Posterior left pericardiotomy reduces postoperative AF after cardiac surgery
Click Here to Manage Email Alerts
In the PALACS trial, patients who underwent posterior left pericardiotomy had a reduced incidence of atrial fibrillation after cardiac surgery compared with patients who received no intervention.
The findings were presented at the American Heart Association Scientific Sessions and simultaneously published in the Lancet.
During a presentation, Mario Gaudino, MD, PhD, the Stephen and Suzanne Weiss Professor of Cardiothoracic Surgery at Weill Cornell Medicine, described posterior left pericardiotomy as a “relatively simple procedure. It is essentially a 4 cm to 5 cm incision in the posterior pericardium that connects the pericardium with the left pleural cavity, and allows drainage of fluid and clogs from the pericardium to the left pleural cavity in the postoperative period.”
To assess whether posterior pericardiotomy reduces postoperative AF after cardiac surgery, Gaudino and colleagues conducted an adaptive, single-center, single-blind randomized controlled trial that included 420 patients (median age, 61 years; 24% women). Patients underwent elective interventions on the coronary arteries, aortic valve and/or ascending aorta, and had no history of AF or other arrhythmias. They were randomly assigned to posterior left pericardiotomy (n = 212) or no intervention (n = 208) during the planned surgical procedure.
Additionally, researchers stratified patients according to CHA2DS2-VASc score.
Postoperative AF, as assessed via continuous cardiac rhythm monitoring during the entire postoperative in-hospital stay, served as the primary outcome measure.
Significant primary endpoint reduction
Results indicated that postoperative AF was significantly lower with posterior left pericardiotomy (18% vs. 32%; RR = 0.55; 95% CI, 0.39-0.78; P < .001). In addition, the need for postoperative antiarrhythmic medications (17% vs. 31%) and need for systemic anticoagulation (6% vs. 14%) were also lower in the intervention arm.
According to safety data, the rate of postoperative pericardial effusion was reduced with posterior left pericardiotomy (12% vs. 21%), whereas postoperative major adverse events were similar between groups (intervention, 3% vs. no intervention, 2%).
Study limitations included the single-center trial design, the exclusion of patients undergoing mitral or tricuspid valve surgery and the trial not being powered to show differences in clinical events.
“We conclude that posterior left pericardiotomy is associated with a large and statistically significant reduction in the incidence of postoperative atrial fibrillation after coronary artery bypass grafting, aortic valve and aortic surgery, and is not associated with the risk of perioperative complications,” Gaudino said. “We believe that at this stage of knowledge, a large, pragmatic, confirmatory, multicenter trial that includes the entire spectrum of cardiac surgery operations is needed to quantify the potential clinical benefits of the intervention.”
‘Convincing’ proof-of-concept trial
Discussing the PALACS results, Subodh Verma, MD, PhD, professor and the Canada Research Chair in Cardiovascular Surgery at University of Toronto, said posterior left pericardiotomy is a safe strategy with no increased rates of pleural effusion.
“This is important, particularly since the posterior pericardial fluid drains into the pleural, the effect size is large,” Verma said.
Verma noted, however, that the PALACS study employed a liberal definition of AF that included postoperative AF lasting more than 30 seconds.
“The question is whether a more clinically relevant or stringent definition would be actually more important,” Verma said.
“This is a well-conducted surgical trial that provides convincing proof of concept that a simple, inexpensive, generalizable, surgical adjunctive procedure of pericardial drainage can safely reduce postoperative atrial fibrillation after cardiac surgery,” Verma said.
Reference:
Collapse
Gaudino MF, et al. LBS.03. Prevention to Intervention in Atrial Arrhythmias. Presented at: American Heart Association Scientific Sessions; Nov. 13-15, 2021 (virtual meeting).
Click Here to Manage Email Alerts