Postoperative pericardial effusion, pericardiotomy, and atrial fibrillation: An explanatory analysis of the PALACS trial.

Abstract

BACKGROUND:

In the Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery (PALACS) trial, posterior pericardiotomy was associated with a significant reduction in postoperative atrial fibrillation (POAF) after cardiac surgery. We aimed to investigate the mechanisms underlying this effect.

METHODS:

We included PALACS patients with available echocardiographic data (n = 387/420, 92%). We tested the hypotheses that the reduction in POAF with the intervention was associated with 1) a reduction in postoperative pericardial effusion and/or 2) an effect on left atrial size and function. Spline and multivariable logistic regression analyses were used.

RESULTS:

Most patients (n = 307, 79%) had postoperative pericardial effusions (anterior 68%, postero-lateral 51.9%). The incidence of postero-lateral effusion was significantly lower in patients undergoing pericardiotomy (37% vs 67%; P < .001). The median size of anterior effusion was comparable between patients with and without POAF (5.0 [IQR 3.0-7.0] vs 5.0 [IQR 3.0-7.5] mm; P = .42), but there was a nonsignificant trend towards larger postero-lateral effusion in the POAF group (5.0 [IQR 3.0-9.0] vs 4.0 [IQR 3.0-6.4] mm; P = .06). There was a non-linear association between postero-lateral effusion and POAF at a cut-off at 10 mm (OR 2.70; 95% CI 1.13, 6.47; P = .03) that was confirmed in multivariable analysis (OR 3.5, 95% CI 1.17, 10.58; P = 0.02). Left atrial dimension and function did not change significantly after posterior pericardiotomy.

CONCLUSIONS:

Reduction in postero-lateral pericardial effusion is a plausible mechanism for the effect of posterior pericardiotomy in reducing POAF. Measures to reduce postoperative pericardial effusion are a promising approach to prevent POAF.

• Authors: Lisa Q Rong, Antonino Di Franco, Mohamed Rahouma, Arnaldo Dimagli, June Chan, Alexandra J Lopes, Jiwon Kim, Tommaso Sanna, Richard B Devereux, Victoria Delgado, Jonathan W Weinsaft, Filippo Crea, John H Alexander, Marc Gillinov, John Michael DiMaio, Kane O Pryor, Leonard Girardi, Mario Gaudino
• Journal: American heart journal (Am Heart J) Vol. 260 Pg. 113-123 (06 2023) ISSN: 1097-6744 [Electronic] United States
• PMID: 36934978 (Publication Type: Journal Article, Research Support, N.I.H., Extramural)
• Copyright: Copyright © 2023 Elsevier Inc. All rights reserved.

Topics

• Humans
• Atrial Fibrillation (etiology, prevention & control, epidemiology)
• Pericardiectomy (adverse effects, methods)
• Pericardial Effusion (epidemiology, etiology, surgery)
• Treatment Outcome
• Cardiac Surgical Procedures (adverse effects)
• Postoperative Complications (epidemiology, prevention & control)