Abstract
Background: Postoperative atrial fibrillation (POAF) is prevalent in about 30 to 60 percent of patients undergoing cardiac surgery leading to worse outcomes. However, effective POAF therapies are lacking. Botulinum toxin type A (BTX) epicardial injection can prevent POAF by impairing cholinergic signaling. Methods: We conducted a systematic review and meta-analysis synthesizing randomized controlled trials (RCTs), which were retrieved by systematically searching: PubMed, EMBASE, Web of Science, SCOPUS, and Cochrane through November 23 rd , 2022. RevMan version 5.4 software was used to pool dichotomous outcomes using risk ratio (RR) and continuous outcomes using mean difference (MD) presented with the corresponding confidence interval (CI). Results: Three RCTs with a total of 509 patients (308 in the BTX group and 205 in the placebo group) were included in our analysis. Two RCTs included patients undergoing open-chest cardiac surgery, including coronary artery bypass graft (CABG) and/ or valve surgery, while one RCT included patients undergoing CABG only. There was no difference between BTX and placebo regarding POAF incidence (RR: 0.81 with 95% CI [0.65, 1.00], P= 0.05), postoperative hospital length of stay in days (MD: -0.03 with 95% CI [-0.54, 0.49], P= 0.91), all-cause mortality, (RR: 1.64 with 95% CI [0.22, 12.17], P= 0.63), any adverse event (RR: 1.03 with 95% CI [0.94, 1.12], P= 0.51), and any serious adverse event (RR: 0.89 with 95% CI [0.68, 1.15], P= 0.36). Conclusion: There was no difference between epicardial fat injection of BTX versus placebo for preventing POAF; however, BTX showed a similar safety profile compared to placebo and our analysis can be underpowered to detect a significant effect. Hence, further large-scale RCTs are warranted to investigate BTX for POAF, especially in high-risk cohorts.
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