In patients undergoing lung resection is it safe to administer amiodarone either as prophylaxis or treatment of atrial fibrillation?

Abstract

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether the administration of amiodarone is safe in patients undergoing lung resection either for prophylaxis or treatment of de novo postoperative atrial fibrillation (POAF). A total of 30 papers were identified, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date, study type, country of publication, patient demographics, relevant outcomes and results were tabulated. Among the identified papers, there were 2 meta-analyses, 1 best evidence topic and 3 randomized studies, while the remainder were retrospective. When considering perioperative amiodarone for the prophylaxis of POAF, 3 randomized studies reported no significantly increased postoperative complications or amiodarone-related side effects. Mortality and length of hospital stay were similar in patients receiving amiodarone compared with either no amiodarone or other prophylactic antiarrhythmic medication. When considering amiodarone for the treatment of POAF, 1 study reported a significantly increased incidence of ARDS after anatomical lung resection (P < 0.001). Two case series reported that patients developing POAF after lung resection and managed with amiodarone also had either none or acceptable rates of side effects, with no serious respiratory complications. Two retrospective and 1 prospective observational study reported that amiodarone used either for the treatment of POAF, or for prophylaxis against it, had similar rates of postoperative respiratory complications, length of hospital stay and mortality, compared with either no treatment or treatment with other prophylactic or therapeutic agents. In accordance with the Society of Thoracic Surgeons guidelines on prophylaxis and management of POAF in general thoracic surgery, these data suggest that amiodarone is a safe agent for the management of POAF after lung resection. Careful monitoring in patients treated with amiodarone after pneumonectomy should be considered because development of acute lung toxicity can increase length of hospital stay, morbidity and mortality. Further studies may also be needed to identify the subset of pneumonectomy patients at risk of pulmonary toxicity after use of amiodarone.

Management of Hyperacute Amiodarone-induced Pulmonary Toxicity

“…Diagnosis is based on high clinical suspicion, patient's history, radiographic and clinical findings. APT may occur even at any time during treatment or even after cessation of treatment [4] . Applying a cumulative dose of 400 mg/day for 2 months, long duration of therapy, advanced age, and pre-existing pulmonary disease increase the risk of pulmonary toxicity.…”

A review and analysis of strategies for prediction, prevention and management of post-operative atrial fibrillation after non-cardiac thoracic surgery

“…I n i t i a l l y, amiodarone was considered unsafe in thoracic surgery after a small study in 1994 demonstrated an association between the use of amiodarone and acute respiratory distress syndrome (ARDS) after pneumonectomy (26). However, multiple studies have since demonstrated that low doses of amiodarone are safe and effective in patients with chronic lung disease (27,28). Magnesium has also been demonstrated to be effective in reducing the risk of AF.…”

“…The difference may be that more recent studies have used lower doses. Patients in the 1994 trial patients received cumulative doses of over 2,000 mg IV whereas more recent trials have only used up to 1,050 mg IV, which has demonstrated to be safe and effective (27,28). As such, careful consideration of patient comorbidities should be considered prior to administering antiarrhythmic therapy and only low doses of IV amiodarone should be used in patients who have undergone major pulmonary resection.…”

Amiodarone for Postoperative Atrial Fibrillation in Lung Cancer Patients: A 6-Year Follow-Up Study

“…Considering the potentially negative impact of POAF on morbidity and mortality, possibly preventive effect of antiarrhythmic drugs has been investigated [7] [8] [9] [10] [11]. Between 2008 and 2011, Riber et al conducted the randomized control trial, PASCART, of which 242 patients undergoing surgery for lung cancer were randomized to receive either amiodarone or placebo, as prophylaxis for POAF.…”