Post-Operative Atrial Fibrillation After Surgical Aortic Valve Replacement and the Influence of Statins

Study Overview
=================
Brief Summary
-----------------
Statins have rapid and significant actions that have potentially important (but not yet proven) implications for postoperative atrial fibrillation and cardiac protection in patients undergoing cardiac surgery. The focus of this study is, therefore, on patients having surgical aortic valve replacement (with aortotomy) and the development of postoperative atrial fibrillation (POAF). Our aims are: to investigate the risk of POAF, infection or other complications after SAVR in continuous versus preoperative discontinuous treatment with statins. The study is a single centre randomized controlled trial with continuance treatment with statin vs. discontinuance (7 to 14 days prior surgery until the 30th post-operative day included), on patients undergoing elective solitary SAVR with bioprosthesis with prior usage of statins the last 3 months and of at least 7 days. This randomized studies will address 2 separate hypotheses in patients undergoing open heart operation with solitary aortic valve replacement with a bioprosthetic valve that Discontinuation of HMG-CoA reductase inhibitors 7 to 14 days preoperative until 30 days postoperative of AVR in patients with prior use of HMG-CoA reductase inhibitors is not associated with increased early (<30 days) risk of POAF. Discontinuation of HMG-CoA reductase inhibitors 7 to 14 days preoperative until 30 days postoperative of AVR in patients with prior use of HMG-CoA reductase inhibitors is not associated with increased early (<30 days) and intermediate (<1 year) risk of mortality, MI, stroke and rehospitalisation.

Detailed Description
-----------------
Trial Participants: Enrolment for the study is planned to start February 2022 and continue until 100 patients have been enrolled. DEFINITION OF POAF: Postoperative AF (I48) is defined as irregular RR-intervals without a traceable p-wave before each QRS complex during at least 30 seconds or entire 12-lead ECG in symptomatic or asymptomatic patients with no prior history of atrial fibrillation or flutter are considered4. Continuous ECG monitoring (8-lead ward monitor) will recognise AF during the entire hospitalization. Anamnesis, electronic health record (EHR), or confirmatory rhythm strip or 12-lead ECG of AF until 30th postoperative day are also considered. We will also report the burden of atrial fibrillation, and treatment with a rate controlling drug, antiarrhythmic drug, or electrical cardioversion. Course of action: Patients undergoing elective surgical aortic valve replacement with bioprosthesis at the Department of Cardiac Surgery at Odense University Hospital will be offered participation in the study. Potentially eligible patients will be screened according to inclusion/exclusion criteria at the time after eligibility of surgery. This is assessed at a multidisciplinary team (MDT) conference (with attendance of cardiologist, cardiac surgeons and anaesthesiologist) based on clinical evaluation, echocardiographic ultrasound, coronary angiography and lung function test. Patients eligible to participate in the study will be presented with the information of the study at the time of their out-patient appointment, according to normal routine at Odense University Hospital. At this appointment the patient receives a physical examination and journal record is obtained by a cardiac surgeon (approximately 7 to 14 days prior to planned surgery). The study-information will be given by one of the participating doctors, while the patient has been informed of the possibility of bringing an assessor of their choice. The information will be delivered in a quiet room blocked to other appointments in the Department of Cardiothoracic Surgery. During this meeting the patient will be informed of the purpose of this study and the written patient information will be submitted in detail. Patients will be given as much time as wanted after the oral information has been delivered to decide if they wish to participate in the study. Patients will be offered the possibility to call one of the doctors taking part in this study during this time, in case of additional questions. Subjects can leave the study at any time for any reason if they wish to do so, without any consequences. Signed informed consent will be provided prior to any research procedures. A subject is registered when signed informed consent has been provided and assigned a subject identification code by the computer-generated code. A subject is randomized when a treatment and a randomisation number has been provided. A subject is considered enrolled in the study once the subject is randomized. Patient data from EHR will be conducted according to study endpoints after signed informed consent is provided. Signed consent gives sponsor and sponsors representatives Randomization: Allocation to a numbered treatment pack (continuance or discontinuance of statin therapy) Randomization scheme will be set-up by OPEN data manager with control for beta-blockers and age (60-65, 66-70, 71-80, >80), and then randomization per se will be executed with the use of REDCap. The following will be recorded at the day of randomization: Conduct information for baseline characteristics Transthoracic Echocardiography measurements Collect baseline blood sample: • Troponin, CK-MB, Creatinine, CRP Commence intervention Perioperative interventions and outcomes from the day of surgery to the day of discharge: Duration of aortic cross clamp (ACC), extracorporeal circulation (ECC), ventilatory support, intensive care unit stay period, hospital stay period Continue intervention Blood samples: Preoperative: Troponin, CK-MB, Creatinine, CRP, Plasma-Atorvastatin Serial troponin and CK-MB levels: (6, 24, 48, and 96 hours after surgery). Creatinine levels: 48 and 96 hours after surgery. CRP levels: 48 and 96 hours after surgery Monitor ECG by continuous Holter monitoring to commence as soon as possible after surgery and continue up to post-operative day 5 evening Transthoracic Echocardiography on post-operative day 3-5 Record fluid intake and output during the first 48 hours following surgery based on IV fluids administration, blood transfusion (if applicable), oral/nasogastric intake, and urine plus surgical drain output Record intraoperative defibrillation, removal of external pacemaker, new PPM/ICD, vasopressors, blood transfusion, surgical re-exploration, renal replacement therapy, beta-blockers, ACEi/ARB, Amiodarone, Digoxin, Diuretics, Calcium channel blockers, Potassium supplements, NSAIDs or steroids, non-study statin, use of nephrotoxic antibiotics, contrast agents or potassium sparing diuretics (Yes/No) Assessment at/after discharge from hospital: Continue study medications for 30 days after the surgery Phone call on the 30th postoperative day to evaluate symptoms of discomfort compatible with atrial fibrillation At the end of the study, all excess study medication can be returned at the local drugstore for safe disposal Patient data from EHR will be conducted according to study endpoints.

Official Title
-----------------
Post-Operative Atrial Fibrillation After Surgical Aortic Valve Replacement and the Influence of Statins - Randomized Controlled Trial

Conditions
-----------------
Postoperative Atrial Fibrillation

Intervention / Treatment
-----------------
* Drug: Discontinuance of treatment with statins 7 to 14 days prior to surgery until 30 days postoperative
* Drug: No-intervention.


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Patients undergoing elective solitary SAVR with bioprosthesis Patients who are in sinus rhythm and not taking any anti-arrhythmic medication, other than beta-adrenergic blocking agents, at the time of surgery In treatment with HMG-CoA reductase inhibitors in the past 3 months and of at least 7 days Age >60 years Willingness and provision of informed consent to be randomized Exclusion Criteria: Prior history of atrial fibrillation Prior history of cardiac surgery Hepatic dysfunction (Alanin-aminotransferase more than twice the upper limit) Creatinine >200 µmol/L

Ages Eligible for Study
-----------------
Minimum Age: 60 Years
Maximum Age: 95 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Discontinuous of statin Intervention: Discontinuous of statin, n = 50 Length of preoperative discontinuous: 7 to 14 days prior to surgery Length of postoperative discontinuous: 30 days Control group: continuing medication, n = 50 No withdrawal study could be found in the literature. We therefore estimate that 100 patients with 50 patients in each group will be enough to observe significant differences, if withdrawal statin should be a clinically manifested issue for the risk of POAF from 36% to 66%. Sample size Continuance of statins: 50 Discontinuance of statins: 50
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Continuance<br>Continuance prior statin therapy. | Drug: No-intervention.<br>* Continuance of prior statin therapy<br>|
| Experimental: Discontinuance<br>Discontinuance prior statin therapy. Duration: From 7 to 14 days prior to surgery until 30 days postoperative | Drug: Discontinuance of treatment with statins 7 to 14 days prior to surgery until 30 days postoperative<br>* Discontinuance of prior statin therapy<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Participants with POAF - In-hospital | In-hospital POAF assessed by Holter monitoring. | In-hospital up to 10 days. | 
| Number of Participants with POAF - Early | Early assessed by anamnesis and electronic health record (EHR). | Early (≤30 days) incidence of POAF | 
| Number of Participants with POAF - Intermediate | Intermediate POAF assessed by anamnesis and EHR. | Intermediate (1 year) incidence of POAF | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of all-cause mortality - In-hospital | Number of deaths in each group. | In-hospital up to 10 days. | 
| Rate of all-cause mortality - Early | Number of deaths in each group. | Early (≤30 days) | 
| Rate of all-cause mortality - intermediate | Number of deaths in each group. | Intermediate (1 year) | 
| Myocardial injury - Tn | Injury assessed by serial Troponin measurements. Unit:ng/l | After surgery until discharge up to 10 days | 
| Myocardial injury - CKMB | Injury assessed by serial CKMB measurements. Unit: μg/l. | After surgery until discharge up to 10 days | 
| Stroke - Early | Number of patients with stroke in each group. | Early (≤30 days). | 
| Stroke - Intermediate | Number of patients with stroke in each group. | Intermediate (1 year) | 
| Trans ischemic attack - Early | Number of patients with trans ischemic attack in each group. | Early (≤30 days) | 
| Trans ischemic attack - Intermediate | Number of patients with trans ischemic attack in each group. | Intermediate (1 year) | 
| Myocardial infarction - Early | Number of patients with Myocardial infarction in each group. | Early (≤30 days) | 
| Myocardial infarction - Intermediate | Number of patients with Myocardial infarction in each group. | Intermediate (1 year) | 
| Permanent pacemaker - Early | Number of patients with Permanent pacemaker in each group. | Early (≤30 days) | 
| Permanent pacemaker - Intermediate | Number of patients with Permanent pacemaker in each group. | Intermediate (1 year) | 
| ICD implantation - Early | Number of patients with ICD implantation in each group. | Early (≤30 days) | 
| ICD implantation - Intermediate | Number of patients with ICD implantation in each group. | Intermediate (1 year) | 
| Acute kidney injury - Early | Number of patients with Acute kidney injury in each group. | Early (≤30 days) | 
| Acute kidney injury - Intermediate | Number of patients with Acute kidney injury in each group. | Intermediate (1 year) | 
| LVEF | Describe echocardiography assessed differences in pre and postoperative measurements of LVEF(left ventricular ejection fraction) between groups. Unit: % | Before surgery compared with prior to discharge (On the 3rd to 5th postoperative day). | 
| Strain | Describe echocardiography assessed differences in pre and postoperative measurements of Strain between groups.Unit: % | Before surgery compared with prior to discharge (On the 3rd to 5th postoperative day). | 
| Peak gradient | Describe echocardiography assessed differences in pre and postoperative measurements of peak gradient between groups. Unit: mmHg | Before surgery compared with prior to discharge (On the 3rd to 5th postoperative day). | 
| Mean gradient | Describe echocardiography assessed differences in pre and postoperative measurements of mean gradient between groups. Unit: mmHg | Before surgery compared with prior to discharge (On the 3rd to 5th postoperative day). | 
| TAPSE | Describe echocardiography assessed differences in pre and postoperative measurements of TAPSE (tricuspid annular plane systolic excursion) between groups. Unit: mm | Before surgery compared with prior to discharge (On the 3rd to 5th postoperative day). | 
| Length of stay on ICU | Length of stay on ICU after surgery. Unit: Days | Day of surgery to the day of discharge from ICU. Up to 52 weeks. | 
| Length of stay in hospital | Length of stay in hospital after surgery. Unit: Days | Day of surgery to the day of discharge from the hospital. Up to 52 weeks. |