An Overview of the Pharmacokinetics and Pharmacodynamics of Landiolol (an Ultra-Short Acting β1 Selective Antagonist) in Atrial Fibrillation

Landiolol is an ultra-short-acting, selective β1-adrenergic receptor blocker that was originally approved in Japan for the treatment of intraoperative tachyarrhythmias. It has gained attention for its use in the management of tachyarrhythmias and perioperative tachycardia, especially atrial fibrillation for both cardiac and non-cardiac surgeries. It can be the ideal agent for heart rate control due to its high β1-selectivity, potent negative chronotropic effect, a limited negative inotropic potential, and an ultrashort elimination half-life (around 4 min); moreover, it may have a potential therapeutic effects for sepsis and pediatric patients. Landiolol seems to be superior to other short-acting and selective beta-blockers such as esmolol. This review aims to provide a comprehensive overview of landiolol, a new ultra-short-acting β1 selective antagonist, including its pharmacology, clinical applications, efficacy, safety profile, and future directions in research and clinical data.

Exploring postoperative atrial fibrillation after non-cardiac surgery: mechanisms, risk factors, and prevention strategies

Atrial fibrillation (AF) stands as the most prevalent persistent arrhythmia and a common complication after surgical procedures. Although the majority of non-cardiac surgery patients experience postoperative AF (POAF) and the condition is typically self-limited and asymptomatic, its detrimental impact on patient outcomes, prolonged hospitalization, and heightened risk of stroke and overall mortality has become increasingly evident. Of significant concern, POAF emerges as a noteworthy risk factor for stroke, myocardial infarction, and mortality in comparison to patients with non-surgical atrial fibrillation. Multiple studies have corroborated the association between POAF and an elevated risk of stroke and mortality. The development of postoperative atrial fibrillation is multifactorial, with the inflammatory response being a primary contributor; additionally, factors such as hypovolemia, intraoperative hypotension, anemia, trauma, and pain can trigger POAF. Risk factors for POAF in non-cardiac surgery primarily relate to age, hypertension, obesity, prior cardiac disease, obstructive sleep apnea, and male sex. Prophylactic treatment with β-blockers, amiodarone, or magnesium has demonstrated efficacy, but further trials are warranted, especially in high-risk populations. This review provides an account of the incidence rate, pathophysiology, and prognosis of atrial fibrillation after non-cardiac surgery, elucidates the underlying mechanisms of its occurrence, and explores various preventive strategies investigated in this domain.

Laparoscopic reconstruction in McKeown esophagectomy is a risk factor for postoperative diaphragmatic hernia

Diaphragmatic hernia is a very rare but high-risk complication after esophagectomy. Although there are many studies on the Ivor Lewis esophagectomy procedure for diaphragmatic hernia, there are fewer studies on the McKeown procedure. The present study aimed to estimate the incidence of diaphragmatic hernia after esophagectomy, describing its presentation and management with the McKeown procedure. We retrospectively evaluated the 622 patients who underwent radical esophagectomy between January 2002 and December 2020 at the Wakayama Medical University Hospital. Statistical analyses were performed to evaluate risk factors for diaphragmatic hernia. Emergency surgery for postoperative diaphragmatic hernia was performed in nine of 622 patients (1.45%). Of these nine patients, one developed prolapse of the small intestine into the mediastinum (11.1%). The other eight patients underwent posterior mediastinal route reconstructions (88.9%), one of whom developed prolapse of the gastric conduit, and seven of whom developed transverse colon via the diaphragmatic hiatus. Laparoscopic surgery was identified in multivariate analysis as the only independent risk factor for diaphragmatic hernia (odd's ratio [OR] = 9.802, p = 0.034). In all seven cases of transverse colon prolapse into the thoracic cavity, the prolapsed organ had herniated from the left anterior part of gastric conduit. Laparoscopic surgery for esophageal cancer is a risk factor for diaphragmatic hernia. The left anterior surface of gastric conduit and diaphragmatic hiatus should be fixed firmly without compromising blood flow to the gastric conduit.

Impact of pulmonary vein anatomy and left atrial size on postoperative atrial fibrillation after esophagectomy for esophageal cancer

BACKGROUND

This study aimed to investigate the relationship between postoperative atrial fibrillation (POAF) after esophagectomy and pre-existing cardiac substrate.

METHODS

We retrospectively analyzed 212 consecutive patients from between July 2010 and December 2022 who were scheduled to undergo esophagectomy for esophageal cancer without previous history of atrial fibrillation. All the patients underwent both echocardiography and contrast-enhanced multi-detector computed tomography (MDCT).

RESULTS

POAF occurred in 49 patients (23.1%). Multivariable logistic analysis demonstrated that independent predictors for POAF were age [OR; 1.06 (1.01-1.10), P < 0.01), three-field lymph node dissection [OR; 2.55 (1.25-5.23), P < 0.01), left atrial dilatation (> 35 mm) assessment by echocardiography [OR; 3.05 (1.49-6.25), P < 0.01) and common left pulmonary vein [OR; 3.03 (1.44-6.39), P < 0.01). The correlation coefficient was high for left atrial dimensions assessed by echocardiography and MDCT (r = 0.91, P < 0.01). Combination of left atrial dilatation by echocardiography and common left pulmonary vein had high odds ratio [OR; 8.10 (2.62-25.96), P < 0.01). Instead of echocardiographic assessment, combination of left atrial enlargement (> 35 mm) assessed by MDCT and common left pulmonary vein also showed high odds ratio for POAF [OR; 11.23 [2.19-57.63], P < 0.01).

CONCLUSION

Incidence of POAF after esophagectomy was related to both left atrial enlargement and common left pulmonary vein assessed by preoperative MDCT. Additional analysis of atrial size and pulmonary vein variation would facilitate preoperative assessment of the risk of POAF, but future studies must ascertain therapeutic strategy.

Landiolol: An Ultra-Short-Acting β-Blocker

Landiolol is an ultra-short-acting, highly cardio-selective, β-blocker, that is currently approved for clinical use in Japan and the European Union, for the treatment of tachyarrhythmias. Landiolol is highly cardio-selective with high β1 selectivity and receptor affinity, resulting in a more potent chronotropic effect and less potent hypotensive effect compared with other β-blockers such as esmolol and propranolol. Based on the recent randomized controlled trials, low-dose landiolol may have a beneficial role in the prevention and management of postoperative atrial fibrillation following noncardiac and cardiac surgeries, including on-pump and off-pump coronary artery bypass grafting and valve surgery. Additionally, landiolol may have potential utility for myocardial salvage and prevention of postpercutaneous coronary intervention myocardial infarction. Furthermore, the use of landiolol may also have a therapeutic effect for rate control of sepsis-related tachyarrhythmias. Positive results of recent randomized controlled trials should continue to inspire clinicians to conduct further, larger studies, to find new potential clinical applications for this novel drug.

The fragility of significant results from randomized controlled trials in esophageal surgeries

While randomized controlled trials (RCTs) are regarded as one of the highest forms of clinical research, the robustness of their P values can be difficult to ascertain. Defined as the minimum number of patients in a study arm that would need to be changed from a non-event to event for the findings to lose significance, the Fragility Index is a method for evaluating results from these trials. This study aims to calculate the Fragility Index for trials evaluating perioperative esophagectomy-related interventions to determine the strength of RCTs in this field. MEDLINE and EMBASE were searched for RCTs related to esophagectomy that reported a significant dichotomous outcome. Two reviewers independently screened articles and performed the data extractions with risk of bias assessment. The Fragility Index was calculated using a two-tailed Fisher's exact test. Bivariate correlation was conducted to evaluate associations between the Fragility Index and study characteristics. 41 RCTs were included, and the median sample size was 80 patients [Interquartile range (IQR) 60-161]. Of the included outcomes, 29 (71%) were primary, and 12 (29%) were secondary. The median Fragility Index was 1 (IQR 1-3), meaning that by changing one patient from a non-event to event, the results would become non-significant. Fragility Index was correlated with P value, number of events, and journal impact factor. The RCTs related to esophagectomy did not prove to be robust, as the significance of their results could be changed by altering the outcome status of a handful of patients in one study arm.

Risk Factors for Chronic Atrial Fibrillation Development After Esophagectomy for Esophageal Cancer

BACKGROUND

This study investigates the prognosis of patients with postoperative atrial fibrillation (POAF), aiming to elucidate predictors of occurrence of atrial fibrillation (AF) in the chronic phase after esophagectomy.

METHODS

We retrospectively analyzed 415 consecutive patients between July 2010 and December 2021 who were scheduled to undergo esophagectomy for esophageal cancer and had no previous history of AF.

RESULTS

POAF occurred in 73 patients (18%). Their ages were higher than those without POAF (72 [66-77] vs 68 [62-75], P < 0.01). Three-field lymph node dissection was more frequent in patients with POAF (63% vs 50%, P = 0.04). Overall survival rates were not significantly different between those with and without POAF in patients with stage III/IV cancer (P = 0.37), but overall survival rate of patients with POAF was lower than in those without POAF in stage I/II cancer (P = 0.03). Seventeen patients (4.1%) had recurrence of AF or new onset 31 days after esophagectomy. POAF was the only independent predictor of AF development in the chronic phase (HR: 4.09, 95%CI: [1.42-11.74], P = 0.01). AF development in the chronic phase was observed in 8 patients (11.0%) with and 9 patients (2.6%) without POAF (P < 0.01). AF development rates were not significantly different in patients with stage III/IV cancer (P = 0.05), but there was significant difference in patients with stage I/II cancer (P < 0.01).

CONCLUSION

The occurrence of POAF after esophagectomy is related with future development of AF and overall survival prognosis. Future studies must ascertain optimal therapeutic strategy.

Dose-dependent scavenging activity of the ultra-short-acting β1-blocker landiolol against specific free radicals

Landiolol, a highly cardioselective ultra-short-acting β1-blocker, prevents perioperative atrial fibrillation associated with systemic inflammation and oxidative stress. We evaluated the direct scavenging activity of landiolol against multiple free radical species. Nine free radical species (hydroxyl, superoxide anion, ascorbyl, tert-butyl peroxyl, tert-butoxyl, singlet oxygen, 2,2-diphenyl-1-picrylhydrazyl, nitric oxide, and tyrosyl radicals) were directly quantified using an X-band ESR spectrometer with the spin-trapping method. IC50 and reaction rate constants were estimated from the dose-response curve for each free radical. Landiolol scavenged six of the free radical species examined: hydroxyl radical (IC50 = 0.76 mM, k landiolol = 1.4 × 10‍10 M‍-1 s‍-1, p<0.001), superoxide anion (58 mM, 2.1 M‍-1 s‍-1, p = 0.044), tert-butoxyl radical (4.3 mM, k landiolol/k CYPMPO = 0.77, p<0.001), ascorbyl free radical (0.31 mM, p<0.001), singlet oxygen (0.69 mM, k landiolol/k 4-OH ‍TEMP = 2.9, p<0.001), and nitric oxide (15 mM, 1.7 × 10 M‍-1 s‍-1, p<0.001). This study is the first to report that landiolol dose-dependently scavenges multiple free radical species with different reaction rate constants. These results indicate the potential clinical application of landiolol as an antioxidative and anti-inflammatory agent in addition to its present clinical use as an anti-arrhythmic agent.

Nutritional benefit of remnant gastric preservation in patients with esophageal cancer undergoing radical esophagectomy and ileo-colon interposition

Background

This retrospective study aimed to investigate the short-term surgical outcomes and nutritional status of ileo-colon interposition in patients with esophageal cancer who could not undergo gastric tube reconstruction.

Methods

Sixty-four patients underwent subtotal esophagectomy with reconstruction using ileo-colon interposition for esophageal cancer at the Wakayama Medical University Hospital between January 2001 and July 2020. Using propensity scores to strictly balance the significant variables, we compared treatment outcomes.

Results

Before matching, 18 patients had cologastrostomy and 46 patients had colojejunostomy. After matching, we enrolled 34 patients (n = 17 in cologastrostomy group, n = 17 in colojejunostomy group). Median operation time in the cologastrostomy group was significantly shorter than that in the colojejunostomy group (499 min vs. 586 min; P = 0.013). Perforation of the colon graft was observed in three patients (7%) and colon graft necrosis was observed in one patient (2%) in the gastrojejunostomy group. Median body weight change 1 year after surgery in the cologastrostomy group was significantly less than that of the colojejunostomy group (92.9% vs. 88.5%; P = 0.038). Further, median serum total protein level 1 year after surgery in the cologastrostomy group was significantly higher than that of the colojejunostomy group (7.0 g/dL vs. 6.6 g/dL, P = 0.030).

Conclusions

Subtotal esophagectomy with reconstruction using ileo-colon interposition is a safe and feasible procedure for the patients with esophageal cancer in whom gastric tubes cannot be used. Cologastrostomy with preservation of the remnant stomach had benefits in the surgical outcomes and the postoperative nutritional status.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01704-x.

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.

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.

Predictive value of preoperative echocardiographic assessment for postoperative atrial fibrillation after esophagectomy for esophageal cancer

BACKGROUND

Postoperative atrial fibrillation (POAF) after esophagectomy for esophageal cancer is not uncommon. The aim of this study is to examine whether preoperative transthoracic echocardiography is useful for predicting new-onset POAF in esophageal cancer.

METHODS

In this prospective observational study, we evaluated 200 patients with esophageal cancer who underwent esophagectomy at our hospital between January 2016 and July 2019. Conventional echocardiographic assessment and tissue Doppler imaging were performed before surgery. We investigated the utility of preoperative transthoracic echocardiography for predicting new-onset POAF in esophageal cancer.

RESULTS

New-onset POAF occurred in 51 (25.5%) of 200 patients. POAF was significantly associated with older age (p = 0.007), higher body mass index (p = 0.020), preoperative hypertensive disease (p = 0.021), and lower hemoglobin level (p = 0.028). The incidence of postoperative complications was significantly higher in patients with POAF than in patients without POAF (43.1% vs. 24.2%, p = 0.013). Transthoracic echocardiography showed that left atrial diameter (LAD) and E wave/e' wave ratio (E/e') were significantly higher in patients with POAF than in patients without POAF (34.1 vs. 31.3 mm, p < 0.001 and 11.6 vs. 10.5, p = 0.003, respectively). Multivariate analysis showed that LAD ≥ 36.0 mm, E/e' ≥ 8.4 are independent risk factors for POAF (odds ratios 2.47 and 3.64; p values 0.035 and 0.027, respectively) CONCLUSIONS: Preoperative echocardiographic evaluation is useful for predicting the onset of POAF after esophagectomy for esophageal cancer. Risk stratification using LAD and E/e' enables clinicians to identify patients at high risk for POAF before esophagectomy.

Esophageal cancer surgery: review of complications and their management

Esophagectomy, even with the progress in surgical technique and perioperative management, is a highly specialized surgery, associated with a high rate of complications. Early recognition and adequate treatment should be a standard of care for the most common postoperative complications: anastomotic leakage, pneumonia, atrial fibrillation, chylothorax, and recurrent laryngeal nerve palsy. Recent progress in endoscopy with vacuum and stent placement, or in radiology with embolization, has changed the management of these complications. The success of nonoperative treatments should be frequently reassessed and reoperation must be proposed in case of failure. We have summarized the clinical signs, diagnostic process, and management of the frequent complications after esophagectomy for esophageal cancer.

Risk factors and therapeutic measures for postoperative complications associated with esophagectomy

Esophageal cancer is one of the most common cancers associated with the high mortality rate. Timely diagnosis and treatment are important to manage the disease and prevent comorbidities. Surgical resection of the tumor and lymph nodes is usually practiced either with or without chemo or chemoradiotherapy. Despite advancements in surgical methods and skills, complex nature of the esophagus and invasiveness of the surgery can lead to serious complications in these patients. In order to predict postoperative outcomes, preoperative examination of the patients, in addition to risk factors, should be conducted. Conclusion: Lastly, early detection of adverse postoperative events may help faster recovery, reduce hospital stay and prevent other morbidities.

Postoperative atrial fibrillation does not impact on overall survival after esophagectomy in patients with thoracic esophageal cancer: results from a randomized, double-blind, placebo-controlled trial

Background: Administration of landiolol hydrochloride was found to be associated with reduced incidence of atrial fibrillation (AF) after esophagectomy for esophageal cancer in our previous randomized controlled trial (RCT). In addition, reduced incidence of AF was associated with reduction of other complications. Meanwhile, the effects of postoperative AF and other complications on long-term survival following esophagectomy are not well understood.

Materials and Methods: Between March 2014 and January 2016, 100 patients with esophageal cancer were registered in an RCT trial and randomly allocated to receive either administration of landiolol or a placebo. We analyzed data from this RCT to better understand the effect of postoperative AF and severe associated complications on overall survival (OS) after esophagectomy for cancer. We also examined whether prophylactic administration of landiolol hydrochloride directly affects prolonged survival in patients with esophageal cancer.

Results: The five-year rates of OS in the patients with and without AF were 60%, and 68.6%, respectively, there was no significant difference (P = 0.328). Five-year rates of OS of the patients with and without severe complications were 64.6%, and 67.5%, respectively (P = 0.995). The five-year rates of OS in the placebo and landiolol groups were 65.8% and 68%, respectively (P = 0.809). In multivariate analysis, high stage (stage III/IV) alone was an independent prognostic factor for esophageal cancer patients following esophagectomy.

Conclusions: New-onset AF and the other severe complications were not associated with poorer long-term survival following esophagectomy. In addition, administration of landiolol hydrochloride after esophagectomy did not contribute to prolonging the OS.

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.

Diltiazem Prophylaxis for the Prevention of Atrial Fibrillation in Patients Undergoing Thoracoabdominal Esophagectomy: A Retrospective Cohort Study

Background

Atrial fibrillation (AF) represents the most frequent arrhythmic disorder after thoracoabdominal esophageal resection and is associated with a significant increase in perioperative morbidity and mortality.

Methods

In this retrospective cohort study, 167 patients who underwent thoracoabdominal esophagectomy at a large university hospital were assessed. We compared patients who received a 14-day postoperative course of diltiazem with a control group of patients who did not undergo diltiazem prophylaxis. Diltiazem therapy started immediately upon admission to the intensive care unit (ICU) with a loading dose of 0.25 mg/kg bodyweight (i.v.) followed by continuous infusion (0.1 mg/kg bodyweight/h) for 40–48 h. Oral administration (Dilzem^® 180 mg uno retard, once a day) was started on postoperative day 3.

Results

A total of 117 patients were assessed. Twelve (10.3%) of all patients developed postoperative new-onset atrial fibrillation in the first 30 days after surgical intervention. Prevalence of new-onset AF showed no significant differences between the diltiazem group and control group (p = 0.74). The prevalence of bradycardia (14.7% vs. 3.6%; p = 0.03) and dose of norepinephrine required (0.09 vs. 0.04 µg/kg bodyweight/min; p = 0.04) were higher in the diltiazem group. There were no significant differences between the groups for the median postoperative duration of hospital/ICU stay or mortality.

Conclusions

A prophylactic 14-day postoperative course of diltiazem was not associated with a reduction in new-onset AF or 30-day mortality following thoracoabdominal esophagectomy. Prophylactic diltiazem therapy was associated with drug-related adverse effects such as bradycardia and increased requirement of norepinephrine.

German Clinical Trial Registration Number: DKRS00016631.

Contemporary personalized β-blocker management in the perioperative setting

Beta-adrenergic blockers (β-blockers) are clearly indicated for the long-term treatment of patients with systolic heart failure and post-acute myocardial infarction. Early small-scale studies reported their potential benefits for perioperative use; subsequent randomized controlled trials, however, failed to reproduce earlier findings. Furthermore, their role in reducing major postoperative cardiac events following noncardiac and cardiac surgery remains controversial. This case-based review presents an overview of contemporary literature on perioperative β-blocker use with a focus on data available since 2008 when the PreOperative ISchemic Evaluation (POISE) trial was published. Our review suggests that studies should determine the effects of situational-based guidelines on perioperative β-blocker use on the risk of cardiac adverse events and mortality in the perioperative period.

Perioperative beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery

BACKGROUND

Randomized controlled trials (RCTs) have yielded conflicting results regarding the ability of beta-blockers to influence perioperative cardiovascular morbidity and mortality. Thus routine prescription of these drugs in an unselected population remains a controversial issue. A previous version of this review assessing the effectiveness of perioperative beta-blockers in cardiac and non-cardiac surgery was last published in 2018. The previous review has now been split into two reviews according to type of surgery. This is an update, and assesses the evidence in non-cardiac surgery only.

OBJECTIVES

To assess the effectiveness of perioperatively administered beta-blockers for the prevention of surgery-related mortality and morbidity in adults undergoing non-cardiac surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Biosis Previews and Conference Proceedings Citation Index-Science on 28 June 2019. We searched clinical trials registers and grey literature, and conducted backward- and forward-citation searching of relevant articles.

SELECTION CRITERIA

We included RCTs and quasi-randomized studies comparing beta-blockers with a control (placebo or standard care) administered during the perioperative period to adults undergoing non-cardiac surgery. If studies included surgery with different types of anaesthesia, we included them if 70% participants, or at least 100 participants, received general anaesthesia. We excluded studies in which all participants in the standard care control group were given a pharmacological agent that was not given to participants in the intervention group, studies in which all participants in the control group were given a beta-blocker, and studies in which beta-blockers were given with an additional agent (e.g. magnesium). We excluded studies that did not measure or report review outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We assessed the certainty of evidence with GRADE.

MAIN RESULTS

We included 83 RCTs with 14,967 participants; we found no quasi-randomized studies. All participants were undergoing non-cardiac surgery, and types of surgery ranged from low to high risk. Types of beta-blockers were: propranolol, metoprolol, esmolol, landiolol, nadolol, atenolol, labetalol, oxprenolol, and pindolol. In nine studies, beta-blockers were titrated according to heart rate or blood pressure. Duration of administration varied between studies, as did the time at which drugs were administered; in most studies, it was intraoperatively, but in 18 studies it was before surgery, in six postoperatively, one multi-arm study included groups of different timings, and one study did not report timing of drug administration. Overall, we found that more than half of the studies did not sufficiently report methods used for randomization. All studies in which the control was standard care were at high risk of performance bias because of the open-label study design. Only two studies were prospectively registered with clinical trials registers, which limited the assessment of reporting bias. In six studies, participants in the control group were given beta-blockers as rescue therapy during the study period.The evidence for all-cause mortality at 30 days was uncertain; based on the risk of death in the control group of 25 per 1000, the effect with beta-blockers was between two fewer and 13 more per 1000 (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.89 to 1.54; 16 studies, 11,446 participants; low-certainty evidence). Beta-blockers may reduce the incidence of myocardial infarction by 13 fewer incidences per 1000 (RR 0.72, 95% CI 0.60 to 0.87; 12 studies, 10,520 participants; low-certainty evidence). We found no evidence of a difference in cerebrovascular events (RR 1.65, 95% CI 0.97 to 2.81; 6 studies, 9460 participants; low-certainty evidence), or in ventricular arrhythmias (RR 0.72, 95% CI 0.35 to 1.47; 5 studies, 476 participants; very low-certainty evidence). Beta-blockers may reduce atrial fibrillation or flutter by 26 fewer incidences per 1000 (RR 0.41, 95% CI 0.21 to 0.79; 9 studies, 9080 participants; low-certainty evidence). However, beta-blockers may increase bradycardia by 55 more incidences per 1000 (RR 2.49, 95% CI 1.74 to 3.56; 49 studies, 12,239 participants; low-certainty evidence), and hypotension by 44 more per 1000 (RR 1.40, 95% CI 1.29 to 1.51; 49 studies, 12,304 participants; moderate-certainty evidence).We downgraded the certainty of the evidence owing to study limitations; some studies had high risks of bias, and the effects were sometimes altered when we excluded studies with a standard care control group (including only placebo-controlled trials showed an increase in early mortality and cerebrovascular events with beta-blockers). We also downgraded for inconsistency; one large, well-conducted, international study found a reduction in myocardial infarction, and an increase in cerebrovascular events and all-cause mortality, when beta-blockers were used, but other studies showed no evidence of a difference. We could not explain the reason for the inconsistency in the evidence for ventricular arrhythmias, and we also downgraded this outcome for imprecision because we found few studies with few participants.

AUTHORS' CONCLUSIONS

The evidence for early all-cause mortality with perioperative beta-blockers was uncertain. We found no evidence of a difference in cerebrovascular events or ventricular arrhythmias, and the certainty of the evidence for these outcomes was low and very low. We found low-certainty evidence that beta-blockers may reduce atrial fibrillation and myocardial infarctions. However, beta-blockers may increase bradycardia (low-certainty evidence) and probably increase hypotension (moderate-certainty evidence). Further evidence from large placebo-controlled trials is likely to increase the certainty of these findings, and we recommend the assessment of impact on quality of life. We found 18 studies awaiting classification; inclusion of these studies in future updates may also increase the certainty of the evidence.

New-onset atrial fibrillation after esophagectomy for cancer

Esophagectomy with en-bloc lymphadenectomy after neoadjuvant chemo(radio)therapy is the standard of care for resectable locally advanced esophageal cancer. Postoperative complications may have a significant impact on the duration of hospital stay and quality of life. Early recognition and treatment of complications may reduce failure to rescue rates and improve postoperative outcomes. New-onset atrial fibrillation (AF) after esophagectomy for cancer is frequently observed, and may be related to other postoperative complications. AF could function as an early warning sign for other complications in the postoperative course after esophagectomy and may thus be of clinical value. This review discusses the pathophysiology and possible risk factors of AF, the association between AF and other postoperative complications, and the influence of AF on postoperative outcomes after esophagectomy for cancer. Furthermore, clinical recommendations for the management of new-onset AF after esophagectomy for cancer are provided.

Meta-analysis of risk factors and complications associated with atrial fibrillation after oesophagectomy

Background

Oesophagectomy is associated with high morbidity and mortality rates. New-onset atrial fibrillation (AF) is a frequent complication following oesophagectomy. Several studies have explored whether new-onset AF is associated with adverse events after oesophagectomy.

Methods

This review was performed according to PRISMA guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane CENTRAL databases up to 25 November 2018. A meta-analysis was conducted with the use of random-effects modelling. The I2 statistic was used to assess for heterogeneity.

Results

In total, 53 studies including 9087 patients were eligible for analysis. The overall incidence of postoperative AF was 16·5 per cent. Coronary artery disease and hypertension were associated with AF, whereas diabetes, smoking and chronic obstructive pulmonary disease were not. Patients with AF had a significantly higher risk of overall postoperative adverse events than those without fibrillation (odds ratio (OR) 5·50, 95 per cent c.i. 3·51 to 8·30), including 30-day mortality (OR 2·49, 1·70 to 3·64), anastomotic leak (OR 2·65, 1·53 to 4·59) and pneumonia (OR 3·42, 2·39 to 4·90).

Conclusion

Postoperative AF is frequently observed in patients undergoing oesophagectomy for cancer. It is associated with an increased risk of death and postoperative complications.

Landiolol for managing post-operative atrial fibrillation

Beta-blockers are a potential option to manage peri-operative atrial fibrillation. Landiolol is a new ultra-short beta-blocker with a half-life of only 4 minutes and very high beta-1 selectivity which has been used for treatment and prevention of atrial fibrillation in pulmonary surgery and gastro-intestinal surgery. Due to its limited negative inotropic effect and high beta-1 selectivity landiolol allows for control of heart rate with minimal impact on blood pressure. Landiolol is well tolerated by the respiratory system. Additional benefits are related to the regulation of the inflammatory response and blunting of the adrenergic pathway. There is a limited number of trials with total of 61 patients undergoing lung resection or oesophagectomy who developed post-operative atrial fibrillation and were treated with landiolol. The experience with landiolol for prevention is more documented than landiolol application for treatment of post-operative atrial fibrillation. There are 9 comparative studies with a total of 450 patients administered landiolol for prevention of post-operative atrial fibrillation. The use of low dosage (5-10mcg/kg/min) is usually sufficient to rapidly control heart rate which is associated with earlier and higher rate of conversion to sinus rhythm as compared to the controls. The excellent tolerance of landiolol at lower dosage (3-5mcg/kg/min) allows to initiate prophylactic use during surgery and postoperatively. Landiolol prophylaxis is associated with reduced incidence of post-operative atrial fibrillation without triggering adverse events related to a beta-blockade.

Prevention of atrial fibrillation after cardiac surgery using low-dose landiolol: A systematic review and meta-analysis

STUDY OBJECTIVE

Atrial fibrillation (AF) is associated with mortality after cardiac surgery. Several studies have reported that landiolol might help to prevent postoperative AF. The objective of this study was to investigate whether low-dose landiolol is useful in terms of balance of benefit and risk.

DESIGN

We conducted a meta-analysis after systematically searching the PubMed, the Cochrane library and the ICHUSHI to identify randomized, controlled trials investigating the preventive effect of landiolol on incidence of AF after cardiac surgery.

PATIENTS

Six randomized trial with 571 patients were included.

MEASUREMENTS

The primary outcome was incidence of AF after surgery, while secondary outcomes were mortality and complications.

MAIN RESULTS

Incidence of AF within 1week after surgery was significantly lower in the landiolol group than in the control group (odds ratio, 0.27; 95% confidence interval, 0.18-0.42; p<0.001). Three of the 6 studies reported data regarding in-hospital mortality and complications, showing no significant differences between groups (0.7 vs 3.0%; OR, 0.45; 95% CI, 0.07-2.74; p=0.39; and 4.5 vs 9.7%; OR, 0.45; 95% CI, 0.16-1.23; p=0.12, respectively).

CONCLUSIONS

Our systematic review revealed that low-dose landiolol might help to prevent AF after cardiac surgery and further large trials are needed to evaluate safety because mortality and morbidity rate were very low in included studies.