Efficacy of Posterior Left Pericardiotomy in Reducing Incidence of Atrial Fibrillation in Patients Undergoing Cardiac Surgery

Table of Content

Introduction

Atrial fibrillation is the most common complication after cardiac surgery, being reported in 30–40% of patients depending on the type of operation and the assessment method used. Posterior left pericardiotomy is a simple surgical procedure that connects the pericardial sac with the left pleural space and drains fluids and thrombi from the pericardial cavity in the postoperative period.

Aim

To study whether posterior left pericardiotomy, a surgical manoeuvre that drains the pericardial space into the left pleural cavity, might reduce the incidence of atrial fibrillation after cardiac surgery

Patient Profile

  • Adult patients (aged ≥18 years) undergoing elective interventions on the coronary arteries, aortic valve, or ascending aorta, or a combination of these
  • No history of atrial fibrillation or other arrhythmias or contraindications to the experimental intervention

Methods

  • Adaptive, randomised, controlled trial
  • Patients were randomly assigned (1:1), stratified by CHA2DS2-VASc score and using a mixed-block randomisation approach (block sizes of 4, 6, and 8), to posterior left pericardiotomy or no intervention
  • 420 were included and randomly assigned to
    • posterior left pericardiotomy group (n=212) or
    • the no intervention group (n=208)
  •  Patients were followed up until 30 days after hospital discharge.

Study endpoint

  • The primary outcome was the incidence of atrial fibrillation during postoperative in-hospital stay, which was assessed in the intention-to-treat (ITT) population.
  • Safety was assessed in the as-treated population

Results

  • The posterior left pericardiotomy group showed significantly lower incidence of postoperative atrial fibrillation than in the no intervention group
Figure 1: Primary endpoint: Incidence of postoperative atrial fibrillation

  • Death within 30 days after hospital discharge was reported in two (1%) of 209 patients in the posterior left pericardiotomy group and one (<1%) of 211 in the no intervention group
  • The incidence of postoperative pericardial effusion was lower in the posterior left pericardiotomy group than in the no intervention group (26 of 209 vs 45 of 211; relative risk 0·58
Table 1: Primary and secondary outcomes

 

Overall population (n=420)

Posterior left pericardiotomy group (n=212)

No intervention group (n=208)

Relative risk

Risk difference

Primary outcome

 

 

 

 

 

Postoperative atrial fibrillation

103

(25%)

37

(17%)

66

(32%)

0·55

–0·14

Secondary outcomes

 

 

 

 

 

Need for postoperative antiarrhythmic medications*

100

(24%)

36

(17%)

64

(31%)

0·55

–0·14

Need for systemic anticoagulation (post hoc) *

42

(10%)

13

(6%)

29

(14%)

0·44

–0·08

Need for postoperative electrical cardioversion

23

(5%)

8

(4%)

15

(7%)

0·52

–0·03

Cumulative time in atrial fibrillation, h

3539·4

1262·2

2277·3

NA

NA

Median time in atrial fibrillation, h

24·0 (12·4 to 38·9)

23·6 (10·0 to 39·0)

24·1

0·50

0·50

Median duration of postoperative in-hospital stays, days

5·0 (5·0 to 7·0)

5·0 (5·0 to 7·0)

5·0

0·00

0·00

Median duration of total in- hospital stay, days

6·0 (5·0 to 7·0)

6·0 (5·0 to 7·0)

6·0

0·00

0·00

Any postoperative atrial arrhythmias

113

(27%)

45

(21%)

68

(33%)

0·65

–0·11

Data n (%) or median (IQR), unless otherwise stated NA=not applicable. *Due to postoperative atrial fibrillation

  • Postoperative major adverse events occurred in six (3%) patients in the posterior left pericardiotomy group and in four (2%) patients in the no intervention group
  • No complications attributable to posterior left pericardiotomy was reported and the time added to the duration of surgery was minimal

Conclusion

Posterior left pericardiotomy at the time of surgery was associated with a significant reduction in the incidence of postoperative atrial fibrillation in patients undergoing coronary, aortic valve, and aortic operations without additional risk of postoperative complications.

Reference

Lancet 2021; 398: 2075–83