Impact of pre-implant amiodarone exposure on outcomes in cardiac transplant recipients.
Amiodarone remains one of the preferred antiarrhythmic medications for patients with advanced heart failure awaiting cardiac transplant. However, the long half-life and rapid redistribution of this agent into donor myocardium expose heart transplant recipients to potential adverse outcomes. In reviewing the current body of literature, we found that pre-operative amiodarone exposure can increase the risk of bradycardia post-transplant; however, this is unlikely to require permanent pacemaker implant. Further, amiodarone has several serious drug-drug interactions with calcineurin inhibitors. Clinicians should therefore consider empiric reduction in initial dosing for tacrolimus or cyclosporine, and carefully monitor blood levels for at least 3 months post-transplant. Although the evidence is conflicting, amiodarone exposure pre-operatively may increase the risk of early graft failure and mortality. Amiodarone use should be minimized whenever possible; if amiodarone cannot practically be discontinued in the pre-transplant phase, judicious monitoring for QTc prolongation and ventricular arrhythmia should be implemented after transplant. As most of the studies included in this review suffered from small sample sizes and limited follow-up, additional research in this area is warranted.
Department of Pharmacy, New York-Presbyterian Hospital, Columbia University Medical Center, 622 West 168th Street VC-B, New York, NY, 10032, USA, doug.jennings.pharmd@gmail.com.
Douglas L
DL
Jennings
Brandon
B
Martinez
Sheila
S
Montalvo
David E
DE
Lanfear
D000638:Amiodarone / Q000009:adverse effects / Q000493:pharmacokinetics; D000889:Anti-Arrhythmia Agents / Q000009:adverse effects / Q000493:pharmacokinetics; D001682:Biological Availability; D001919:Bradycardia / Q000139:chemically induced / Q000175:diagnosis / Q000517:prevention & control; D004347:Drug Interactions; D006333:Heart Failure / Q000188:drug therapy / Q000601:surgery; D016027:Heart Transplantation / Q000379:methods*; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000493:pharmacokinetics; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000139:chemically induced / Q000175:diagnosis / Q000517:prevention & control; D011300:Preoperative Care / Q000009:adverse effects* / Q000379:methods; D012720:Severity of Illness Index; D019737:Transplants / Q000187:drug effects*
D000889:Anti-Arrhythmia Agents; D007166:Immunosuppressive Agents; D000638:Amiodarone