Commentary: A small incision to cut in half postoperative atrial fibrillation.

Abstract

Central MessagePosterior pericardiotomy reduces the incidence of postoperative atrial fibrillation. Due to the favorable risk/benefit ratio, this technique should probably be routinely adopted in cardiac surgery.See Article page 114. Postoperative atrial fibrillation (POAF) is the most frequent complication of cardiac surgery and carries an increased risk of mortality and morbidity.1Dobrev D. Aguilar M. Heijman J. Guichard J.B. Nattel S. Postoperative atrial fibrillation: mechanisms, manifestations and management.Nat Rev Cardiol. 2019; 16: 417-436https://doi.org/10.1038/s41569-019-0166-5Crossref PubMed Scopus (168) Google Scholar Due to its frequency and increased risk of adverse events, prevention of this condition is paramount. The Posterior left pericardiotomy for the prevention of AtriaL fibrillation After Cardiac Surgery (PALACS) trial showed how performing a posterior pericardiotomy at the time of cardiac surgery significantly decreases the risk of developing postoperative atrial fibrillation by more than 50% (odds ratio, 0.44; 95% confidence interval, 0.27-0.70; P = .0005).2Gaudino M. Sanna T. Ballman K.V. Sanna T. Ballman K.V. Robinson N.B. et al.Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: an adaptive, single-centre, single-blind, randomised, controlled trial.Lancet. 2021; 398: 2075-2083https://doi.org/10.1016/S0140-6736(21)02490-9Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar In addition, there were no complications attributable to posterior pericardiotomy, and performing it did not add significant time to the duration of surgery. Furthermore, a meta-analysis of nearly 3500 patients from 19 clinical trials found that posterior pericardiotomy decreased the odds of POAF by 58% (P < .001), reduced the risk of cardiac tamponade by 90% (P < .001), and was associated with shorter hospital stays (P < .001).3Gozdek M. Pawliszak W. Hagner W. Zalewski P. Kowalewski J. Paparella D. et al.Systematic review and meta-analysis of randomized controlled trials assessing safety and efficacy of posterior pericardial drainage in patients undergoing heart surgery.J Thorac Cardiovasc Surg. 2017; 153: 865-875.e12https://doi.org/10.1016/j.jtcvs.2016.11.057Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar In a small randomized trial, Kaleda and colleagues4Kaleda V.I. Boldyrev S.Y. Belash S.A. Yakuba I.I. Babeshko S.S. Belan I.A. et al.Efficacy of posterior pericardiotomy in prevention of atrial fibrillation and pericardial effusion after aortic valve replacement: a randomized controlled trial.Patol Krovoobrashcheniya Kardiokhirurgiya. 2017; 21: 60https://doi.org/10.21688/1681-3472-2017-2-60-67Crossref Google Scholar looked at 100 patients undergoing primary isolated aortic valve replacement and found no significant difference in the incidence of POAF between patients who received a posterior pericardiotomy and those who did not (16% in intervention group vs 14% in the control group; P = .71). In addition, postoperative outcomes were similar between the 2 groups. However, the trial was designed to test a very large treatment effect (a reduction in POAF from 35% to 11%, ie, a 68% absolute reduction) and, as the event rate in the control group was 40% of what assumed for sample size calculation, it was also very largely underpowered to detect even large differences between groups. The lack of treatment effect was likely due to the limited power and a classic Type II error. In this issue of the Journal,5Kaleda V.I. Babeshko S.S. Boldyrev S.Y. Belash S.A. Barbuhatti K.O. Prophylactic routine posterior pericardiotomy: Should we perform it in every patient?.J Thorac Cardiovasc Surg Tech. 2022; 14: 114-116Scopus (1) Google Scholar the same authors maintain in fact that, despite the findings in their trial, posterior pericardiotomy should be performed in all patients undergoing cardiac surgery via a median sternotomy. In view of the limitations of the small trial by Kaleda and colleagues and the consistent results of several other trials and meta-analysis, as well as the very favorable risk to benefit ratio of the intervention, we agree with the authors that a posterior pericardiotomy should be performed in most patients undergoing cardiac surgery via a median sternotomy, although a large, multicenter, randomized clinical trial is warranted to further understand the complete spectrum of benefits conferred by the procedure and to potentially trigger the pertinent changes in clinical practice guidelines. Prophylactic routine posterior pericardiotomy: Should we perform it in every patient?JTCVS TechniquesVol. 14PreviewDuring the American Heart Association Scientific Sessions 2021, Dr Mario Gaudino presented the results of the PALACS (Posterior Left pericardiotomy for the prevention of postoperative Atrial fibrillation after Cardiac Surgery) trial, which were simultaneously published in The Lancet.1 This trial attracted attention to posterior pericardiotomy (PP)—an intervention first applied in cardiac surgery a quarter-century ago,2 whose mechanism of action is linked to the elimination of pericardial effusion—a known trigger of atrial fibrillation. Full-Text PDF Open Access