Interact CardioVasc Thorac Surg 2009;9:811-813. doi:10.1510/icvts.2009.212837
© 2009 European Association of Cardio-Thoracic Surgery
Institutional report - Arrhythmia |
Postoperative administration of landiolol hydrochloride for patients with supraventricular arrhythmia: the efficacy of sustained intravenous infusion at a low dose
Seiichiro Wariishia,b*,
Koichi Yamashitac,
Hideaki Nishimoria,
Takashi Fukutomia,
Masaki Yamamotoa,
Geethalakshmi Radhakrishnana and
Shiro Sasaguria
a Department of Surgery II, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi 783-8505, Japan
b Intensive Care Unit, Kochi University Hospital, Kochi, Japan
c Emergency Medicine, Kochi University Hospital, Kochi, Japan
Received 2 June 2009;
received in revised form 20 July 2009;
accepted 22 July 2009
 A summary of this study was introduced at the 38th Annual Meeting of the Japanese Society for Cardiovascular Surgery in February 2008, at Fukuoka.
*Corresponding author. Tel.: +81-88-880-2375; fax: +81-88-880-2376.
E-mail address: wari{at}kochi-u.ac.jp (S. Wariishi).
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Abstract
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The purpose of this study was to investigate the efficacy of landiolol hydrochloride, a short-acting β1 blocker, by initiating its administration at a low dose (5 µg·kg–1·min–1) in patients with postoperative supraventricular arrhythmia. The efficacy of landiolol was evaluated in 38 patients who, after developing postoperative atrial flutter or fibrillation, with sinus tachycardia and two patients who had a history of paroxysmal atrial fibrillation with frequent atrial extrasystole. The heart rate and blood pressure before and 2 h after the administration of landiolol were compared. A return to the sinus rhythm from supraventricular arrhythmia was noted in 89%. The heart rate was reduced from 137±26 bpm (before landiolol administration) to 93±18 bpm (2 h after the start of the medication, P<0.01). As an agent to correct an arrhythmic condition, landiolol successfully raised the systolic blood pressure from 108±24 mmHg (before medication) to 120±19 mmHg (2 h after the medication was started, P<0.05). Continuous intravenous infusion of landiolol at a low dose was found to be effective for postoperative supraventricular arrhythmia.
Key Words: β blocker; Landiolol hydrochloride; Postoperative care; Supraventricular arrhythmia
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1. Introduction
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The perioperative care is necessarily conducted under unique conditions, such as excitation of the sympathetic nervous system, administration of agents to stimulate the circulatory system and systemic inflammatory responses [1, 2]. It has been found that β blockers are not only effective in controlling myocardial ischemia and arrhythmia but also in suppressing inflammatory cytokines and stabilizing intravascular plaques [3–5], thus attracting further attention to their efficacy during perioperative care. In Japan, however, propranolol hydrochloride (hereafter abbreviated to propranolol) is the only β blocker that is currently available for intravenous administration, which was not always convenient for perioperative care because of its relatively long half-life [6]. Landiolol hydrochloride (hereafter abbreviated to landiolol) is a short-acting β1 blocker that has been developed in Japan [7]. Because of its extremely short half-life in blood ( 4 min) [8], it appears to be highly promising as an agent in adjusting the timing of intravenous administration.
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2. Patients and method
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The subjects were 40 patients (mean age, 70±9; range, 41–84 years; 30 men and 10 women) who underwent continuous infusion of landiolol at a low dose during postoperative care at the Kochi University Hospital that started between April 2004 and December 2007. The group comprised those with: ischemic heart disease (12), valvular diseases (5), aortic diseases (9), respiratory tract diseases (5), digestive system diseases (7) and others (2) (Table 1).
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Table 1 The background of patients who underwent continuous infusion of landiolol at a low dose during postoperative care
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Among those individuals who suffered from atrial flutter or fibrillation during the postoperative period, the following were selected as the subjects of the present study: 38 who failed in an attempt to correct the water–electrolyte balance and resisted the treatment of 50 mg of pilsicainide hydrochloride (hereafter abbreviated to pilsicainide) and two who had a history of paroxysmal atrial fibrillation and had began to develop frequent bouts of atrial extrasystole. Based on the clinical experience in the use of landiolol, a continuous intravenous infusion was started at a dose of 5 µg·kg–1·min–1 for defibrillation; and depending on the heart rate and blood pressure, it was adjusted to 2 µg·kg–1·min–1 every 5–10 min. These patients suffered from the following clinical conditions: atrial fibrillation (28, with two maintaining the sinus rhythm after MAZE operation), atrial flutter (5), sinus tachycardia (5) and prophylaxis for paroxysmal atrial fibrillation (2).
The heart rate and blood pressure before and 2 h after the administration of landiolol were compared. The age, dosages, heart rate and blood pressure of the patients were recorded as a mean±standard deviation. For statistical analysis, the Student's t-test was used with the significance level set at P<0.05.
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3. Results
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For the most patients, landiolol administration was started between days 2 and 5 after surgery (Fig. 1). Restoration of the normal sinus rhythm from supraventricular arrhythmia was noted in 34 of the 38 patients (89%). This effect was noted in 24 of the 28 patients (86%) of those with atrial fibrillation and all of those with atrial flutter or sinus tachycardia. Subsequently, the heart rate was reduced from 137±26 bpm (before the start of landiolol administration) to 93±18 bpm (2 h after the start of the medication, P<0.01) (Fig. 2, Table 2). As a consequence of antiarrhythmic treatment, the systolic blood pressure rose from 108±24 mmHg (before the start of landiolol administration) to 120±19 mmHg (2 h after the start of the medication, P<0.05) (Fig. 3, Table 2). The maximum dosage given was 7.5±7.6 µg·kg–1·min–1. Reductions in the heart rate were noted even in the two patients who were treated for tachycardia associated with chronic atrial fibrillation. In one patient who developed an electrical storm in addition to postoperative atrial fibrillation, a complete atrioventricular block developed even at the dosage of 1 µg·kg–1·min–1 but cessation of medication restored the previous state.
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Fig. 1. The number of days after surgery when the medication was started (n=36). After the 7th day. Op, surgery; POD, number of days after surgery.
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Fig. 2. Changes in heart rate (n=38). Before the start of landiolol administration. 2 h after the start of landiolol administration.  , heart rate; *Comparison with the data before landiolol administration, P<0.05.
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Table 2 The changes in heart rate and systolic blood pressure before and 2 h after the start of landiolol administration (n=38)
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In both of the two patients who were treated to prevent paroxysmal atrial fibrillation, it was possible to maintain the sinus rhythm when landiolol administration was started when atrial extrasystoles repeatedly developed. None of the patients have experienced the reoccurrence of atrial fibrillation or atrial flutter not sinus arrest.
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4. Discussion
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Landiolol is outstanding in its immediate efficacy and adjustability [8]. Because of its high selectivity with β1 receptors [6], it is readily administered to patients with respiratory tract diseases. Recently, there have been occasional reports in which landiolol, with its outstanding adjustability, was found to be effective in the treatment of not only arrhythmia due to supraventricular tachycardia [9], but also for correction of a left ventricular outflow tract obstruction [10, 11] and amelioration of myocardial infarction [12]. In this country, the application of landiolol has been approved by National Health Insurance for the emergency treatment of intraoperative and postoperative arrhythmia due to supraventricular tachycardia [13, 14]. More recently, however, its clinical efficacy at a low dosage has been recognized. Amiodarone exerts preventive effect on both atrial fibrillation and atrial flutter whereas in the case of landiolol the conversion rate to the sinus rhythm is increased. The major pharmacological actions of β blockers are the suppression of the abnormal responses of the myocardium to stimuli and reductions in the heart rate, but direct defibrillating effects are rarely included. For the management of supraventricular arrhythmia, which is caused by surgical stress, the application of landiolol, a β blocker with an outstanding modulatory effect, is effective and, therefore, should be considered for inclusion in the therapeutic modalities [15]. Esmolol has been used for the treatment of hypertension and supraventricular tachycardia. Whereas landiolol having high β1 selectivity is used only for the treatment of supraventricular tachycardia without hypotensive effect. On the clinical scene, landiolol is unlikely to cause hypotension and is effective even in emergencies.
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5. Conclusion
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Continuous intravenous infusion of landiolol at a low dose was found to be effective for postoperative supraventricular arrhythmia. Because it is a short-acting agent, the early treatment to suit to each clinical finding was possible.
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References
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Top
Abstract
1. Introduction
, systolic blood pressure; 
, diastolic blood pressure; *, a comparison with the value before landiolol administration, P<0.05.