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Eur J Cardiothorac Surg 2002;22:278-281
© 2002 Elsevier Science NL

Posterior pericardiotomy reduces the incidence of supra-ventricular arrhythmias and pericardial effusion after coronary artery bypass grafting

Bora Farsak*, Serdar Günaydin, Hilmi Tokmakoglu, Özer Kandemir, Cem Yorgancioglu, Yaman Zorlutuna

Department of Cardiovascular Surgery, Bayindir Hospital, Kizilirmak mah.28.sok., No:2 Söütözü, 06520 Ankara, Turkey

Received 2 November 2001; received in revised form 25 March 2002; accepted 18 April 2002.

* Corresponding author. Tel.: +90-312-287-9000; fax: +90-312-284-1378
e-mail: gunaydin{at}marketweb.net.tr


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 References
 
Objective: The aim of this prospective study was to demonstrate the effectiveness of posterior pericardiotomy in reducing the incidence pericardial effusions and consequently reducing the related supraventricular tachyarrhythmias and development of delayed posterior cardiac effusions. Methods: This prospective randomized study was carried out in 150 patients undergoing coronary artery bypass grafting in Bayindir Hospital Department of Cardiovascular Surgery between April 2000 and October 2001. One hundred and fifty patients were divided into two groups; each group included 75 patients. A 4-cm longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm in posterior pericardiotomy group (group I). Posterior pericardiotomy was not performed in conventional treatment group (group II). Results: Atrial fibrillation was developed in seven patients (9.3%) in group I and in 24 patients (32%) in group II (P<0.001). Atrial flutter and other supraventricular tachyarrhythmia (SVT) prevalence was not statistically significant. Early pericardial effusion was developed 42.6% (32/75) and 10.6% (8/75), respectively, in group II and group I (P<0.0001), but no late pericardial effusion developed in group I despite seven (9.3%) late pericardial effusions developing in group II (P<0.013). Conclusion: Posterior pericardiotomy is a simple, safe and effective technique for reducing not only the prevalence of early pericardial effusion and related atrial fibrillation but also delayed posterior pericardial effusion and tamponade.

Key Words: Coronary artery bypass grafting • Posterior pericardiotomy • Atrial fibrillation


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 References
 
Pericardial effusion which is commonly seen after coronary artery bypass surgery (CABG) adds a wide range of morbidity to the operation. It is often small in amount and benign but can be circumferential and quite large which may impede cardiac filling, reduce cardiac output, and lead to tamponade or it may be regional and located in a strategic area incriminates in the development of SVT after CABG [1]. Regional pericardial effusions are often localized posterior. Previous reports have dealt with the clinical features and management of this problem and have emphasized the high mortality rates associated with delayed treatment [2–4]. Supraventricular tachyarrhythmias, mainly in the form of atrial fibrillation, occur in up to 40% of patients undergoing coronary artery bypass grafting (CABG) [5,6] and although usually benign, can cause hemodynamic instability, prolong hospital stay and increase cost, and rarely predispose to a cerebrovascular accident [7]. Posterior pericardiotomy has recently been reported to reduce the prevalence of echocardiographically defined pericardial effusions from 40% in a control group to 8% in a pericardiotomy group, with a simultaneous reduction in the prevalence of SVT from 36 to 8% [8]. The aim of this prospective, randomized trial was to test the hypothesis that posterior pericardiotomy reduces the postoperative incidence of SVT by improving pericardial drainage.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 References
 
Between April 2000 and October 2001, 987 coronary artery bypass operations were performed in Bayindir Hospital Cardiovascular Surgery Department. 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 30–50%), or poor (ejection fraction <30%).

Patients with hyperthyroidism, chronic obstructive pulmonary disease, renal dysfunction, left ventricular aneurysm, valvular heart disease and patients with preoperative paroxystic atrial fibrillation were not included in this study. Patients who were receiving ß-blocker agents were also excluded from the study. This prospective randomized clinical study was performed in the first 150 patients undergoing coronary artery bypass surgery who had not had exclusion criteria. For randomization of the patients, the table of random digits [9] was used and posterior pericardiotomy was performed in the patients on the first 75 lines of the table; the second 75 lines were accepted as control group. A 4-cm longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm (posterior pericardiotomy) as described by Mulay and coworkers [8]. Informed consent was obtained from all patients. Posterior pericardiotomy was not performed in group II. Two chest tubes (one in the left pleural cavity and the other in anterior mediastinum) were inserted and the pericardium was left open anteriorly in both groups. No drain was placed behind the heart to avoid tube-induced ventricular arrhythmias in both groups. Anesthetic medication and surgical techniques were similar in each group. Cardiopulmonary bypass was established with a roller pump non-pulsatile flow between 2.0 and 2.4 l/m2 per min using Polystan membrane oxygenators (Polystan A-S 8, Walgerholm, Waerlose, Denmark) with an activated clotting time of more than 480 s. Alpha-stat arterial carbon dioxide tension management were used and arterial pressure maintained at 50–80 mmHg. Single cross-clamp, antegrade and retrograde blood cardioplegia was used which was repeated in every 20 min and a hot shot before the removal of the cross-clamp. Heparin was reversed by protamine at the end of the cardiopulmonary bypass. The left pleural cavity was opened down to the phrenic nerve in all patients in order to ensure a better drainage of the pericardium into the pleura and patients with dense adhesion of left lung were excluded. The left internal thoracic artery (LITA) was the graft of choice for left anterior descending coronary artery (LAD) in all patients and saphenous vein grafts (SVG) for the other anastomosis. Patient demography is summarized in Table 1. After routine closure of the chest, continuous suction (10 mmHg) was applied to the drains, which were milked and stripped at 30-min intervals to ensure tube patency. Chest tubes were removed the following day when the drainage was less than 20 ml/h for consecutive 4 h. The presence of pericardial effusion was assessed by two-dimensional echocardiography, which was performed in postoperative days 1, 5, before discharge and 1 month after discharge. The presence of pericardial effusion on two-dimensional echocardiography was assessed with criteria described by Martin and colleagues [10]. The maximum diastolic separation between pericardium and epicardium was measured at the level of the tip of mitral valve leaflet. Any effusion greater than 1 cm was considered significant. Patients were examined echocardiographically after discharge. Patients with posterior effusion were recorded. Late posterior effusions and tamponade were recorded. Electrocardiograms of patients were monitored continuously for 96 h for detecting arrhythmias and if needed, by using standard 12-lead electrocardiograms to detect persistent clinically relevant AF that would necessitate medication.


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  		Table 1. Demographic, preoperative and intraoperative characteristics of the two groupsa

 
In the event of SVT the serum potassium level was corrected if less than 4.5 mmol/l. If the SVT persisted; propofenon or amiodarone administration was begun. Although the patients were discharged, we taught the family to monitor radial artery pulses at least three times a day. In addition, standard 12-lead electrocardiograms were obtained from all patients when the echocardiographic examinations were performed.

Arrhythmias were thought to be persistent and clinically significant when the they were longer than 30 min; we did not count arrhythmias that lasted less than 30 min.

Statistical analysis was performed with SPSS software version 7.0 (SPSS Inc., Chicago, IL). Clinical data are expressed as the mean±SD. Differences were analyzed with {chi}2 Fisher's exact test and independent t-tests.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 References
 
There was no difference between the two treatment groups with regard to age, sex, medication received, LV ejection fraction, right coronary artery involvement and unstable angina necessitating administration of intravenous heparin and nitrates (Table 1) or parameters of coagulation. The number of the distal anastomosis, LITA, SVG usage, duration of cross-clamp, total perfusion time, total volume of drainage, and hospital stay were not statistically significant (Table 1).

There was one hospital death because of low cardiac output. One patient underwent reoperation because of bleeding from a side branch of the internal thoracic artery and another one for the re-exploration of the grafts because of hemodynamic instability and uncontrollable arrhythmias, which were soon found to be because of a protruded sequential SVG from the pericardiotomy side. One patient in each group required insertion of an intra-aortic balloon pump but both patients recovered and were discharged from the hospital. The groups were similar with regard to duration of mechanical ventilation.

Thirty-eight patients (25.3%) developed supraventricular arrhythmias. All SVTs were seen in the first 5 days after the operation, mostly on the second (20 patients, 52.6%) and third (11 patients, 28.9%) postoperative days. Ventricular arrhythmias were rare (18 patients,12%) and showed no difference between the groups. Total number of supraventricular arrhythmias was significantly more common in group II (28 vs. 10 patients, (P<0.001) (Table 2). Arrhythmias were also significantly more commonly associated with the presence of pericardial effusion (28 of 40 patients with pericardial effusion vs. 10 of 110 patients with no pericardial effusion, P<0.0001). Total incidence of SVT was seven of 64 patients younger than 60 years old and 24 of 86 patients older than 60 years (P<0.014). More interestingly, the elapsed period for the development of SVTs (especially atrial fibrillation) was shorter in group II (49.6±1.6 vs. 52.1±3.6 h (P=0.066) and the period elapsed for the response to anti-arrhythmic drugs was longer (4.2±1.8 vs. 3.6±1.1 h, P<0.01). The incidence of the re-occurrence of AF despite anti-arrhythmic therapy and the need for electrical cardioversion was higher in group II (8 vs. 1 patients (P<0.03). Although any statistical significance was not reached, the need for positive inotropes was higher in group II (17 vs. 12 patients) (Table 2).


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  		Table 2. Postoperative dataa

 
The posterior pericardiotomy group (group I) had significantly greater pleural drainage at 24 h (565±133 vs. 355±116 ml) and in total (712±141 vs. 677±136 ml) compared with values in group II (Table 2). There was a statistically significant difference in early pericardial effusion; early pericardial effusion detected by echocardiography was significantly higher in group II (8 vs. 32 patients) (P<0.0001). Late pericardial effusion (more than 30 days after operation) was also very common in group II (seven patients). We did not find late posterior pericardial effusion in group I (P<0.013). There was no significant difference between the two groups regarding hospital stay (7 vs. 8 days, P>0.05).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
References
 
Supraventricular arrhythmia is a common complication following CABG and occurs up to 30–50% of cases in different studies with the major occurrence 2 days after the operation [5,6]. Although many etiologic factors have been emphasized such as age, right coronary artery involvement, atrial dilatation, hyperthyroidism, left ventricular aneurysm/aneurysmectomy, additional valve surgical procedures, perioperative myocardial infarction, low cardiac output, renal failure, respiratory complications and lately, pericardial effusion, influence the development of supraventricular arrhythmias, especially atrial fibrillation [11–13]. The development of atrial fibrillation cannot depend on a single cause, and there is no reliable prophylaxis known [5,14]. Univariate and multivariate analyses identified increased patient age to be the dominant factor promoting AF [6]. Similar results have been identified in our study where in the two groups the combined incidence of SVT was seven of 64 patients younger than 60 years old and 24 of 86 patients older than 60 years (P<0.014). Previous reports have demonstrated that patients with pericardial effusion had a higher prevalence of supraventricular arrhythmias. [1,15,16]. Mulay and associates [8] have demonstrated a reduction in both pericardial effusion and related supraventricular arrhythmias with posterior pericardiotomy (8 vs. 36%). Angelini et al. [17] presented refractory (to medication and cardioversion) supraventricular arrhythmias due to pericardial effusion following open-heart surgery, which responded well to the evacuation of the effusion and a consequent sinus rhythm. Asimakopoulos and coworkers [18] have shown that posterior pericardiotomy was more effective for pericardial drainage, but they also have shown that atrial fibrillation or SVT prevalence were not significantly reduced (20%) in comparison with the conventional technique (26%). In our study, although we did not find any statistically significant difference regarding atrial flutter and SVTs; atrial fibrillation prevalence was significantly lower in the posterior pericardiotomy group (P<0.001). Also the elapsed time for the occurrence, response to medication and re-occurrence of AF was significantly different in favor of group I. Asimakopoulos and coworkers [18] included patients who were receiving ß-blockers, which could be the reason for the reduced AF in the groups, and also pointed out that pericardiotomy groups have significantly higher blood loss, but we did not find significant total blood loss difference between the two groups; however, the pleural drainage was higher in the posterior pericardiotomy group as expected. 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.

Mulay and colleagues [8] used echocardiography to confirm pericardial effusion (8 vs. 40%) (P<0.001) and concluded that pericardiotomy reduced the incidence of pericardial effusions and SVT. Asimakopoulos et al. [18] expressed that echocardiography was lacking in their study. Although the total volume drained was similar in both groups, we revealed an increased volume of posterior effusion in the conventional treatment group and an increased incidence of SVTs. Postoperative echocardiographic follow up in a mean period of 38±9.1 days revealed 4.6% delayed pericardial effusion without causing any signs of tamponade. The increased chest drainage in the posterior pericardiotomy group and the results obtained from the echocardiographic follow-up confirmed that this maneuver results in more effective pericardial drainage. Although Yorgancioglu et al. [19] experienced the protrusion of a sequential graft from the posterior pericardiotomy side, posterior pericardiotomy is a technically easy, safe and effective technique that does not add any morbidity to the patient and any harm to the surgeon. It reduces not only the prevalence of early pericardial effusion and related atrial fibrillation but also delayed posterior pericardial effusion and tamponade.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 References
 

  1. Angelini G.D., Penny W.I., El-Ghamary F. The incidence and significance of early pericardial effusion after open heart surgery. Eur J Cardiothorac Surg 1987;1:165-168.[Abstract]
  2. Borkon A.M., Schaff H.V., Gardner T.I., Merrill W.H., Brawley R.K., Donahoo I.S. Diagnosis and management of postoperative pericardial effusion and late cardiac tamponade following open-heart surgery. Ann Thorac Surg 1981(31):512-519.
  3. Chuttani K., Tischer M.D., Pandian N.G., Lee R.T., Mohanty P.K. Diagnosis of cardiac tamponade after cardiac surgery: Relative value of clinical, echocardiographic and hemodynamic signs. Am Heart J 1994;127:913-918.[Medline]
  4. Sahni I., Tvert T., Herzfeld I., Brondin L.A. Late cardiac tamponade after open-heart surgery. Scand J Thorac Cardiovasc Surg 1991;25:63-68.[Medline]
  5. Curzen N., Poole-Wilson P. Atrial tachyarrhythmias and coronary artery bypass surgery patient. Br J Cardiol 1994;1:57-59.
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  7. Pires L.A., Wagshal A.B., Lancey R., Huang S.K. Arrhythmias and conduction disturbance after coronary artery bypass grafting surgery: epidemiology, management, and prognosis [review]. Am Heart J 1995;129:799-808.[Medline]
  8. Mulay A., Kirk M.B., Angelini G.D., Wishheart I.D., Hutter J.A. Posterior pericardiotomy reduces the incidence of supraventricular arrhythmias following coronary artery bypass surgery. Eur J Cardiothorac Surg 1995;9:150-152.[Abstract]
  9. Tull D., Albawn G.S. Appendix I. Survey research: a decisional approach. New York: Intext Press, 1973:225.
  10. Martin R.P., Rakowski H., French I., Popp R.L. Localization of pericardial effusion with wide angle phased array echocardiography. Am J Cardiol 1978;42:904-912.[Medline]
  11. Mendes L.A., Connelly G., McKenney P., Podrid P.J., Cupples L.A., Shemin R.J., Ryan T.J., Davidoff R. Right coronary artery stenosis. An independent predictor of atrial fibrillation after cardiac surgery. J Am Coll Cardiol 1995;25:198-202.[Abstract]
  12. Zarse M., Deharo J.C., Mast F., Allessie M.A. Importance of right atrium and left atrium dilatation and linear ablation for perpetuation of sustained atrial fibrillation. J Cardiovasc Electrophysiol 2002;13:164-171.[Medline]
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  14. Cujec B., Johnson D., Bharadwaj B. Cardiac tamponade by located pericardial hematoma following open heart surgery: diagnosis by transesophageal echocardiography. Can J Cardiol 1991;7:37-40.[Medline]
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  16. Ikaheimo M.I., Huikuni H.V., Airaksinen I., Korhonem U., Linnaluoto M.K., Tarkka M.R., Takkunen J.T. Pericardial effusion after cardiac surgery: incidence relation to the type of surgery, antithrombotic therapy and early coronary bypass graft patency. Am Heart J; l 1988;16:97-102.
  17. Angelini G.D., Bryan A.J., Lamarra M. Refractory supra-ventricular tachyarrhythmias due to early posterior pericardial effusion following open heart surgery. Thorac Cardiovasc Surg 1988;36:162-163.[Medline]
  18. Asimakopoulos O., Della-Santa R., Taggart D.P. Effects of posterior pericardiotomy on the incidence of atrial fibrillation and chest drainage after coronary revascularization: a prospective randomized trial. J Thorac Cardiovasc Surg 1997;113:797-799.[Free Full Text]
  19. Yorgancioglu Y., Farsak B., Tokmakoglu T., Günaydin S. An unusual experience with posterior pericardiotomy. Eur J Cardiothorac Surg 2000;18:727.[Free Full Text]



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