Review of the evidence supports role for routine prophylaxis against postoperative supraventricular arrhythmia in patients undergoing pulmonary resection: Table 1:

Abstract

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'Is there an indication for routine prophylaxis against postoperative supraventricular arrhythmia in patients undergoing pulmonary resection surgery?' Altogether almost 150 papers were found as a result of the reported search, of which 14 represented the best evidence to reach conclusions regarding the issues of interest for this review. The major outcome of interest that was investigated was the incidence of supraventricular arrhythmia (SVA), notably atrial fibrillation (AF). The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weakness of the papers were tabulated. Current guidance from the Society of Thoracic Surgeons (STS) supports the use of diltiazem and amiodarone in most patients undergoing major pulmonary resection. Robust data from a large randomized, controlled trial (RCT) showed a reduction from 25 to 15% in the incidence of clinically significant atrial arrhythmia with diltiazem; P<0.03. Moreover, numerous RCTs have shown that there is a clear benefit with the use of amiodarone in reducing the incidence of postoperative SVA. Of note, one prospective clinical trial randomized 242 patients into a treatment group with amiodarone (n = 122) and a placebo group (n = 120). The incidence of postoperative AF was reduced from 32 to 9% in the active arm; P < 0.001. The risk of acute lung injury with amiodarone has not been substantiated further in more recent clinical trials and has in fact been shown to be safe. The STS guidelines do, however, advise against the use of amiodarone in extensive lung resection such as pneumonectomy. We conclude that there is an indication for routine prophylaxis against postoperative supraventricular arrhythmia in patients undergoing pulmonary resection. However, further data are needed to ascertain the impact of said anti-arrhythmic medications on the length of postoperative hospital stay, intensive care unit stay and cost. Those patients deemed high-risk need to be promptly identified, so the anti-arrhythmic therapy can be tailored to the cohort thus optimizing on cost and safety.