Posterior pericardiotomy: An effective strategy for reducing post-coronary artery bypass grafting complications, with considerations for pleural effusion risk

Abstract

BACKGROUND

Postoperative complications such as atrial fibrillation and pericardial effusion are frequent after coronary artery bypass grafting (CABG), contributing to increased morbidity and prolonged hospital stays. Posterior pericardiotomy (PP), a surgical technique involving incision of the posterior pericardium to allow drainage, has been suggested as a preventive measure. However, its overall efficacy and safety profile, including potential risks like pleural effusion, require comprehensive evaluation amid varying study qualities. We hypothesized that PP reduces key post-CABG complications compared to standard care.

AIM

To determine the efficacy of PP in reducing postoperative complications following CABG.

METHODS

This systematic review and meta-analysis included randomized controlled trials (RCTs) from PubMed, Cochrane, ClinicalTrials.gov, and Ovid, comparing PP vs no PP in adult CABG patients. Studies were conducted in tertiary care hospital settings. Twenty RCTs with 5331 participants were selected based on predefined inclusion criteria. The intervention involved intraoperative PP. Primary outcome was postoperative atrial fibrillation (POAF); secondary outcomes included effusions, tamponade, hospital/intensive care unit stay, and bleeding revisions. Risk ratios (RRs), mean differences, and 95% confidence intervals (CIs) were calculated using random-effects models; heterogeneity assessed via I² statistic.

RESULTS

Twenty RCTs analyzed 5331 patients (2665 with PP vs 2666 without). PP significantly lowered POAF (10% vs 21%; RR = 0.48, 95%CI: 0.36-0.65, P < 0.00001; I² = 70%), cardiac tamponade (0.5% vs 3%; RR = 0.16, 95%CI: 0.08-0.34, P < 0.00001; I² = 0%), early pericardial effusion (2% vs 6%; RR = 0.31, 95%CI: 0.14-0.68, P = 0.004; I² = 96%), and late pericardial effusion (1% vs 9%; RR = 0.11, 95%CI: 0.05-0.21, P < 0.00001; I² = 0%). Hospital stay decreased (mean difference = -1.23 days, 95%CI: -1.87 to -0.59, P = 0.0002; I² = 85%). Pleural effusion risk increased (25% vs 17%; RR = 1.46, 95%CI: 1.21-1.76, P < 0.0001; I² = 0%). No significant effects on mortality (RR = 0.92, 95%CI: 0.48-1.76, P = 0.80; I² = 0%), intensive care unit stay, or bleeding revisions.

CONCLUSION

PP effectively reduces POAF, pericardial effusions, tamponade, and hospital stay in CABG patients, though it increases pleural effusion risk and shows heterogeneity in some outcomes.

Keywords: Posterior pericardiotomy; Coronary artery bypass grafting; Safety; Postoperative complications; Pleural effusion; Atrial fibrillation; Pericardial effusion

Core Tip: Posterior pericardiotomy is considered a safe and effective intervention for coronary artery bypass grafting to reduce complications. Our meta-analysis reported a significant reduction in postoperative atrial fibrillation, cardiac tamponade, early and late pericardial effusion, and the length of hospital stay, while improving postoperative outcomes. However, due to the limitations of our study and heterogeneity recorded in some of our outcomes calls for a systematic approach for postoperative protocols and surgical interventions.