eComment. Amiodarone-induced pulmonary toxicity in patients with atrial fibrillation undergoing lung resection

We read with great interest the article by Kolokotroni et al. [1]. The authors concluded that current evidence obtained from retrospective studies and meta-analyses pointed out that amiodarone is a safe agent for prophylaxis or management of atrial fibrillation after lung resection and that there is no increase in pulmonary toxicity, even when pneumonectomy patients are involved. At the same time, they mention that there is only one paper regarding the association of amiodarone and lung toxicity in post-lung surgery patients. But is this the whole picture? In order to answer this question, we performed a thorough search of the literature which resulted in a large number of reported cases of lung toxicity after administration of amiodarone in post-lung surgery patients [2–4]. Amiodarone induced pulmonary toxicity is well established and it consists of acute respiratory distress syndrome (ARDS), pneumonia, interstitial pneumonitis, pulmonary nodules, haemorrhage, pulmonary mass, fibrosis and pleural effusion [2–4]. The reported cases trace back to 1994 [3, 4]. The incidence of amiodarone-induced postoperative ARDS was approximately 15% in these studies and the mortality rate was approximately 10% [4]. Furthermore, current guidelines from the Society of Thoracic Surgeons [5] clearly state that the use of amiodarone prophylaxis in patients with lung resection is Class IIa, level of evidence B. This means that it is evaluated in a limited population (data derived from a single randomized trial or non-randomized trials) and is supled as reasonable or “can” be useful. These statements are far from safe nor are they beneficial (as Class I would suggest). In addition, the same guidelines do not recommend the use of amiodarone in pneumonectomy patients (Class III, level of evidence B) suggesting no benefit or even harm. The recommendations from the American Association for Thoracic Surgery [5] are of the same essence, suggesting that amiodarone can be useful to maintain sinus rhythm in patients with postoperative atrial fibrillation (POAF), depending on underlying heart disease, renal status and other comorbidities (Class IIa, evidence level B). Atrial fibrillation increases morbidity and mortality in post-lung surgery patients. Amiodarone is the best treatment in order to achieve rhythm or rate control in postoperative atrial fibrillation. It is the most effective drug but not the safest. Further large-scale prospective randomized clinical studies are required before we can really identify the safety of amiodarone use in post lung surgery patients. Conflict of interest: none declared.