Landiolol for preventing postoperative atrial fibrillation: lessons from Japan for all?

Q: What is the clinical evidence from this study?

Study design: Editorial. Population: Postoperative atrial fibrillation (n=318). Intervention: Landiolol vs. Placebo. Primary outcome: Postoperative atrial fibrillation (POAF) (RR 0.93, 95% CI 0.67-1.30, p=0.77).

Isabelle Frei; David Santer; Eckhard Mauermann

doi:10.21037/jtd-2026-1107

September 1, 2026Journal of Thoracic DiseaseOpen Access

Landiolol for preventing postoperative atrial fibrillation: lessons from Japan for all?

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Key result

Low-dose landiolol administered postoperatively for 24 hours did not significantly reduce the incidence of postoperative atrial fibrillation compared to placebo in non-Asian patients undergoing elective cardiac surgery (RR 0.93).

Why the study?

Does landiolol prevent postoperative atrial fibrillation in non-Asian patients aged 65 years or older undergoing elective cardiac surgery?

Key Points

Assess the efficacy, dosing duration, and population-specific applicability of landiolol for the prevention of postoperative atrial fibrillation following cardiac surgery.
Analyzed clinical evidence and meta-analyses evaluating perioperative landiolol, an ultra-short-acting selective beta-1 blocker, against postoperative arrhythmias.
Evaluated protocol discrepancies between predominantly Japanese cohorts and a trial in French centers where 1,794 patients were screened, 400 consented, and 80 were excluded postoperatively.
Unlike earlier Japanese protocols administering landiolol for 48 to 96 hours, terminating fixed-rate landiolol (2 mcg/kg/min) after 24 hours failed to demonstrate an arrhythmia reduction.

Structured PICO

Does landiolol prevent postoperative atrial fibrillation in non-Asian patients aged 65 years or older undergoing elective cardiac surgery?

P

Population

318 non-Asian adults aged 65 years and older undergoing elective cardiac surgery with sternotomy and cardiopulmonary bypass, evaluated for postoperative atrial fibrillation.

I

Intervention

Landiolol 2 mcg/kg/min initiated within the first 4 hours after arrival in the ICU and continued for at least the first 24 hours.

C

Comparator

Placebo initiated within the first 4 hours after arrival in the ICU and continued for at least the first 24 hours.

O

Outcome

Postoperative atrial fibrillation (POAF)

Main Result

Relative Risk: 0.93 (95% CI 0.67–1.3)

Absolute Event Rate: 29.8% vs 31%

p-value: p=0.77

Limitations

High exclusion rate during screening (nearly two-thirds excluded) may indicate limited transferability and selection toward healthier, less at-risk patients.
Stopping landiolol after 24 hours may be too early to cover the most vulnerable window for postoperative atrial fibrillation, which generally occurs 2 to 4 days post-surgery.
The fixed low dose of 2 mcg/kg/min may have been insufficient for the studied population.
Genetic polymorphisms between non-Asian and East Asian populations may alter the required dosing and timing for the beta-blocker to be effective.
Stopping landiolol after 24 hours may have resulted in suboptimal beta-blockade during the most vulnerable window for POAF
Fixed rate of 2 mcg/kg/min may have been insufficient for the population studied
High exclusion rate potentially indicating selection bias toward healthier, less at-risk patients
Differences in genetic polymorphisms between non-Asian and East Asian populations may alter dosing and timing requirements

Implication

A 24-hour postoperative administration of low-dose landiolol did not reduce the incidence of postoperative atrial fibrillation in non-Asian patients, potentially highlighting differences in dosing requirements or genetic polymorphisms compared to prior studies in Japanese cohorts.

Abstract

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Discussion

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Cite This Study

Frei et al. (2026) conducted an editorial in Postoperative atrial fibrillation (n=318). Landiolol vs. Placebo was evaluated on Postoperative atrial fibrillation (POAF) (RR 0.93, 95% CI 0.67-1.30, p=0.77). Low-dose landiolol administered postoperatively for 24 hours did not significantly reduce the incidence of postoperative atrial fibrillation compared to placebo in non-Asian patients undergoing elective cardiac surgery (RR 0.93).

synapsesocial.com/papers/6ad1159300741cc3fba7d63f https://doi.org/10.21037/jtd-2026-1107

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Landiolol for preventing postoperative atrial fibrillation: lessons from Japan for all?

Key Points

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Landiolol for preventing postoperative atrial fibrillation: lessons from Japan for all?

Key Points

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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