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J Thorac Cardiovasc Surg 1997;113:797-799
© 1997 Mosby, Inc.

BRIEF COMMUNICATIONS

EFFECTS OF POSTERIOR PERICARDIOTOMY ON THE INCIDENCE OF ATRIAL FIBRILLATION AND CHEST DRAINAGE AFTER CORONARY REVASCULARIZATION: A PROSPECTIVE RANDOMIZED TRIAL

Oxford, United Kingdom

Received for publication June 25, 1996 accepted for publication Sept. 11, 1996. Address for reprints: D. P. Taggart, MD (Hons), FRCS, Consultant Cardiothoracic Surgeon, The John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.

Supraventricular tachyarrhythmia (SVT), mainly in the form of atrial fibrillation (AF), occurs in up to 40% of patients undergoing coronary artery bypass grafting (CABG) and although usually benign can cause hemodynamic instability, prolong hospital stay and increase costs, and, rarely, predispose to a cerebrovascular accident. ¹

Pericardial effusions are incriminated in the development of SVT after CABG. ² Posterior pericardiotomy has recently been reported to reduce the incidence of echocardiographically defined pericardial effusions from 40% in a control group to 8% in a pericardiotomy group with a simultaneous reduction in the incidence of SVT from 36% to 8%. ³ That study was not, however, strictly randomized and neither the number of participating surgeons nor their method or methods of myocardial protection was specified.

In a prospective, randomized trial we tested the hypothesis that posterior pericardiotomy reduces the postoperative incidence of SVT by improving pericardial drainage.

Methods.
One hundred consecutive patients undergoing isolated first-time CABG by one surgeon (D. P. T.) were randomized to receive posterior pericardiotomy or no posterior pericardiotomy (control group). Patients with unstable angina were included and left ventricular (LV) function was assessed at cardiac catheterization and defined as good (ejection fraction >50%), moderate (ejection fraction 30% to 50%), or poor (ejection fraction <30%).

Operation.
All operations were done with the use of intermittent global ischemia with the systemic temperature allowed to drift to 34° C. Cardiopulmonary bypass was established with a roller pump and nonpulsatile flow between 2.0 and 2.4 L m min. A Cobe CML membrane oxygenator and alpha-stat arterial carbon dioxide tension management were used and arterial pressure maintained at 50 to 80 mm Hg.

Pericardiotomy.
Patients randomized to the pericardiotomy group received a 4 cm posterior pericardial incision below the left inferior pulmonary vein parallel and posterior to the phrenic nerve as described by Mulay and colleagues. ³

Drainage.
Anterior mediastinal and left pleural drains were routinely placed with suction at 10 mm Hg. Hourly blood loss was recorded until drain removal the following day.

Postoperative electrocardiography.
The electrocardiogram (ECG) was monitored continuously for the first 48 hours after operation and subsequently by 12-lead ECGs as required. In the event of SVT the serum potassium level was corrected if less than 4.5 mmol/L. If the SVT persisted sotalol or digoxin administration was begun depending on LV function.

Statistics.
The analysis of the data was done with SPSS software. Clinical data are expressed as the mean plus or minus the standard deviation. Differences were analyzed with a t test or a Mann-Whitney test for nonparametric data. The differences were considered to be significant for p values <0.05.

Results.
The groups were well matched with regard to age, sex, medications received (particularly beta blockers), LV function, and unstable angina necessitating administration of intravenous heparin and nitrates (Table I). The groups were similar with respect to the number of grafts (including the use of internal thoracic and radial artery grafts), ischemic time, and cardiopulmonary bypass time (Table I).

Incidence of SVT.
There was no significant difference between the two groups with respect to the incidence of SVT or AF, which occurred in 13 patients (26%) in the pericardiotomy group and in 10 patients (20%) in the control group (Table II). In the two groups the combined incidence of SVT was 5 patients of 45 patients younger than 60 years old and 18 of 55 patients older than 60 years (p < 0.01).

Discussion.
The cause of postoperative SVT is not entirely clear. In a study of 1666 patients undergoing isolated CABG the overall incidence of AF was 28%, with the major occurrence 2 days after the operation. ⁴ Univariate and multivariate analyses identified increased patient age to be the dominant factor promoting AF and multivariate analysis showed that postoperative beta-blocker therapy conveyed considerable protection against AF (p = 0.001) but was less effective in older patients. ⁴

Pericardial effusion has also been implicated in the development of AF, ² and Mulay and colleagues ³ reported a dramatic reduction in the incidence of pericardial effusions and SVT with a posterior pericardial incision. Their findings were, however, weakened by nonrandomization of the patients and failure to describe either the number of surgeons involved or the method or methods of myocardial protection used.

In our study prospective randomization and the fact that all operations were done by one surgeon resulted in two similar groups with respect to preoperative, intraoperative, and postoperative factors. The incidence of SVT was not statistically different in the two groups and occurred in 10 patients (20%) in the control group and 13 (26%) in the fenestration group. The overall incidence of SVT of 23% is similar to the 19% incidence previously reported from this unit also with the use of intermittent global ischemia. ⁵ The observation that increased age may be the most important factor for the development of AF is supported in the current study. In the two groups combined the incidence of SVT was 5 patients of 45 patients younger than 60 years old and 18 of 55 patients older than 60 years (p < 0.01).

Our study demonstrated a significantly greater pleural drainage in the posterior pericardiotomy group both at 12 hours and in total, which implies that this does result in more effective pericardial drainage but does not reduce the incidence of AF. It is unlikely that increased drainage was the result of bleeding from the pericardial incision because the edges were cauterized and specifically checked for bleeding.

There are two potential limitations of our study. First, we did not perform continuous ECG monitoring after 48 hours unless there was clinical suspicion of cardiac arrhythmia. The aim of our study was, however, only to detect persistent "clinically relevant" AF that would necessitate medication. Second, we did not perform echocardiography to quantify the incidence or size of any pericardial effusions. Mulay and colleagues ³ used echocardiography to confirm pericardial effusions in 8% of patients with a posterior pericardiotomy and in 40% of control patients (p < 0.001) and concluded that pericardiotomy reduced the incidence of pericardial effusions and SVT. Although the increased chest drainage in the posterior pericardiotomy group confirms that this maneuver results in more effective pericardial drainage, posterior pericardiotomy does not reduce the incidence of SVT and is not associated with any other difference in outcome. Unless clinical benefit of improved pericardial drainage is confirmed the routine performance of posterior pericardiotomy cannot be recommended.

Footnotes

From the Department of Cardiothoracic Surgery, Oxford Heart Center, The John Radcliffe Hospital, Oxford, United Kingdom.

References

1. Pires LA, Wagshal AB, Lancey R, Huang SK. Arrhythmias and conduction disturbances after coronary artery bypass grafting surgery: epidemiology, management, and prognosis [Review]. Am Heart J 1995;129:799-808.[Medline]
   
2. Angelini GD, Penny WJ, El-Ghamary F, et al. The incidence and significance of early pericardial effusion after open heart surgery. Eur J Cardiothorac Surg 1987;1:165-8.[Abstract]
   
3. Mulay A, Kirk AJB, Angelini GD, Wisheart JD, Hutter JA. Posterior pericardiotomy reduces the incidence of supra-ventricular arrhythmias following coronary artery bypass surgery. Eur J Cardiothorac Surg 1995;9:150-2.[Abstract]
   
4. Fuller JA, Adams GG, Buxton B. Atrial fibrillation after coronary artery bypass grafting: is it a disorder of the elderly? 1989;97:821-5.
   
5. Butler J, Chong JL, Rocker GM, Pillai R, Westaby S. Atrial fibrillation after coronary artery bypass grafting: a comparison of cardioplegia versus intermittent aortic cross-clamping. Eur J Cardiothorac Surg 1993;7:23-5.[Abstract]
   

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