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Postoperative atrial fibrillation is quite common after cardiac surgery with up to 1 in 3 patients experiencing this abnormal heart rhythm. Amiodarone, a medication commonly used to treat atrial fibrillation, has been previously shown to be an effective prophylactic agent at decreasing the occurrence of postoperative atrial fibrillation in patients who underwent coronary artery bypass surgery. However, despite many studies which have demonstrated its effectiveness, it has not been widely used due to the concern of side effects that can occur such as slow heart rate, low blood pressure, and lung toxicity. We have designed a study to test the effectiveness and safety of a short course of postoperative prophylactic amiodarone for patients undergoing non-coronary artery bypass cardiac surgery. We hypothesize that patients who receive the prophylactic amiodarone will have decreased rates of postoperative atrial fibrillation without significantly increased side effects compared to patients who receive the standard postoperative care after non-coronary artery bypass cardiac surgery.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Amiodarone Arm | Experimental | In addition to the regular care provided to cardiac surgery patients, those in the Amiodarone Arm will also receive the amiodarone regimen. |
|
| Standard of Care Arm | No Intervention | Patients randomized to the Standard of Care Arm will receive the regular care provided to cardiac surgery patients. |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Amiodarone | Drug | Patients randomized to the Amiodarone Arm will receive a 5-day course of amiodarone after surgery. |
|
| Measure | Description | Time Frame |
|---|---|---|
| Postoperative atrial fibrillation | The occurrence of postoperative atrial fibrillation detected by continuous telemetry, 12-lead electrocardiogram, and/or continuous ambulatory monitoring device through postoperative day 7. | At least 1 minute duration, occurring before or on postoperative day 7 |
| Measure | Description | Time Frame |
|---|---|---|
| Operative mortality | Operative mortality as defined by either in-hospital death or death within 30 days of discharge. | Either in-hospital or within 30 days of procedure |
| Stroke | characterized by deficits lasting > 24 hours and/or imaging findings of infarction |
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Inclusion Criteria:
Exclusion Criteria:
Pre-existing atrial fibrillation or atrial arrhythmias
Pre-existing heart block
Cardiogenic shock
Sick sinus syndrome
Marked sinus bradycardia
Preoperative amiodarone use
Contraindication to amiodarone use
Emergent operation
Planned MAZE or Pulmonary Vein Isolation procedure
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Asishana A Osho, MD, MPH | Contact | 617-643-9745 | asishana.osho@mgh.harvard.edu |
| Name | Affiliation | Role |
|---|---|---|
| Asishana A Osho, MD, MPH | Massachusetts General Hospital | Principal Investigator |
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| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 28369234 | Background | Greenberg JW, Lancaster TS, Schuessler RB, Melby SJ. Postoperative atrial fibrillation following cardiac surgery: a persistent complication. Eur J Cardiothorac Surg. 2017 Oct 1;52(4):665-672. doi: 10.1093/ejcts/ezx039. | |
| 23440790 | Background | Arsenault KA, Yusuf AM, Crystal E, Healey JS, Morillo CA, Nair GM, Whitlock RP. Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery. Cochrane Database Syst Rev. 2013 Jan 31;2013(1):CD003611. doi: 10.1002/14651858.CD003611.pub3. |
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| ID | Term |
|---|---|
| D001281 | Atrial Fibrillation |
| ID | Term |
|---|---|
| D001145 | Arrhythmias, Cardiac |
| D006331 | Heart Diseases |
| D002318 | Cardiovascular Diseases |
| D010335 | Pathologic Processes |
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| ID | Term |
|---|---|
| D000638 | Amiodarone |
| ID | Term |
|---|---|
| D001572 | Benzofurans |
| D006574 | Heterocyclic Compounds, 2-Ring |
| D000072471 | Heterocyclic Compounds, Fused-Ring |
| D006571 | Heterocyclic Compounds |
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| Either in-hospital or within 30 days of procedure |
| Transient ischemic attack | characterized by examination findings lasting < 24 hours without associated imaging findings | Either in-hospital or within 30 days of procedure |
| Electrical cardioversion | Whether the patient required electrical cardioversion for hemodynamically unstable atrial fibrillation | Either in-hospital or within 30 days of procedure |
| Hemodynamic instability | New hemodynamic instability (mean arterial pressure < 65 mmHg) after surgery | Either in-hospital or within 30 days of procedure |
| Initiation of systemic anticoagulation | New indication of systemic anticoagulation for stroke prophylaxis due to atrial fibrillation | Either in-hospital or within 30 days of procedure |
| Myocardial infarction | Myocardial infarction diagnosed based on ECG and laboratory testing including pursued intervention and/or findings from subsequent angiography will be compared between intervention groups. To be considered a myocardial infarction, the diagnosis will have to be confirmed and documented in the chart by a board-certified cardiologist. | Either in-hospital or within 30 days of procedure |
| Persistence of atrial fibrillation at discharge | Atrial fibrillation as diagnosed by final ECG | Up to 90 days |
| Postoperative hospital length of stay | The postoperative length of stay will be calculated starting from the end of the procedure to time of discharge. | Up to 90 days |
| Readmission | Rates of hospital readmission will be estimated for patients in each of the study intervention groups. Readmissions will be counted in this calculation if patients are admitted to the hospital. Emergency room visits without admission and outpatient visits will not count toward this calculation of readmission rates. | Within 30 days of procedure |
| Symptomatic bradycardia | Symptomatic bradycardia (HR < 55 bpm) requiring intervention | Either in-hospital or within 30 days of procedure |
| Number of patients with Amiodarone-related pulmonary toxicity | Clinical diagnosis of amiodarone-related pulmonary toxicity that uses a combination of x-ray findings consistent with known amiodarone-related pulmonary toxicity and clinical findings including shortness of breath, non-productive cough, and other diagnoses have been excluded. | Either in-hospital or within 30 days of procedure |
| 23627761 | Background | Chatterjee S, Sardar P, Mukherjee D, Lichstein E, Aikat S. Timing and route of amiodarone for prevention of postoperative atrial fibrillation after cardiac surgery: a network regression meta-analysis. Pacing Clin Electrophysiol. 2013 Aug;36(8):1017-23. doi: 10.1111/pace.12140. Epub 2013 Apr 29. |
| 17316148 | Background | Buckley MS, Nolan PE Jr, Slack MK, Tisdale JE, Hilleman DE, Copeland JG. Amiodarone prophylaxis for atrial fibrillation after cardiac surgery: meta-analysis of dose response and timing of initiation. Pharmacotherapy. 2007 Mar;27(3):360-8. doi: 10.1592/phco.27.3.360. |
| 34882435 | Background | Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS Jr, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 Jan 18;145(3):e18-e114. doi: 10.1161/CIR.0000000000001038. Epub 2021 Dec 9. No abstract available. |
| 31447894 | Background | Colunga Biancatelli RM, Congedo V, Calvosa L, Ciacciarelli M, Polidoro A, Iuliano L. Adverse reactions of Amiodarone. J Geriatr Cardiol. 2019 Jul;16(7):552-566. doi: 10.11909/j.issn.1671-5411.2019.07.004. |
| 19597088 | Background | Orr CF, Ahlskog JE. Frequency, characteristics, and risk factors for amiodarone neurotoxicity. Arch Neurol. 2009 Jul;66(7):865-9. doi: 10.1001/archneurol.2009.96. |
| 19399307 | Background | Wolkove N, Baltzan M. Amiodarone pulmonary toxicity. Can Respir J. 2009 Mar-Apr;16(2):43-8. doi: 10.1155/2009/282540. |
| D013568 |
| Pathological Conditions, Signs and Symptoms |