Postoperative Pericardial Effusion Research Articles

Posterior pericardial window: a simple and reproducible technique in order to prevent pericardial tamponade in paediatric cardiac surgery.

Pericardial tamponade, which increases postoperative mortality and morbidity, is still not uncommon after paediatric cardiac surgery. We considered that posterior pericardiotomy may be a useful and safe technique in order to reduce the incidence of early and late pericardial tamponade. Herein, we present our experience with creation of posterior pericardial window following congenital cardiac surgical procedures. This retrospective study evaluated 229 patients who underwent paediatric cardiac surgical procedures between June 2021 and January 2023. A posterior pericardial window was created in all of the patients. In neonates and infants, pericardial window was performed at a size of 2x2 cm, whereas a 3x3 cm connection was established in elder children and young adults. A curved chest tube was placed and positioned at the posterolateral pericardiophrenic sinus. An additional straight anterior mediastinal chest tube was also inserted in every patient. Transthoracic echocardiographic evaluations were performed daily to assess postoperative pericardial effusion. A total of 229 (135 male, 94 female) patients were operated. Mean age and body weight were 24.2 ± 26.7 months and 10.2 ± 6.7 kg, respectively. Eight (3.5%) of the patients were neonates where 109 (47.6%) were infants and 112 (48.9%) were in childhood. Fifty-two (22.7%) re-do operations were performed. Six (2.6%) patients underwent postoperative surgical re-exploration due to surgical site bleeding. Any early or late pericardial tamponade was not encountered in the study group. Posterior pericardial window is an effective and safe technique in order to prevent both the early and late pericardial tamponade after congenital cardiac surgery.

Pericardial window as a surgical method for preventing significant postoperative pericardial effusion

Postoperative pericardial effusion (PPE) represents a very common complication in cardiac surgery. Accumulation of a significant amount of free fluid in the pericardial cavity is a multifactorial process. Identifying the cause is not always possible. This complication occurs more frequently in patients after heart transplantation than in patients who underwent reconstructive cardiac surgery. Having hemodynamically significant effusion requires surgical evacuation of fluid from the pericardial cavity. This can affect the postoperative period and increase the length of stay at the hospital. For this reason, developing and ensuring widespread use of methods for prevention of this complication are urgent and relevant tasks.

Posterior pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: a systematic review and meta-analysis of 25 randomised controlled trials.

Atrial fibrillation (AF) associated with postoperative pericardial effusion is the most commonly reported adverse event after cardiac surgery. We aimed to determine the role of posterior pericardiotomy in preventing postoperative AF (POAF). We searched PubMed, Scopus, Web of Science, Ovid, and EBSCO from inception until 30 June 2022. We included randomised clinical trials (RCTs) that compared posterior pericardiotomy (PP) versus control (no PP) in patients undergoing cardiac surgery. The primary endpoint was the incidence of POAF after cardiac surgery. The secondary endpoints were supraventricular arrhythmias, early/late pericardial effusion, pericardial tamponade, pleural effusion, length of hospital/intensive care unit stay, intra-aortic balloon pump use, revision surgery for bleeding, and mortality. Twenty-five RCTs comprising 4,467 patients were included in this systematic review and meta-analysis. The overall incidence rate of POAF was 11.7% in the PP group compared with 23.67% in the no PP or control group, with a significant decrease in the risk of POAF following PP (odds ratio [OR] 0.49, 95% confidence interval [CI]: 0.38-0.61). Compared with the control group, the risk of supraventricular tachycardia (OR 0.66, 95% CI: 0.43-0.89), early pericardial effusion (OR 0.32, 95% CI: 0.22-0.46), late pericardial effusion (OR 0.15, 95% CI: 0.09-0.25), and pericardiac tamponade (OR 0.18, 95% CI: 0.10-0.33) were lower in the PP group. PP is an effective intervention for reducing the risk of POAF after cardiac surgery. Also, PP is economically efficient in terms of decreasing the length of hospital stay.

Variations in current clinical practice of postoperative pericardial effusion: a questionnaire study

ObjectivePostoperative pericardial effusion (PPE) occurs frequently after cardiac surgery, potentially leading to life-threatening cardiac tamponade. Specific treatment guidelines are currently lacking, possibly leading to variations in clinical practice. Our goal...

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

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. 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. 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. 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.

Can Posterior Pericardial Incision Truly Improve Postoperative Complications After Cardiac Surgery? A Systematic Review and Meta-Analysis.

Postoperative atrial fibrillation (POAF) and pericardial effusion are important factors affecting prognosis after cardiac surgery. Recently, it has been reported that posterior pericardiotomy (PP) can effectively prevent the occurrence of POAF and pericardial effusion. To validate these conclusions and guide clinical practice, we conducted a systematic review with meta-analysis. We searched multiple databases for manuscripts published before July 2022 on the use of PP to prevent POAF and pericardial effusion and included only randomized controlled trials. The main outcome was atrial fibrillation after coronary artery bypass grafting, and secondary outcomes were included. This meta-analysis included 14 randomized controlled trials with a total of 2275 patients. Meta-analysis showed that the incidence of POAF after cardiac surgery in the PP group was significantly lower than that in the control group (risk ratio=0.48; 95% confidence interval=0.33~0.69; P<0.00001). PP effectively reduced postoperative pericardial effusion (risk ratio=0.34, 95% confidence interval=0.21-0.55; P<0.00001). PP has shown good results in preventing POAF, pericardial effusion, and other complications, which indicates that PP is a safe and effective surgical method, but attention still needs to be paid to the potential risk of coagulation dysfunction caused by PP.

Transthoracic Color Doppler Ultrasound-Guided Grooved Negative Pressure Drainage Tube Implantation in Pericardial Effusion After Cardiac Surgery.

Pericardial effusion is a common complication without a standard postoperative effusion treatment after cardiac surgery. The grooved negative pressure drainage tube has many advantages as the emerging alternative for drainage of pericardial effusion, such as it changes the structure of the traditional side hole, uses the capillary function to ensure drainage smooth, etc. The purpose of this study was to assess the feasibility and effectiveness of transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube implantation in pericardial effusion after cardiac surgery. All patients with pericardial effusion after cardiac surgery who underwent transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube implantation between January 2019 and December 2021 were retrospectively analyzed. Treatment results (including clinical symptoms, effusion volume, color Doppler ultrasonography, and computed tomography scan) were investigated to evaluate the effectiveness and safety of this method. A total of 20 patients successfully underwent transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube implantation. After the operation, their symptoms (chest tightness, shortness of breath, etc.) were all relieved, and dark red or light red drainage fluid (> 200 ml) appeared in the newly placed drainage bottle. Color Doppler ultrasonography showed that the volume of pericardial effusion decreased significantly. The transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube is a safe and effective method for the treatment of postoperative pericardial effusion with less trauma, faster recovery, shorter in-hospital stay, and fewer complications.

Benefit of Posterior Pericardiotomy in Heart Valve Surgery

Posterior pericardiotomy (PP) is helpful to prevent arrhythmia; especially atrial fibrillation (AF), and cardiac tamponade postoperative cardiac valve surgery. The incidence of postoperative AF is increased due to postoperative pericardial effusion (PE).

Exploring variations in current clinical practice regarding postoperative pericardial effusion: a questionnaire study

Abstract Background Postoperative pericardial effusion (PPE) is a frequently occurring event after cardiac surgery, potentially leading to life-threatening cardiac tamponade. Unfortunately, no guidelines are currently available on this subject, possibly leading to unwarranted variations in care in clinical practice. Purpose The goal of our study was to determine the diagnostic and therapeutic preferences of cardiologists and cardiothoracic surgeons in the Netherlands regarding PPE, and to evaluate possible variations in this matter between specialties and centers. Methods A web-based questionnaire was sent to all interventional cardiologists and cardiothoracic surgeons in the Netherlands. Diagnostic preferences for the evaluation of PPE were examined. Additionally, clinical preferences were explored in response to 4 patient scenarios with each illustrating a combination of either high or low clinical suspicion of cardiac tamponade and either high or low echocardiographic suspicion. Each scenario was also stratified by 3 different amounts of PPE (&amp;lt;1cm, 1–2cm, &amp;gt;2cm), leading to a total of 12 fictional patient cases (Figure 1). Results From 27 of the 31 contacted centers, a total of 94 clinicians responded to the survey, of whom 46 interventional cardiologists and 48 cardiothoracic surgeons. Cardiologists were more in favor of routine postoperative echocardiography in all patients (44%), whereas cardiothoracic surgeons preferred routine imaging after specific procedures, especially after mitral (85%) and tricuspid (79%) valve surgery. Overall, drainage of PPE (&amp;gt;48 hours postoperatively) was preferred through pericardiocentesis (83%) instead of surgical evacuation (17%). Regarding the patient scenarios, cardiothoracic surgeons were significantly more inclined to evacuate PPE compared to cardiologists for all scenarios combined (51% vs 37%, p&amp;lt;0.001) (Figure 1). In addition, evacuation was overall significantly more preferred by cardiologists employed in surgical centers when compared to those working in non-surgical centers (43% vs 31%, p=0.02). Results from the interrater agreement analysis of groups of clinicians working in the same center varied from very poor up to very good (kappa value of 0.22–0.67), suggesting existing variation of PPE treatment preferences even within one center. Conclusions Our study highlights the significant variation of preferences in contemporary PPE management between cardiothoracic surgeons and interventional cardiologists in the Netherlands, sometimes even within the same center. These findings are the possible consequences of a current lack of general recommendations or guidelines. This could lead to unwarranted variation in care and additional research is necessary to provide general recommendations. Funding Acknowledgement Type of funding sources: None.

Impact of posterior pericardial drain and risk factors on late pericardial effusion after coronary artery bypass surgery

The blood retained in posterior pericardium can trigger an inflammatory response that increases postoperative atrial fibrillations (POAFs), and it can complicate postoperative course. We retrospectively investigated the impact of a posterior pericardial drain (PPD) in reducing late postoperative pericardial effusion (pPE) and POAFs during the first 30 postoperative days. Two hundred and fifty coronary artery bypass grafting patients were divided into two groups according to the presence of a PPD in addition to the anterior one. Perioperative data and the incidence of POAF were compared. Risk factor analysis was used to determine the predictors of pPE and postpericardiotomy syndrome. Late pPE was present in 16% of all patients. It proved to be much more frequent in patients with a posterior drain (odds ratio 2.58; 95% confidence interval 1.23-5.79; P = 0.015) where it seemed to be almost mild and anterior. 'Anterior Drain' patients showed an increased rate of moderate ( P < 0.001) and posterior effusions ( P < 0.001). POAF was much more frequent in patients without a PPD (25.2 vs. 6.3%; P < 0.001). Univariate risk factor analysis revealed a significant association between late pPE and lower preoperative weight ( P = 0.003), lower preoperative and postoperative serum albumin ( P < 0.001) and a greater amount of blood transfusion ( P = 0.02). Even if a PPD is associated with a higher rate of pPE, the patients with only anterior drains were shown to have a greater amount of pericardial effusion and an increased risk of POAFs. Therefore, a PPD should be considered to improve postoperative course.

The effect of posterior pericardiotomy after thoracic aortic surgery

BackgroundPostoperative pericardial effusion is common after cardiovascular surgery. We aimed to examine the effectiveness of posterior pericardiotomy in reducing the incidence of postoperative pericardial effusion and postoperative atrial fibrillation after thoracic aortic surgery.MethodsThis study included 201 patients who underwent thoracic aortic open surgery between January 2014 and November 2021. We compared surgical outcomes between patients who underwent posterior pericardiotomy and those who did not.ResultsThe group that did not undergo posterior pericardiotomy had significantly longer mechanical ventilation duration than the group who did, both in the overall (p = 0.005) and in the propensity-matched cohorts (p = 0.001). The lengths of intensive care unit and hospital stays were significantly longer in the group that did not undergo posterior pericardiotomy compared to the group that did, both in the overall and in the propensity-matched cohorts. The occurrence of postoperative atrial fibrillation and stroke did not differ significantly between the two groups. The amount of pericardial drainage was not significantly lower in the group that underwent posterior pericardiotomy in the overall cohorts (p = 0.09), but the difference was significant in the propensity-matched cohorts (p = 0.04). The amount of mediastinal drainage was significantly lower in the group that underwent posterior pericardiotomy, both in the overall cohorts (< 0.001) and in the propensity-matched cohort (< 0.001). Late pericardial tamponade occurred significantly more frequently in the group that did not undergo posterior pericardiotomy than in the group that did, both in the overall (p = 0.03) and in the propensity-matched cohorts (p = 0.03).ConclusionsPosterior pericardiotomy has no effect on reducing postoperative atrial fibrillation after thoracic aortic surgery. However, posterior pericardiotomy reduced the occurrence of late pericardial tamponade, length of ICU stay, length of hospital stay, and mechanical ventilation duration after surgery.

Posterior pericardiotomy in heart valve surgery; is it still performed or neglected?

Background: Posterior pericardiotomy (PP) is helpful to prevent arrhythmia; especially atrial fibrillation (AF), and cardiac tamponade postoperative cardiac valve surgery. The incidence of postoperative AF is increased due to postoperative pericardial effusion (PE). This study aimed to investigate the early outcome of PP after heart valve surgery. Methods: In this prospective study, 120 patients underwent elective valve heart surgery at our center from January 2020 until April 2022. Patients were followed up for AF and pericardial effusion, and reopening due to tamponade. Results: The mean age of patients was 35.26 years, 70.2% were female and 29.8% were male. Surgery was elective and all were valve surgery. The incidence of postoperative AF was 2%, and pericardial effusion was seen in 1% of patients. Tamponade was not seen in any case. Left PE needed intervention tube drainage of 2%. Conclusion: Posterior pericardiotomy is a simple and safe procedure during valve heart surgery, and it is effective in reducing the incidence of atrial fibrillation, pericardial effusion, and tamponade.

Post-cardiotomy pericardial effusion and postoperative atrial fibrillation risk.

Postoperative atrial fibrillation is a poor prognostic factor associated with increased mortality rates. Patients experiencing significant pericardial effusion develop postoperative atrial fibrillation; however, little is explored about the association between postoperative atrial fibrillation and post-cardiotomy pericardial effusion. This retrospective, single-center study included adult patients who underwent cardiovascular surgery via median sternotomy from January 2016 to December 2019. Patients who underwent routine postoperative computed tomography at 7 ± 3days after surgery (n = 294) were included. Pericardial effusion was measured at the thickest point. Patients were classified into those with (n = 127) and without (n = 167) postoperative atrial fibrillation. The association of pericardial effusion with other factors was evaluated. A possible confounder-adjusted logistic regression analysis after multiple imputation was performed to obtain odds ratios for postoperative atrial fibrillation using previously published risk factors. Age, intraoperative bleeding volume, and pericardial effusion size were all significantly higher in the group with postoperative atrial fibrillation. Multivariate logistic regression after multiple imputation revealed that age, intraoperative bleeding volume, and postoperative pericardial effusion were significantly associated with postoperative atrial fibrillation. Our findings suggest that post-cardiotomy pericardial effusion is associated with postoperative atrial fibrillation. However, the causality remains unknown, making further studies mandatory.

Pericardial effusion after congenital heart surgery

ObjectivePericardial effusion after cardiac surgery remains an important cause of morbidity and mortality. We describe the risk factors of pericardial effusion after congenital heart surgery through analyzing data from a nationwide, multi-institutional registry. MethodsThe Japan Congenital Cardiovascular Surgery Database, which reflects routine clinical care in Japan, was used for this retrospective cohort study. Multivariable regression analysis was done after univariable comparison of patients with pericardial effusion and no pericardial effusion. ResultsThe study enrolled 64,777 patients registered with the Japan Congenital Cardiovascular Surgery Database between 2008 and 2016; 909 of these had postoperative pericardial effusion (1.4%) and were analyzed along with 63,868 patients without pericardial effusion. Univariable analysis found no difference between the groups in terms of gender, early delivery, or preoperative mechanical ventilatory support. In the pericardial effusion group, cardiopulmonary bypass use was lower (58.4% vs 62.1%), whereas the cardiopulmonary bypass time (176.9 vs 139.9 minutes) and aortic crossclamp time (75.1 vs 62.2 minutes) were longer, and 30-day mortality was higher (4.1% vs 2.2%). Multivariable analysis identified trisomy 21 (odds ratio, 1.54), 22q.11 deletion (odds ratio, 2.17), first-time cardiac surgery (odds ratio, 2.01), and blood transfusion (odds ratio, 1.43) as independent risk factors of postoperative pericardial effusion. In contrast, neonates, infants, ventricular septal defect, atrial septal defect, tetralogy of Fallot repair, and arterial switch operation were correlated with a low risk of pericardial effusion development. ConclusionsThe incidence of postoperative pericardial effusion in congenital cardiac surgery was 1.4%. Trisomy 21, 22q.11 deletion, first-time cardiac surgery, and blood transfusion were identified as the principal factors predicting the need for pericardial effusion drainage.

Expert Opinions on the Debate of Pericardial Reconstruction in Cardiovascular Surgery: To Close or Not to Close?

As of 2019, pericardial closure was performed in only a small portion of the over 320,000 cardiac surgeries performed annually. However, evidence regarding the benefits of pericardial closure or reconstruction has been accruing, particularly with the publication of the RECON study in 2019. Methods: This group of authors convened to try to arrive at consensus expert opinion regarding pericardial reconstruction. Structured topic questions initially were used to stimulate discussion. Subsequently, a survey of proposed expert opinion statements was conducted among the authors. Based on that survey, consensus expert opinion statements and recommendations were compiled. The expert opinions encompass various topics relating to pericardial reconstruction, including definitions, benefits/risks, and technique. Observed benefits include reductions in: (1) adhesions; (2) postoperative pericardial effusion, atrial fibrillation, and bleeding; and (3) readmissions and length of hospital stay. Expert opinion recommendations regarding surgical technique are compiled into a single chart. Complete pericardial reconstruction should be performed, using native pericardial tissue if available and viable; if not feasible, a patch may be used. Patches that stimulate the formation of site-specific tissue in situ (such as natural extracellular matrix) may have additional benefits (including bioregenerative properties and lack of inflammatory response). Closure should be taut, but tension-free. Adequate drainage of the closed pericardium must be ensured. Based on available data and collective surgical experience, we endorse pericardial reconstruction as standard approach in appropriately selected patients. We also endorse adoption of standardized pericardial reconstruction techniques to optimize patient outcomes and improve evidence quality in future studies.

Echocardiography and Laboratory Factors Associated With Prolonged Postoperative Pericardial Effusion

Objective: Pericardial effusion is a frequent finding in patients who undergo cardiac surgery. There are currently limited data providing information regarding the factors that may contribute to postoperative pericarditis. The aim was to evaluate laboratory and echocardiographic features that may influence the presence of pericardial effusion 6 to 8 weeks following coronary artery bypass grafting (CABG). Materials and Methods: This was a prospective cross-sectional study that included 90 patients after CABG operation who were divided into two groups. A total of 32 (35.56%) patients with pericardial effusion on follow-up echocardiography formed the first group and 58 patients without pericardial effusion the second group, which were compared in respect to components that were taken prior to the operation. Results: The groups did not differ regarding sex (males 65.62% vs 63.79%, P = .86) or age (59.59 ± 9.29 vs 61.69 ± 10.71, P = .35). Platelet count (184.74 ± 58.79 vs 222.62 ± 88.97, P = .03) and left ventricular (LV) global longitudinal strain (GLS) (−14.64 ± 6.86 vs −16.96 ± 4.1, P = .04) demonstrated statistical significance. Conclusion: Prolonged postoperative pericardial effusion in small amounts may be found in patients, with preoperative lower thrombocyte count and LV GLS, which could be possible predisposing factors.

“Pleurotomy during CABG on the Clinical Outcome Following Left Internal Mammary Artery (LIMA) Harvesting”

Background: The internal mammary artery (IMA) is the graft of choice for coronary artery bypass grafting (CABG) due to superior patency and enhanced patient survival. Pleurotomy during coronary artery bypass grafting (CABG) may cause post-operative events, mostly pulmonary complications. Objective: To assess the impact of intact pleura during left internal mammary artery harvesting on clinical outcome. Materials and Methods: This Cross sectional observational study was carried out in the Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2019 to December 2019.101 patients who underwent Department of Cardiac Surgery, BSMMU were enrolled in this study and divided into two groups: group A (n = 48, 36 male and 12 female patients at a mean age of 56.5 ± 11.2 years) underwent routine CABG and pleurotomy and group B (n = 53, 45 male and 8 female patients at a mean age of 55.4 ± 10.3 years) had CABG with intact pleura. The patients were compared regarding their demographic data, surgical data, and postoperative events. Results: The Incidence Of Postoperative Pericardial Effusion Was Similar Between The Groups, But The Incidence Of Postoperative Pulmonary Complications Such As Pleural Effusion (Except For Mild Pleural Effusion) On The Second (No: 10.4%, mild: 41.7%, moderate: 45.8% and severe: 2.1% in group A versus no: 42.6%, mild: 44.4%, moderate: 13%, and severe: 0 in group B) and fifth postoperative days (no: 27.1%, mild: 33.3%, moderate: 35.4%, and severe: 4.2% in group A versus no: 42.6%, mild: 44.4%, moderate: 13%, and severe: 0 in group B) was significantly lower in group B (p value &lt; 0.001 and p value = 0.007, respectively). Also, the incidence of atelectasis (except for mild atelectasis) on the second (no: 2.1%, mild: 22.9%, moderate: 72.9%, and severe: 2.1% in group A versus no: 9.2%, mild: 59.3%, moderate: 31.5%, and severe: 0 in group B) and fifth postoperative days (no: 22.9%, mild: 39.6%, moderate: 35.4%, and severe: 2.1% in group A versus no: 39.6%, mild: 49.1%, moderate: 11.3%, and severe: 0 in group B) was significantly higher in group A (p value &lt; 0.001 and p value = 0.004, respectively). Postoperative partial oxygen pressure and O2 saturation were similar between the groups, but partial carbon dioxide pressure was significantly lower in group A (p value = 0.017). Amount of bleeding (p value = 0.008) and duration of hospitalization (p value = 0.002) were significantly higher in group A than those in group B. Conclusion: Our results indicate that keeping the pleura intact has beneficial effects on the respiratory function, without increasing the incidence of postoperative pericardial effusion.

Efficacy of Short-Term Oral Prednisolone Treatment in the Management of Pericardial Effusion Following Pediatric Cardiac Surgery

A standard treatment for pericardial effusion without cardiac tamponade after pediatric cardiac surgery has not been established. We evaluated the efficacy of short-term oral prednisolone administration, which is the initial treatment for postoperative pericardial effusion without cardiac tamponade at our institution. Between October 2008 and March 2020, 1429 pediatric cardiac surgeries were performed at our institution. 91 patients required postoperative treatment for pericardial effusion. 81 were treated with short-term oral prednisolone. Pericardial effusion was evaluated using serial echocardiography during diastole. Pericardial drainage was performed for patients with circumferential pericardial effusion with a maximum diameter of ≥ 10 mm or signs of cardiac tamponade. Short-term oral prednisolone treatment was administered to patients with circumferential pericardial effusion with a maximum diameter of < 10 mm or localized pericardial effusion with a maximum diameter of ≥ 5 mm. Patients with localized pericardial effusion with a maximum diameter of < 5 mm were observed. Prednisolone (2 mg/kg/day) was administered orally for 3 days, added as needed. Short-term oral prednisolone treatment was effective in 71 cases and 90% of patients were regarded as responders. The remaining patients were deemed non-responders who required pericardial drainage. Overall, 55 responders were deemed early responders whose pericardial effusion disappeared within 3 days. There were no cases of deaths, infections, or recurrence of pericardial effusion. The amount of drainage fluid on the day of surgery was higher in the non-responders. In conclusion, short-term oral prednisolone treatment is effective and safe for treating pericardial effusion without cardiac tamponade after pediatric cardiac surgery.

Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: an adaptive, single-centre, single-blind, randomised, controlled trial

Atrial fibrillation is the most common complication after cardiac surgery and is associated with extended in-hospital stay and increased adverse outcomes, including death and stroke. Pericardial effusion is common after cardiac surgery and can trigger atrial fibrillation. We tested the hypothesis that 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. In this adaptive, randomised, controlled trial, we recruited adult patients (aged ≥18 years) undergoing elective interventions on the coronary arteries, aortic valve, or ascending aorta, or a combination of these, performed by members of the Department of Cardiothoracic Surgery from Weill Cornell Medicine at the New York Presbyterian Hospital in New York, NY, USA. Patients were eligible if they had no history of atrial fibrillation or other arrhythmias or contraindications to the experimental intervention. Eligible 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. Patients and assessors were blinded to treatment assignment. Patients were followed up until 30 days after hospital discharge. 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. This study is registered with ClinicalTrials.gov, NCT02875405, and is now complete. Between Sept 18, 2017, and Aug 2, 2021, 3601 patients were screened and 420 were included and randomly assigned to the posterior left pericardiotomy group (n=212) or the no intervention group (n=208; ITT population). The median age was 61·0 years (IQR 53·0-70·0), 102 (24%) patients were female, and 318 (76%) were male, with a median CHA2DS2-VASc score of 2·0 (IQR 1·0-3·0). The two groups were balanced with respect to clinical and surgical characteristics. No patients were lost to follow-up and data completeness was 100%. Three patients in the posterior left pericardiotomy group did not receive the intervention. In the ITT population, the incidence of postoperative atrial fibrillation was significantly lower in the posterior left pericardiotomy group than in the no intervention group (37 [17%] of 212 vs 66 [32%] of 208 [p=0·0007]; odds ratio adjusted for the stratification variable 0·44 [95% CI 0·27-0·70; p=0·0005]). Two (1%) of 209 patients in the posterior left pericardiotomy group and one (<1%) of 211 in the no intervention group died within 30 days after hospital discharge. The incidence of postoperative pericardial effusion was lower in the posterior left pericardiotomy group than in the no intervention group (26 [12%] of 209 vs 45 [21%] of 211; relative risk 0·58 [95% CI 0·37-0·91]). Postoperative major adverse events occurred in six (3%) patients in the posterior left pericardiotomy group and in four (2%) in the no intervention group. No posterior left pericardiotomy related complications were seen. Posterior left pericardiotomy is highly effective in reducing the incidence of atrial fibrillation after surgery on the coronary arteries, aortic valve, or ascending aorta, or a combination of these without additional risk of postoperative complications. None.

The Efficacy, Safety, and Side Effects of Intrapericardial Triamcinolone Treatment in Children with Post-surgical Pericardial Effusion: A Case Series

Intrapericardial triamcinolone can be used to treat chronic pericardial effusion (PE) in adults; however, pediatric data are lacking. In this case series we aim to evaluate the efficacy, safety, and side effects of intrapericardial triamcinolone in children with PE. The incidence and treatment of post-surgical PE from 2009 to 2019 were determined using the institutional surgical database and electronic patient records. Furthermore, a retrospective analysis of efficacy, safety, and side effects of intrapericardial triamcinolone treatment for chronic post-surgical PE was performed. The incidence of postoperative PE requiring treatment was highest after atrial septal defect (ASD) closure when compared to other types of cardiac surgery (9.7% vs 4.3%). Intrapericardial treatment with triamcinolone resolved pericardial effusion in 3 out of 4 patients. All patients developed significant systemic side effects. Surgical ASD closure is associated with an increased risk of development of PE requiring treatment. Intrapericardial triamcinolone is an effective treatment for chronic postoperative PE in children, but is always associated with significant systemic side effects. Close monitoring and treatment of adrenal insufficiency are mandatory in these cases.