Dr Sandeep Kumar Kar, Dr.Chaitali Sen, Prof. Anupam Goswami 2nd year M.

D (Anaesthesiology) Institute of Post Graduate Medical Education & Research, Kolkata

 In

developing countries like India, rheumatic heart disease (MS, MR) is the most frequent underlying condition in patients with AF. is associated with the risk of thromboembolic complications in 17% 18% of patients.

AF

 LA

size is the most consistent predictor of AF. Cardiovascular Health Study cohort Left atrial enlargement can precede the development of AF. Again AF itself may lead to left atrial dilation.
3

 The

presence of AF after mitral valve replacement (MVR) is associated with Worse New York Heart Association (NYHA) functional class.
J Heart Valve Dis 2004

 It

is not known whether interventions that reduce left atrial size also decrease the risk of AF.
Mayo Clin Proc 2001

 Maintenance

of normal sinus rhythm (NSR) is superior to ventricular rate control in patients with rheumatic AF.
is difficult to achieve and maintain in patients with RHD.
6

NSR

 Hence,

special efforts should be taken to correct AF in intraoperative and post operative period.

 Mitral

valve surgery restores NSR in only 8.5% of patients with chronic AF.
J Heart Valve Dis 2004

Rx OPTIONS AVAILABLE

Electrical cardioversion Pharmacological cardioversion

 Amiodarone Wonderful

versatile antiarrhythmic agent

10

&

 Promising

results seen with Amiodarone with successful conversion and maintenance of NSR in 50%70% of patients.
(J Thoracic Cardiovascular Surg 1981. )

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Relevance of this study

Reports regarding the use of intraoperative intravenous amiodarone in patients with AF of rheumatic origin, undergoing valvular heart surgery seem to be scarce.
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 To

evaluate the effect of prophylactic intraoperative single-dose intravenous amiodarone 3mg/Kg to convert AF into NSR in patients undergoing open Heart surgery.

13

 Arrhythmia

prevention potential of 3mg/Kg I.V. amiodarone after the release of aortic cross clamp and the duration of maintenance in sinus rhythm after pharmacological cardioversion in patients undergoing Open Heart Surgery.
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Study

Prospective

Double* blinded

Randomized#

* Data in ICU collected by surgery resident blinded to study

#Computer generated randomization sheet
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Inclusion criteria
Age:18 years to 65 years MVR Under (CPB)
16

Both sexes

Exclusion criteria Patients with pregnancy Resting heart rate of < 50/min Uncontrolled heart failure Sick sinus syndrome Atrioventricular block Serum creatinine > 2 mg/dl
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Approval of institutional ethics committee

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 Written

informed consent of the patient

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Twenty eight patients (n=28) in each group IV line & arterial line under LA

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Induction:- Fentanyl 5g/kg Sleep dose of Thiopentone

Intubation:- Rocuronium 1.2 mg/kg

Ventilation to keep PCO2 30-35 Torr

Central venous line
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Random allocation into 2 groups by a computer generated randomization sheet. Amiodarone gr (Gr A):-3mg/kg Amiodarone in100ml N.S IVI in 20 mins through the central venous route Control gr (Gr C) :-100 ml of NS infused in 20 mins through the central venous route
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 If

bradycardia (HR<50/min) or Hypotension (SBP <90 mm of Hg )

infusion discontinued, preload optimized to (CVP of 10-12mm of Hg).

Amiodarone

23

 Inotrope

infusion used to treat persistent hypotension.

infusion was restarted after achieving haemodynamic stability.

Amiodarone

24

Sternotomy Heparinisation Cannulation

CPB started
25

After completion of surgery patients weaned off CPB and transferred to ICU with elective ventilation.

26

 It

was estimated that 28 subjects would be required per group in order to detect a difference of 30 percent in this proportion between the two groups with 90 percent power and 5% probability of type 1 error.

27

 The

proportion of subjects reverting to normal sinus rhythm (NSR) was taken as the outcome parameter of primary interest. Numerical variables was compared between groups by Students independent sample ttest if normally distributed or Mann- Whitney U test if otherwise.
28

 Chi

square test or Fisher s exact test was employed for inter group comparison of categorical variables.
Two tailed P value <0.05 was considered as statistically significant.

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Patient characteristic Age (in years) Male: female Body weight (in kg) Number of patients in AF Preinduction

Gr A (n = 28) 36.89 12.14 16:12 51 11.35 12

Gr C (n = 28) 35.25 8.4 14:14 50.53 6.77 12

P value 0.55 0.85 1

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Gr A (n= 28)
NYHA class Class II* Class III* Severity of mitral stenosis Mild* Moderate* Severe*

Gr C (n = 28)

P value

28 0

28 0

1 1

4 3 0

3 1 O

0.675 0.774 1
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Gr A (n= 28)
Severity of MR Mild* Moderate* Severe* Lt vent dfn mild Lt vent dfn moderate Lt vent dfn severe 13 15 0 5 22

Gr C (n = 28)

P value

0 27 12 16 0

0.776 0.875 0.673 0.711

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Gr A (N= 28)
MVR* AVR* DVR* Pre operative LA size in <45mm Pre operative LA size in 45-49 mm Pre operative LA size in > 60 mm

Gr C (n = 28)
24 0 4 13 15 0

P value

26 0 2 0 28 0

0.456 0 0.633 0.356 0.765

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Intraoperative events

Gr A Mean S.D (n = 28)

79.53 6.53 63.78 8.6 101.25 12.3 2

Gr C Mean S.D (n = 28)

78 7.9 63.7810.5 108.89 11.4 13

P value

CPB time (min) ACC time (min) Basal HR (/min) Use of antiarrhythmic agent Inotrope use (no. of patients)

0.43 0.34 0.24

25

28

0.365

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Primary outcome

Gr A (n = 28)

Gr C (n = 28)

P value

Rhythm at aortic clamp release (N) AF after Axcl OFF VT/VF at Axcl off Defibrillation/cardi oversion after Axcl off 2 (7.14%) 6 (21.43%) 2 (7.14%) 8 (28.57%) 13 (46.43%) 8 (28.57%) 0.078 0.089 0.078

AF at end of surg
Recc of AF in ICU in 24 hrs Amdrn contd for AF in 24 hrs (n)

0 (0.00%)
4 (14.29%) 4 (14.29%)

4 (14.29%)
7 (25.00%) 7 (25.00%)

0.11
0.503 0.503

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Difference between two grs regarding NSR, Lignocaine,Pacemaker,AF in 24 hrs

p=0.002
30 25 20 15 10 5 0 NSR Lignocaine Pacemaker AF/24 hrs
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p=0.002
p=0.002 p=0.003
Gr A Gr C

Difference between the Grs regarding Extubation (hrs) , ICU stay (days) & Discharge(days)
p < 0.001
20 15

p < 0.001
10 5 0 Extubation ICU stay Discharge

Gr A Gr C

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 AF

is commonly encountered in patients posted for elective mitral valve surgery. a large atrial size predisposes to arrhythymias. Sinus rhythm is always preferred preinduction and after the release of aortic cross clamp.
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Benefits of restoring NSR in patients with rheumatic AF are Relief of symptoms Prevention of fast ventricular rate induced dysfunction Improved exercise tolerance Improved quality of life Possible reduction in embolic strokes and Improved survival
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 Newer

anti- arrhythmic such as flecainide, propafenone and cibenzoline are less useful in established AF.

(Levy S. Pharmacologic management of atrial fibrillation: Current therapeutic strategies, Am heart J 2001;141;S15-21.)
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 So

this study throws considerable light on the impact of prophylactic amiodarone therapy in preventing AF and other forms of arrhythmia after aortic cross clamp release. The same prophylactic dose administered prior induction was effective to revert a considerable proportion of patients with preexisting AF to normal sinus rhythm.(NSR)
41

 This

prophylactic dose of amiodarone may be applicable for better management of intraoperative arrhythymia after aortic cross clamp release in valvular heart surgery.

42

 As

per the Stroke Prevention in Atrial Fibrillation Trial, intolerance to warfarin therapy leads to withdrawal in up to 38%.
(N Engl J Med 1990)

Contraindications to amiodarone, including active hepatitis and hyperthyroidism occur less frequently than those for warfarin.

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Conversion

to NSR and maintenance of normal sinus rhythm after aortic cross clamp release is the only best option available to patients who have clinical conditions contraindicating the use of warfarin or those intolerant to it.
The Copenhagen AFASAK study. Lancet 1989

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 Onset

of the anti-arrhythmic effect of intravenous amiodarone is rapid.

Hence

intravenous low dose amiodarone(3mg/kg) is always preferable to oral amiodarone as a preoperative prophylactic measure and is more reliable and dependable strategy.
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 Prophylactic

oral amiodarone was shown to reduce the incidence of new onset AF in patients undergoing open heart surgery.
J Thorac Cardiovasc Surg 1981

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This study shows: A significant reduction in the incidence of AF in the amiodarone group.

Need of cardioversion/defibrillation was less in the amiodarone group. Similar to a previous study
Annals of Cardiac Anaesthesia 2009; 12:10-16
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 Even

in patients whose rhythm was not converted to NSR, Amiodarone decreased the ventricular rate significantly. need of temporary epicardial pacing was significantly high in the amiodarone group as compared to control group .
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The

 In

another study, in patients with rheumatic mitral valve disease with AF, intravenous amiodarone increased the incidence of conversion of AF to NSR, reduced the frequency and energy required for cardioversion. Recurrence of AF until hospital discharge and occurrence of fast ventricular rate was also reduced Annals of Cardiac Anaesthesia 2009

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In this study, study population was valvular heart disease irrespective of having atrial fibrillation and single prophylactic amiodarone dose was found to be similarly effective in reducing incidence of arrhythmia intraoperatively and postoperatively.
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A single prophylactic intra operative dose of intravenous amiodarone is effective in preventing the occurrence of atrial fibrillation and so, it may be used routinely in patients undergoing open heart surgery for rheumatic valve disease.

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1. Wolf PA, Benjamin EJ, Belanger AJ, Kannel WB, Levy D, DAgostino RB. Secular trends in the prevalence of atrial fibrillation: the Framingham Study. Am Heart J. 1996;131(4):790795. 2. Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologi features of chronic atrial fibrillation: the Framingham Study. N Engl Med 1982;306:1018-22. 3. Alpert JS, Petersen P, Godtfredsen J. Atrial fibrillation: Natural history complications, and management. Annu Rev Med 1988;39:41-52. 4 PsatyBM,ManolioTA,KullerLH,KronmalRA,CushmanM,FriedLP,etal. Incidence of and risk factors for atrial fibrillation in older adults. Circulation 1997; 96:24552461. 5.VaziriSM,LarsonMG,BenjaminEJ,LevyD.Echocardiographicpredictorsof nonrheumatic atrial fibrillation. The Framingham Heart Study. Circulation 1994; 89:724730. 6.TsangTS,BarnesME,BaileyKR,LeibsonCL,MontgomerySC,TakemotoY,e t al. Left atrial volume: important risk marker of incident atrial fibrillation in 1655 older men and women. Mayo Clin Proc 2001; 76:467475.
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7.Vora A, Karnad D, Goyal V, Naik A, Gupta A, Lokhandwala Y, et al. Con of rate versus rhythm in rheumatic atrial fibrillation: A randomized study. Indian Heart J 2004;56:110-67. 8.Raine D, Dark J, Bourke JP. Effect of mitral valve repair/replacement surg on atrial arrhythmia behavior. J Heart Valve Dis 2004;13:615-21. 9.Installe E, Schoevaerdts JC, Gadisseux P, Charles S, Tremouroux J. Intravenous amiodarone in the treatment of various arrhythmias following cardiac operations. J Thorac Cardiovasc Surg 1981;81:302-8. 10.Singh BN, Vaughan Williams EM. The effect of amiodarone: A new anti-anginal drug, on cardiac muscle. Br J Pharmacol 1970;39:657-67. 11.Levy S. Pharmacologic management of atrial fibrillation: Current therapeutic strategies, Am heart J 2001;141;S15-21. 12.ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillationexecutive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation). J Am Coll Cardiol. 2006;48:854906. 53

13. Singer DE, Albers GW, Dalen JE, et al. Antithrombotic therapy in atrial fibrillation. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:429s456s. 14. Hersi A, Wyse DG. Management of atrial fibrillation. Current Probl Cardiol. 2005;30:175234. 15. Levy S. Pharmacologic management of atrial fibrillation: Current therapeutic strategies, Am heart J 2001;141;S15-21. 16.Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, et al. Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators: A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002;347:1825-33. 17.Preliminary report of the stroke prevention in atrial fibrillation study. N Engl J Med 1990;322:863-8. 18.Petersen P, Boysen G, Godtfredsen J, Andersen ED, Andersen B. Placebo-controlled, randomised trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation: The Copenhagen AFASAK study. Lancet 1989;1:175-9.
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19.Connolly SJ, Laupacis A, Gent M, Roberts RS, Cairns JA, Joyner C. Canadian Atrial Fibrillation Anticoagulation (CAFA) Study. J Am Coll Cardiol 1991;18:349-55. 20.Hohnloser SH, Klingenheben T, Singh BN. Amiodarone-associated proarrhythmic effects: A review with special reference to torsade de pointes tachycardia. Ann Intern Med 1994;121:529-35. 21. Selvaraj T, Kiran U, Das S, Chauhan S, Sahu B, Gharde P. Effect of single intraoperative dose of amiodarone in patients with rheumatic valvular heart disease and atrial fibrillation undergoing valve replacement surgery, Annals of Cardiac Anaesthesia 2009; 12:10-16

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THANK YOU

THANK YOU
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