Posterior pericardiotomy to prevent new-onset atrial fibrillation after coronary artery bypass grafting: a systematic review and meta-analysis of 10 randomized controlled trials

Abstract

Background: Atrial fibrillation (AF) is associated with adverse events after cardiac surgery. Multiple studies have reported that posterior pericardiotomy (PP) may be effective for preventing AF after coronary artery bypass grafting (CABG), but some conflicting results have been reported and the quality of evidence from previous meta-analyses has been limited. The present study aimed to systematically evaluate the safety and efficacy of PP for preventing AF after CABG in adults.

Methods: We conducted a quantitative meta-analysis of randomized controlled trials (RCTs) published before May 31, 2021. The primary outcome was AF after CABG under cardiopulmonary bypass. Secondary outcomes included early pericardial effusion, late pericardial effusion, pericardial tamponade, pleural effusion, length of hospital stay, length of intensive care unit (ICU) stay, pulmonary complications, intra-aortic balloon pump use, revision surgery for bleeding, and mortality.

Results: Ten RCTs with 1829 patients (910 in the PP group and 919 in the control group) were included in the current meta-analysis. The incidence of AF was 10.3% (94/910) in the PP group and 25.7% (236/919) in the control group. A random-effects model indicated that incidence of AF after CABG significantly lower in the PP group than in the control group (risk ratio = 0.45, 95% confidence interval 0.29-0.64, P < 0.0001). PP also effectively reduced the post-CABG occurrence of early pericardial effusion (RR = 0.28, 95% CI 0.15-0.50; P < 0.05), late pericardial effusion (RR = 0.06, 95% CI 0.02-0.16; P < 0.05), and pericardial tamponade (RR = 0.08, 95% CI 0.02-0.33; P < 0.05) as well as the length of ICU stay (weighted mean difference [WMD] = 0.91,95% CI 0.57-1.24; P < 0.05), while increasing the occurrence pleural effusion (RR = 1.51, 95% CI 1.19-1.92; P < 0.05). No significant differences length of hospital stay (WMD = - 0.45, 95% CI - 2.44 to 1.54, P = 0.66), pulmonary complications (RR = 0.99, 95% CI 0.71-1.39, P = 0.97), revision surgery for bleeding (RR = 0.84, 95% CI 0.43-1.63, P = 0.60), use of IABP (RR = 1, 95% CI 0.61-1.65, P = 1.0), or death (RR = 0.45, 95% CI 0.07-3.03, P = 0.41) were observed between the PP and control groups.

Conclusions: PP may be a safe, effective, and economical method for preventing AF after CABG in adult patients.

Keywords: Coronary artery bypass grafting; Posterior pericardiotomy; Postoperative atrial fibrillation.

Fig. 1

Flow chart of the selection process for studies included in the systematic review and meta-analysis

Fig. 2

Quality assessments according risk of bias. a Risk of bias summary: judgments about each risk of bias item for each included study. b Risk of bias graph: judgments about each risk of bias item presented as percentages across all included studies

Fig. 3

Pooled estimates from RCTs evaluating effects of PP on the incidence of AF after CABG surgery with a random-effects model. PP, posterior pericardiotomy; CI, confidence interval

Fig. 4

Trial sequential analysis of 10 RCTs (black square icons) illustrating that the cumulative z-curve crossed both the conventional boundary for benefit and the trial sequential monitoring boundary for benefit and entered the area of benefit, establishing sufficient and conclusive evidence and suggesting further trials are not needed. A diversity adjusted required information size of 5869 patients was calculated using an alpha error of 0.05, a beta error of 0.20 (power 80%), an anticipated RR reduction of 20% in AF, and a control event proportion of 25.3%, as calculated from the control group in our meta-analysis

Fig. 5

Tests for publication bias among the 10 included studies on the effect of PP on AF after CABG

Fig. 6

Improvement of the stability of the results through the trim and fill method