10: 229-34.
18. 18. Greenberg JW, Lancaster TS, Schuessler RB, Melby SJ. Postoperative atrial fibrillation following cardiac surgery: a persistent complication. Eur J Cardiothorac Surg 2017; 52: 665-72.
19. 19. Samuels LE, Holmes EC, Samuels FL. Selective use of amiodarone and early cardioversion for postoperative atrial fibrillation. Ann Thorac Surg 2005; 79: 113-16.
20. 20. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002; 347: 1825-33.