Prevention of atrial fibrillation with ultra-low dose landiolol after off-pump coronary artery bypass grafting

Intravenous landiolol for the prevention of atrial fibrillation after aortic root, ascending aorta, and aortic arch surgery: A propensity score-matched analysis

Objective

Postoperative atrial fibrillation (POAF) after cardiac surgery is associated with increased mortality. The efficacy of landiolol hydrochloride for POAF prevention after coronary artery bypass grafting procedure and valve surgery has been reported. However, little evidence is available on its role in POAF prevention after aortic root, ascending aorta, and aortic arch surgery. This study aimed to determine the association between intravenous landiolol and the incidence of POAF after these aortic surgeries.

Methods

We included 358 consecutive adult patients without preoperative atrial fibrillation who underwent aortic root, ascending aorta, and aortic arch surgery between January 1, 2011, and December 31, 2018, at our institution. The therapeutic influence of landiolol in preventing POAF was estimated by propensity score-matched analysis (n = 222). The primary end point was the incidence of POAF within 72 hours after surgery. The secondary end points included adverse clinical events such as 30-day mortality and symptomatic cerebral infarction.

Results

The median age of the cohort was 72 years, 68.5% were men, and 46.4% received postoperative oral or transdermal β-blockers. After minimizing differences in patient background by propensity score matching, the incidence of POAF in the landiolol group was significantly lower than that in the reference group (18.9% vs 38.7%; P = .002). Landiolol use was associated with reduced incidence of POAF (odds ratio, 0.39; 95% CI, 0.21 to −0.72; P = .003). There were no significant differences in secondary end points.

Conclusions

Intravenous landiolol was associated with a lower incidence of POAF after aortic root, ascending aorta, and aortic arch surgery.

OUP accepted manuscript

Rate and rhythm control are still considered equivalent strategies for symptom control using the Atrial Fibrillation Better Care algorithm recommended by the recent atrial fibrillation guideline. In acute situations or critically ill patients, a personalized approach should be used for rapid rhythm or rate control. Even though electrical cardioversion is generally indicated in haemodynamically unstable patients or for rapid effective rhythm control in critically ill patients, this is not always possible due to the high percentage of failure or relapses in such patients. Rate control remains the background therapy for all these patients, and often rapid rate control is mandatory. Short and rapid-onset-acting beta-blockers are the most suitable drugs for acute rate control. Esmolol was the classical example; however, landiolol a newer very selective beta-blocker, recently included in the European atrial fibrillation guideline, has a more favourable pharmacokinetic and pharmacodynamic profile with less haemodynamic interference and is better appropriate for critically ill patients.

Blood Pressure Recovery After Dobutamine Antagonism: Partial With Landiolol, None With Esmolol

We investigated the hemodynamic effects of 2 short-acting β₁ -blockers, landiolol and esmolol, in the continuous presence of dobutamine in a prospective, single-center, randomized, crossover study in 16 healthy White volunteers. Dobutamine was infused at a rate sufficient to increase the heart rate by at least 30 beats per minute, followed by a 60-minute infusion of 50 μg/kg/min esmolol or 10 μg/kg/min landiolol on top of the unchanged dobutamine infusion. Concentrations of β-blockers and their metabolites in blood, heart rate, and blood pressure were followed for 180 minutes. Landiolol reduced the dobutamine-induced heart rate and blood pressure increases better than esmolol. After discontinuation of β-blocker administration, heart rate recovered swiftly to preinfusion values in both study arms. Systolic and diastolic blood pressure recovered partially after landiolol but showed a continued reduction after esmolol. No serious adverse events were observed. The heart rate effect is characteristic for β-blockers, whereas the blood pressure effects are likely due to direct and indirect β-blocker effects as well as influences on various ion channels. This may explain why landiolol that is devoid of effects on renin and sodium, calcium, and potassium channels behaves different from esmolol with respect to blood pressure recovery.

Beta-Blocker Landiolol Hydrochloride in Preventing Atrial Fibrillation Following Cardiothoracic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

The purpose of this article was to assess the benefit of perioperative administration of the intravenous beta-blocker landiolol hydrochloride in preventing atrial fibrillation (AF) after cardiothoracic surgery.

METHODS

We performed a systematic search in PubMed, Web of Science, CNKI, and OVID to identify randomized controlled trials (RCTs) and cohorts up to January 2021. Data regarding postoperative atrial fibrillation (POAF) and safety outcomes were extracted. Odds ratios (ORs) with 95% confidence intervals (CIs) were determined using the Mantel-Haenszel method. Meanwhile, subgroup analyses were conducted according to surgery type including lung cancer surgery, esophageal cancer surgery, and cardiac surgery.

RESULTS

Seventeen eligible articles involving 1349 patients within 13 RCTs and four cohorts were included in our meta-analysis. Compared with control group, landiolol administration was associated with a significant reduction of the occurrence of AF after cardiothoracic surgery (OR = 0.32, 95% CI 0.23-0.43, P <0.00001). In addition, the results demonstrated that perioperative administration of landiolol hydrochloride minimized the occurrence of postoperative complications (OR = 0.48, 95% CI 0.33-0.70, P = 0.0002). Funnel plots indicated no obvious publication bias.

CONCLUSIONS

Considering this analysis, landiolol was effective in the prevention of AF after cardiothoracic surgery and did not increase the risk of major postoperative complications.

Pharmacodynamic and pharmacokinetic behavior of landiolol during dobutamine challenge in healthy adults

Background

To study the pharmacokinetic and -dynamic behavior of landiolol in the presence of dobutamine in healthy subjects of European ancestry.

Methods

We conducted a single-center, prospective randomized study in 16 healthy subjects each receiving an infusion of dobutamine sufficient to increase heart rate by 30 bpm followed by a 60 min infusion of 10 μg/kg/min landiolol.

Results

Dobutamine-induced increases in heart rate were stable for at least 20 min before a 60 min landiolol- infusion was started. The dobutamine effects were rapidly antagonized by landiolol within 16 min. A further slight decrease in heart rate during 20–60 min of the landiolol infusion occurred as well. Upon termination of landiolol infusion, heart rate and blood pressure recovered rapidly in response to the persisting dobutamine infusion but did not return to the maximum values before landiolol infusion. The pharmacokinetic parameters of landiolol in presence of dobutamine showed a short half-life (3.5 min) and a low distribution volume (0.3 l/kg). No serious adverse events were observed.

Conclusion

Landiolol can antagonize the dobutamine-induced increases in heart rate and blood pressure in a fast way. A rapid bradycardic effect until steady-state plasma levels is followed by a slow heart rate reduction. The latter can be attributed to an early desensitization to dobutamine. Consequently, after termination of landiolol, the heart rate did not achieve maximum pre-landiolol values. The pharmacokinetics of landiolol during dobutamine infusion are similar when compared to short- and long-term data in Caucasian subjects. Landiolol in the given dose can thus serve as an antagonist of dobutamine-induced cardiac effects.

Trial registration

Registration number 2010–023311-34 at the EU Clinical Trials Register, registration date 2010-12-21.

Temporal Dispersion of Atrial Activation Causes Postoperative Atrial Fibrillation

BACKGROUND

Spatial dispersion of atrial activation is a cause of postoperative atrial fibrillation (PoAF) after cardiac surgery. This study evaluated whether temporal dispersion of atrial activation causes PoAF after surgery in a clinical setting.

METHODS

Nineteen patients were enrolled. Postoperative atrial activation was evaluated by 24-hour Holter electrocardiography, with atrial pacing wires on the right atrium, for 5 days after cardiac surgery. No patient received antiarrhythmic drugs, including beta-blockers. The cycle length of 15 continuous atrial beats was measured at 4 time points: (i) earlier than 12 hours before PoAF, as a control, (ii) just before PoAF onset, (iii) during PoAF, and (iv) just before cessation of PoAF. Inhomogeneity of atrial activation was quantified by using the variation coefficient for a cycle length of 15 atrial beats during each phase.

RESULTS

The median inhomogeneity index of atrial activation (interquartile range) was 0.102 (0.046-0.136) in controls, 0.943 (0.582-1.610) just before PoAF onset (vs. control; p=0.009), 0.966 (0.631-1.117) during PoAF, and 0.471 (0.138-0.645) just before cessation of PoAF.

CONCLUSIONS

Dispersion of atrial activation significantly increased just before PoAF onset. Temporal dispersion of atrial activation is a precursory variation of PoAF.

Landiolol hydrochloride for prevention of atrial fibrillation during esophagectomy: a randomized controlled trial

Introduction

Landiolol hydrochloride reduces the incidence of perioperative atrial fibrillation (AF) in cardiac surgery; however, little evidence is available regarding its effects in other types of surgery, including esophagectomy. We assessed the hypothesis that landiolol reduces perioperative AF and other complications associated with esophagectomy.

Methods

This single-center, randomized, double-blind, parallel-group study enrolled patients scheduled for esophagectomy. Patients were divided into those given landiolol at 3 μg/kg/min or placebo for 24 h. The primary outcome was the proportion of patients who developed AF within 96 h starting at 9:00 am on the day of surgery. The secondary outcomes were the proportion of patients whose AF appeared within 24 h, other complications based on the Clavien–Dindo classification, and the intensive care unit and hospital stays.

Results

Despite early study termination, 80 patients were screened, and 56 were enrolled (28/group) from September 2016 to June 2018. AF occurred within 96 h of surgery in six (21.4%) patients in the landiolol group and five (17.9%) patients in the placebo group (odds ratio, 1.26; 95% confidence interval, 0.33–4.7) and within 24 h of surgery in three (10.7%) patients in the landiolol group and two (7.1%) patients in the placebo group. There were no significant differences in the incidence of complications or in the number of intensive care unit or hospital stays between the groups.

Conclusion

Although our small sample size prevents definitive conclusions, landiolol might not reduce the occurrence of AF or other complications.

Trial registration

UMIN, UMIN000024040. Registered 13 September 2016, http://www.umin.ac.jp/ctr/index/htm

Evaluating the Therapeutic Efficacy and Safety of Landiolol Hydrochloride for Management of Arrhythmia in Critical Settings: Review of the Literature

Background

Landiolol hydrochloride, a highly cardio-selective beta-1 blocker with an ultra-short-acting half-life of 4 minutes, was originally approved by Japan for treatment of intraoperative tachyarrhythmias. This review aims to provide an integrated overview of the current state of knowledge of landiolol hydrochloride in the management of arrhythmia in critical settings.

Methods

We searched MEDLINE, EMBASE, and the Cochrane Library to retrieve relevant articles with a total of 65 records identified.

Results

The high β1 selectivity (β1/β2 ratio of 255:1) of landiolol causes a more rapid heart rate (HR) decrease compared to esmolol while avoiding decreases in mean arterial blood pressure. Recently, it has been found useful in left ventricular dysfunction patients and fatal arrhythmia requiring emergency treatment. Recent random clinical trials (RCT) have revealed therapeutic and prophylactic effects on arrhythmia, and very low-dose landiolol might be effective for preventing postoperative atrial fibrillation (POAF) and sinus tachycardia. Likewise, landiolol is an optimal choice for perioperative tachycardia treatment during cardiac surgery. The high β1 selectivity of landiolol is useful in heart failure patients as a first-line therapy for tachycardia and arrhythmia as it avoids the typical depression of cardiac function seen in other β-blockers. Application in cardiac injury after percutaneous coronary intervention (PCI), protection for vital organs (lung, kidney, etc.) during sepsis, and stabilizing hemodynamics in pediatric patients are becoming the new frontier of landiolol use.

Conclusion

Landiolol is useful as a first-line therapy for the prevention of POAF after cardiac/non-cardiac surgery, fatal arrhythmias in heart failure patients and during PCI. Moreover, the potential therapeutic effect of landiolol for sepsis in pediatric patients is currently being explored. As positive RCT results continue to be published, new clinical uses and further clinical studies in various settings by cardiologists, intensivists and pediatric cardiologists are being conducted.

Cost-Effectiveness Analysis of Landiolol, an Ultrashort-Acting Beta-Blocker, for Prevention of Postoperative Atrial Fibrillation for the Germany Health Care System

OBJECTIVES

Landiolol is an ultrashort-acting beta-blocker with high beta-1 receptor affinity and less blood pressure-lowering properties than other beta-blockers available for intravenous use in Germany. The present analysis aimed to determine whether perioperative treatment with landiolol in cardiac surgical patients is cost-effective under the conditions of the German Diagnosis-Related Groups health cost reimbursement system.

DESIGN

On the basis of clinical outcome data from a meta-analysis that included 622 patients from 7 randomized controlled trials, a decision-model was developed to determine the cost-effectiveness of landiolol versus standard-of-care (SoC).

SETTING

Hospital setting.

PARTICIPANTS

Hospital patients undergoing a representative mix of cardiac surgical procedures (MIX-CS) and isolated coronary artery bypass grafting (CABG).

INTERVENTIONS

Landiolol versus SoC in prevention of atrial fibrillation immediately after cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

The model benefit was expressed in a reduction of postoperative atrial fibrillation (POAF) episodes and reduced complications. The model calculated total inpatient costs over the hospital length of stay. Costs from published sources were used for the German hospital perspective. SoC was associated with POAF rates of 36.0% to 39.2% and 24.4% to 30.1% in the MIX-CS and CABG populations, respectively. Patients with POAF had a higher morbidity and mortality. Estimated total costs for SoC patients in the MIX-CS and CABG groups were 28.792 € and 25.630 €, respectively. Landiolol reduced the incidence of POAF to 12.6% in the MIX-CS and 12.1% in the CABG groups. This was associated with a cost reduction of 2.209 € and 1.470 €.

CONCLUSIONS

This analysis suggests that preventing POAF with landiolol is highly cost-effective. Additional studies are needed to assess whether a comparable reduction in POAF and associated cost savings may be achieved using conventional intravenous beta-blockers or amiodarone.

Landiolol for managing atrial fibrillation in post-cardiac surgery

Landiolol is an intravenous ultra-short acting beta-blocker which has been used in Japan for many years to prevent and/or to treat post-operative atrial fibrillation following cardiac surgery. The drug is now available in Europe. This article is a systematic review of literature regarding the use of landiolol in that specific surgical setting.

Glucose Variability Based on Continuous Glucose Monitoring Assessment Is Associated with Postoperative Complications after Cardiovascular Surgery

PURPOSE

This purpose of this prospective study was to use a continuous glucose monitoring (CGM) system to evaluate the suitability of our institution's glucose management protocol after cardiovascular surgery and to clarify the impact of glycemic variability on postoperative complications.

METHODS

In all, 76 patients who underwent elective cardiovascular surgery and were monitored perioperatively using a CGM system were evaluated. Postoperative glucose management consisted of continuous intravenous insulin infusion (CIII) in the intensive care unit, and subcutaneous insulin injections (SQII) after oral food intake started. CIII and subcutaneous injections were initiated when blood glucose level exceeded 150 mg/dL. CGM data were used to analyze perioperative glycemic variability and association with postoperative complications.

RESULTS

Target glucose levels (71-180 mg/dL) were achieved during 97.1 ± 5.5% and 86.4 ± 19.0% of the continuous insulin infusion and subcutaneous injection periods, respectively. Major postoperative complications were surgical site infections, found in 6.6% of total patients, and atrial fibrillation, found in 44% of patients with off-pump coronary artery bypass grafting. High glycemic variability during SQII was associated with increased risk for both complications.

CONCLUSION

Data analysis revealed that our glucose management protocol during CIII was adequate. However, the management protocol during SQII required improvement.

Randomized clinical trial of landiolol hydrochloride for the prevention of atrial fibrillation and postoperative complications after oesophagectomy for cancer

Background

Atrial fibrillation is common after oesophageal surgery. The aim of this study was to evaluate whether landiolol hydrochloride was effective and safe in the prevention of atrial fibrillation after oesophagectomy, and to see whether a reduction in incidence of atrial fibrillation would reduce other postoperative complications.

Methods

This single-centre study enrolled patients scheduled for transthoracic oesophagectomy in a randomized, double-blind, placebo-controlled trial between March 2013 and January 2016. Enrolled patients were randomized with a 1 : 1 parallel allocation ratio to either landiolol prophylaxis or placebo. The primary endpoint was the occurrence of atrial fibrillation after oesophagectomy. Secondary endpoints were incidence of postoperative complications, and effects on haemodynamic and inflammatory indices.

Results

One hundred patients were enrolled, 50 in each group. Postoperative atrial fibrillation occurred in 15 patients (30 per cent) receiving placebo versus five (10 per cent) receiving landiolol (P = 0·012). The overall incidence of postoperative complications was significantly lower in the landiolol group (P = 0·046). In the landiolol group, postoperative heart rate was suppressed effectively, but the decrease in BP was not harmful. The interleukin 6 level was significantly lower on days 3 and 5 after surgery in the landiolol group (P = 0·001 and P = 0·002 respectively).

Conclusion

Landiolol was effective and safe in preventing atrial fibrillation after oesophagectomy. Registration number: UMIN000010648 (http://www.umin.ac.jp/ctr/).

The suppressive effects of landiolol administration on the occurrence of postoperative atrial fibrillation and tachycardia, and plasma IL-6 elevation in patients undergoing esophageal surgery: A randomized controlled clinical trial

STUDY OBJECTIVE

To determine whether perioperative landiolol administration suppresses postoperative atrial fibrillation (AF) and the plasma cytokines elevation in patients undergoing esophageal cancer surgery.

DESIGN

A prospective, randomized controlled trial.

SETTING

Akita University Hospital, Akita, Japan, from April 2012 to January 2015.

PATIENTS

Forty American Society of Anesthesiologists grade I-II patients undergoing elective esophagectomy.

INTERVENTIONS

Patients were randomly divided into two groups, landiolol group (landiolol: 5μg/kg/min) and control group (the same volume of covered saline). Landiolol or saline was infused continuously from the induction of anesthesia until next morning.

MEASUREMENTS

We examined the new onset of AF and sinus tachycardia, and measured plasma concentrations of cytokines (IL-1β, IL-6, IL-8, IL-10, and TNF-α) just before surgery, at the end of surgery, the next day, and 2days after surgery. Data (mean±SD) were analyzed using two-way ANOVA followed by the Bonferroni"s test for post hoc comparison; a P<0.05 was considered statistically significant.

MAIN RESULTS

Demographic data were similar between the landiolol and the control groups. The incidence of AF was significantly lower in the landiolol group (1/19=5.3%) compared with the control group (7/20=35%) as well as sinus tachycardia (landiolol group, 0/19=0% vs. control group, 5/20=25%). Plasma IL-6 level at the end of surgery was significantly lower in the landiolol group compared with the control group, but the other plasma cytokines levels were similar between the two groups during the entire study period.

CONCLUSIONS

Perioperative landiolol administration suppressed the incidence of new-onset of AF as well as sinus tachycardia, and the plasma IL-6 elevation in patients undergoing esophageal cancer surgery.

Atrial fibrillation following aortic valve replacement: impact of perioperative use of intravenous β-blocker

OBJECTIVES

Despite recent advances in perioperative management, postoperative atrial fibrillation/flutter (POAF) remains the most common complication after cardiac surgery. Therefore, it is important to determine related risk factors to establish effective management. However, most studies have focused on patients undergoing coronary artery bypass grafting and little is known about POAF in those who receive aortic valve replacement (AVR). We investigated the relationship of clinical predictors with POAF in patients undergoing AVR.

METHODS

A total of 119 patients who underwent AVR were enrolled in this study, and the relationships between POAF incidence and perioperative (preoperative, operative, postoperative) factors were examined.

RESULTS

POAF occurred in 47 patients (40%). In univariate analysis, older age was significantly associated with POAF occurrence, which was significantly related to prolonged intensive care unit (ICU) stay and postoperative stroke. It also showed patients with preoperative β-blocker experienced POAF less frequently than those without β-blocker. Multivariate analysis showed that preoperative β-blocker usage was an independent predictor of POAF. In patients who received both preoperative oral and postoperative intravenous β-blocker administrations, the incidence of POAF was reduced to 14% (3/22).

CONCLUSIONS

POAF frequently occurred in patients undergoing AVR, and was significantly related to prolonged ICU stay and postoperative stroke. Our findings show that advanced age and absence of preoperative β-blocker usage are risk factors for POAF. Furthermore, in patients undergoing AVR, perioperative intravenous β-blocker administration may be useful for prevention.

Landiolol infusion during general anesthesia does not prevent postoperative atrial fibrillation in patients undergoing lung resection

OBJECTIVE

We aimed to determine whether intraoperative low-dose infusion of landiolol, an ultra-short-acting beta blocker, can prevent postoperative atrial fibrillation (POAF) after lung resection.

METHODS

A double-blind, randomized, controlled, preliminary study was performed in university academic hospital, single center. Fifty lung surgical patients were key-opened before enrollment of the originally planned 100 patients, who were randomized in a 1:1 ratio in each treatment arm. Landiolol was infused with a dosage of 5 μg/kg/min during general anesthesia in the landiolol group, which was compared with the placebo control group with no landiolol. Atrial fibrillation (AF)-free survival curves were generated by means of Kaplan-Meier estimates and differences in survival were compared with the use of the log-rank test. We examined independent predictors of POAF by the multivariate logistic regression analysis using the perioperative parameters detected with the univariate analysis.

RESULTS

The AF events were recorded for 7 days with Holter monitor in 5 of 25 patients in the landiolol group and 4 of 25 patients in the control group. Kaplan-Meier analysis showed that the landiolol group could not avoid the incidence of POAF in comparison with the placebo saline group (P = 0.806). The multivariate logistic regression analysis for prevalence of POAF identified only one statistically significant predictor: interleukin-6 (IL-6) sampled at 6 h after end of surgery.

CONCLUSIONS

We failed to demonstrate that low-dose infusion of landiolol during general anesthesia could prevent the incidence of AF after lung resection. Only IL-6 sampled at 6 h after end of surgery significantly predicted POAF among pulmonary surgical patients.

Pharmacokinetics and pharmacodynamics of two different landiolol formulations in a healthy Caucasian group

BACKGROUND

To date, no data have been reported on the pharmacokinetic and pharmacodynamic properties of landiolol, a fast-acting cardioselective β1-adrenergic antagonist, in non-Asian subjects. The aim of this study was to compare two landiolol formulations in healthy Caucasian subjects.

MATERIALS AND METHODS

We conducted a single-center, prospective, double-blinded, randomized study in two cross-over periods with 12 healthy subjects (7 women and 5 men) each receiving three doses (0.1, 0.2, and 0.3mg/kg BW) of Onoact® 50 Lyophilized powder (50mg) or Rapibloc® concentrate IV (20mg/2mL) to evaluate the pharmacokinetics (PK), pharmacodynamics (PD), safety, and tolerability of the two landiolol formulations.

RESULTS

For both formulations, maximum blood concentrations of landiolol were rapidly reached (median tmax 2.3±0.65 and 2.8±1.13min for the high dose of each formulation). The compounds had a short half-life (t1/2=3.2±1.2min and 3.0±1.1min for the low dose of the concentrate formulation and the lyophilized powder, respectively). The results showed no statistically significant differences between both formulations of landiolol for any PK parameters, at study doses. Both formulations dose-dependently and significantly decreased the heart rate values from 62.2bpm at baseline to minimum values of 55-56, 52-53, and 50-52bpm after 0.1, 0.2, and 0.3mg/kg respectively. This bradycardic effect was achieved within 1 to 3min. The decrease in systolic blood pressure (baseline: 107mmHg, minimum values were around 99mmHg) was significant but not dose dependent, and occurred within 3 to 12min. Seven mild to moderate AEs occurred after administration of the concentrate formulation. No SAEs were reported in this study.

CONCLUSION

In Caucasians, both landiolol formulations showed similar pharmacokinetic behaviours, displaying very short half-lives (3.0 to 3.6min). In addition, after administration of both formulations, the landiolol-induced heart rate reduction showed fast onset and dose dependence, whilst the decrease of systolic blood pressure occurred more slowly, was less pronounced, and dose independent. In summary, both landiolol formulations delivered comparable plasma concentration profiles and showed good local tolerability. Overall, the pharmacokinetic and pharmacodynamic reactions observed in Caucasians were comparable to those described in Japanese subjects.

Efficacy and Safety of Landiolol Compared to Amiodarone for the Management of Postoperative Atrial Fibrillation in Intensive Care Patients

OBJECTIVE

The authors assessed the efficacy and safety of landiolol, an ultra-short-acting beta-blocker, with those of amiodarone in the restoration of sinus rhythm for postoperative atrial fibrillation (POAF) in intensive care unit (ICU) patients.

DESIGN

A retrospective data analysis.

SETTING

Data were collected from patients admitted to the ICU in a single university hospital between 2012 and 2015.

PARTICIPANTS

Records of a total of 276 patients who developed POAF after ICU admission were collected from hospital records.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Treatment success was defined as restoration of sinus rhythm without concomitant therapy within 24 hours of treatment and lasting for more than an hour. The landiolol dosage was in the range of 0.7 µg/kg/min-to-2.5 µg/kg/min. The authors compared a total of 55 patients with POAF who received either landiolol (n = 32) or intravenous amiodarone (n = 23) in the ICU. The major findings were that the median time required for conversion to sinus rhythm was shorter in landiolol patients compared with amiodarone patients (75 v 150 min respectively, p = 0.0355). However, treatment success rates did not differ significantly after 24 hours (odds ratio 1.25, 95% confidence interval 0.17-9.09, p = 0.60). Adverse events with bradycardia leading to drug discontinuation were seen only in the patients receiving amiodarone (n = 3, p = 0.032).

CONCLUSIONS

Landiolol achieved swift and safe restoration of sinus rhythm in ICU patients with POAF and could be considered as a favorable drug choice over amiodarone in such patients.

Safety and efficacy of landiolol hydrochloride for prevention of atrial fibrillation after cardiac surgery in patients with left ventricular dysfunction: Prevention of Atrial Fibrillation After Cardiac Surgery With Landiolol Hydrochloride for Left Ventricular Dysfunction (PLATON) trial

OBJECTIVES

We previously conducted a prospective study of landiolol hydrochloride (INN landiolol), an ultrashort-acting β-blocker, and reported that it could prevent atrial fibrillation after cardiac surgery. This trial was performed to investigate the safety and efficacy of landiolol hydrochloride in patients with left ventricular dysfunction undergoing cardiac surgery.

METHODS

Sixty patients with a preoperative left ventricular ejection fraction of less than 35% were randomly assigned to 2 groups before cardiac surgery and then received intravenous infusion with landiolol hydrochloride (landiolol group) or without landiolol (control group). The primary end point was occurrence of atrial fibrillation as much as 1 week postoperatively. The secondary end points were blood pressure, heart rate, intensive care unit and hospital stays, ventilation time, ejection fraction, biomarkers of ischemia, and brain natriuretic peptide.

RESULTS

Atrial fibrillation occurred in 3 patients (10%) in the landiolol group versus 12 (40%) in the control group, and its frequency was significantly lower in the landiolol group (P = .002). During the early postoperative period, levels of brain natriuretic peptide and ischemic biomarkers were significantly lower in the landiolol group than the control group. The landiolol group also had a significantly shorter hospital stay (P = .019). Intravenous infusion was not discontinued for hypotension or bradycardia in either group.

CONCLUSIONS

Low-dose infusion of landiolol hydrochloride prevented atrial fibrillation after cardiac surgery in patients with cardiac dysfunction and was safe, with no effect on blood pressure. This intravenous β-blocker seems useful for perioperative management of cardiac surgical patients with left ventricular dysfunction.

Stroke associated with coronary artery bypass grafting

While coronary artery bypass grafting (CABG) has been playing a significant role in the revascularization for ischemic heart disease, neurological complications associated with CABG have been a primary concern. Stroke, although the incidence is low, is one of the most devastating complication of CABG. Many studies have identified the risk factors for stroke with CABG, such as prior stroke, carotid artery stenosis, aortic atherosclerosis, atrial fibrillation and cardiopulmonary bypass. Various rational approaches focusing on individual risk factor have been proposed for the stroke. Prophylactic carotid revascularization is an important strategy, and the diagnosis of carotid stenosis has to be established correctly. Prevention of emboli from aortic plaque is also an essential issue. Intraoperative monitoring with transesophageal or epiaortic ultrasound is useful to identify mobile atheromatous plaques and to select appropriate aortic manipulations. Maintenance of cerebral blood flow and blood pressure during cardiopulmonary bypass might be critical issues. Besides, there are conflicting two opinions regarding off-pump CABG; one supports an efficiency for the prevention of stroke while the other advocates no effect. This discrepancy might be explained by the difference of the risk of stroke in the population of the individual study and by the variation of the percentage of aortic clamping or aortic anastomosis in each study. Pharmaceutical therapies such as statin, preventive medication for atrial fibrillation, or antiplatelet are promising methods. Although it is hard to decrease the incidence of the stroke with any single countermeasure, sustained effort should be continued to overcome the stroke associated with CABG.

Preventive effect of intraoperative landiolol administration on atrial fibrillation after off-pump coronary artery bypass grafting

INTRODUCTION

Postoperative atrial fibrillation (AF) is a common complication of cardiac surgery that is associated with an increased incidence of other complications. This study evaluated the safety and efficacy of landiolol hydrochloride--an ultrashort-acting β1-selective blocker and highly regulated drug, positioned as a class 1 antiarrhythmic in Japan guidelines--for the prevention of AF after off-pump coronary artery bypass grafting (CABG).

METHODS

Between January 2011 and November 2013, 116 patients underwent CABG at Fukuoka University Hospital. They were divided into two groups: group L consisted of patients who were administered landiolol hydrochloride at 2 μg/kg/min after completion of all distal anastomoses; group C was the control group consisting of patients who were not administered landiolol. Patient backgrounds, intraoperative variables and incidence of postoperative complications were compared.

RESULTS

No significant between-group differences were observed in patient backgrounds or incidence of complications other than postoperative AF, which occurred significantly less frequently in group L. After administration of landiolol, heart rate decreased but no change was observed in arterial pressure or other parameters, and patient hemodynamics remained stable.

CONCLUSION

Intraoperative and perioperative administration of low-dose landiolol has a preventive effect on the development of AF after CABG surgery.

Perioperative landiolol administration reduces atrial fibrillation after cardiac surgery: A meta-analysis of randomized controlled trials

Introduction

Postoperative atrial fibrillation (POAF) is one of the most common complications after cardiac surgery. Patients who develop POAF have a prolonged stay in the intensive care unit and hospital and an increased risk of postoperative stroke. Many guidelines for the management of cardiac surgery patients, therefore, recommend perioperative administration of beta-blockers to prevent and treat POAF. Landiolol is an ultra-short acting beta-blocker, and some randomized controlled trials of landiolol administration for the prevention of POAF have been conducted in Japan. This meta-analysis evaluated the effectiveness of landiolol administration for the prevention of POAF after cardiac surgery.

Methods

The Medline/PubMed and BioMed Central databases were searched for randomized controlled trials comparing cardiac surgery patients who received perioperative landiolol with a control group (saline administration, no drug administration, or other treatment). Two independent reviewers selected the studies for inclusion. Data regarding POAF and safety outcomes were extracted. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the Mantel–Haenszel method (fixed effects model).

Results

Six trials with a total of 560 patients were included in the meta-analysis. Landiolol administration significantly reduced the incidence of POAF after cardiac surgery (OR 0.26, 95% CI 0.17–0.40). The effectiveness of landiolol administration was similar in three groups: all patients who underwent coronary artery bypass grafting (CABG) (OR 0.27, 95% CI 0.17–0.43), patients who underwent CABG compared with a control group who received saline or nothing (OR 0.28, 95% CI 0.17–0.45), and all patients who underwent cardiac surgery compared with a control group who received saline or nothing (OR 0.27, 95% CI 0.17–0.42). Only two adverse events associated with landiolol administration were observed (2/302, 0.7%): hypotension in one patient and asthma in one patient.

Conclusion

Landiolol administration reduces the incidence of POAF after cardiac surgery and is well tolerated.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-014-0116-x) contains supplementary material, which is available to authorized users.

Landiolol hydrochloride for prevention of atrial fibrillation after cardiac surgery: a meta-analysis

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmic complication after cardiac surgery. Several studies have compared the efficacy of landiolol and placebo or other agents in preventing new-onset AF in patients after cardiac surgery. In this study, we conducted a meta-analysis to determine whether landiolol is effective in preventing new-onset AF after cardiac surgery.

METHODS AND RESULTS

Five randomized controlled trials and two retrospective analyses were included in this study. The clinical outcomes of interest were the occurrence of AF after cardiac surgery and major complications. Meta-analysis was performed using RevMan 5.0.18 software, and pooled estimates of the effect were reported as risk ratios (RR) with 95% confidence intervals (CI). The results of this meta-analysis indicate that landiolol is significantly associated with a decreased risk of occurrence of AF after cardiac surgery (RR = 0.33; 95% CI: 0.23-0.48; P < 0.00001) and is not associated with an increased risk of major complications (RR = 0.79; 95% CI: 0.43-1.45; P = 0.45) compared with the control group.

CONCLUSION

Landiolol administration in the perioperative period can reduce the occurrence of AF after cardiac surgery without increasing the risk of major complications. It can be used to prevent new-onset AF safely after cardiac surgery.

Landiolol: a review of its use in intraoperative and postoperative tachyarrhythmias

Landiolol (Onoact(®)) is an intravenously administered, ultra short-acting β1-blocker with an elimination half-life of 3-4 min and ≈8-fold greater cardioselectivity than esmolol in vitro. It is approved in Japan for the treatment of intraoperative and postoperative tachyarrhythmias, but in clinical practice is also used to prevent postoperative tachyarrhythmias, such as atrial fibrillation after coronary artery bypass grafting. Randomized controlled trials in patients undergoing open-heart surgery demonstrated that various dosages of landiolol (0.0005-0.04 mg/kg/min) [0.5-40 μg/kg/min] were more effective than diltiazem in converting postoperative atrial fibrillation to normal sinus rhythm during the first 8 h after surgery, and were more effective than placebo (or no landiolol) in preventing the development of atrial fibrillation during the first week after surgery (primary efficacy endpoints). In patients undergoing surgical procedures, landiolol 0.125 mg/kg/min for 1 min followed by 0.04 mg/kg/min for 10 min was superior to placebo in improving intraoperative tachycardia in randomized double-blind trials. The beneficial effects of landiolol in attenuating adverse haemodynamic or other changes that can occur during surgery or invasive procedures (e.g. percutaneous coronary intervention) have been demonstrated in a large number of randomized controlled trials. For example, several studies showed that landiolol attenuated the increase in heart rate associated with tracheal intubation, without adversely affecting blood pressure or other haemodynamic parameters. Landiolol was generally well tolerated in clinical trials, with a relatively low risk of hypotension and bradycardia, although routine monitoring of cardiac function during landiolol administration is important. In general, adverse events such as reduced blood pressure resolve quickly after discontinuation of landiolol. Thus, as an ultra short-acting β1-blocker with a rapid onset of action and readily titratable and rapidly reversible effects, landiolol represents an important agent for the management of intraoperative and postoperative tachyarrhythmias.