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Hassanabad AF, Deniset JF, Fedak PWM. Pericardial Inflammatory Mediators That Can Drive Postoperative Atrial Fibrillation in Cardiac Surgery Patients. Can J Cardiol 2023; 39:1090-1102. [PMID: 37301368 DOI: 10.1016/j.cjca.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023] Open
Abstract
Postoperative atrial fibrillation (POAF) is a common dysrhythmia that affects a significant number of patients undergoing cardiac surgery. Many studies aim to better understand this complex postsurgical complication by analysing circulating biomarkers in patients who develop POAF. More recently, the pericardial space was shown to contain inflammatory mediators that could trigger POAF. In this review we summarise recent studies that examine the immune mediators present in the pericardial space and their potential implications for the pathophysiology of POAF in cardiac surgery patients. Ongoing research in this area should better delineate the multifactorial etiology of POAF, where specific markers may be targeted to reduce the incidence of POAF and improve outcomes for this patient population.
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Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Justin F Deniset
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul W M Fedak
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Abdelaziz A, Hafez AH, Elaraby A, Roshdy MR, Abdelaziz M, Eltobgy MA, Elsayed H, El-Samahy M, Elbehbeh NA, Philip KG, Abdelaty AM, Rizk MA, Al-Tawil M, AboElfarh HE, Ramadan A, Ghaith HS, Wahsh EA, Abdelazeem B, Fayed B. Posterior pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: a systematic review and meta-analysis of 25 randomised controlled trials. EUROINTERVENTION 2023; 19:e305-e317. [PMID: 36927670 PMCID: PMC10336425 DOI: 10.4244/eij-d-22-00948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/31/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) associated with postoperative pericardial effusion is the most commonly reported adverse event after cardiac surgery. AIMS We aimed to determine the role of posterior pericardiotomy in preventing postoperative AF (POAF). METHODS We searched PubMed, Scopus, Web of Science, Ovid, and EBSCO from inception until 30 June 2022. We included randomised clinical trials (RCTs) that compared posterior pericardiotomy (PP) versus control (no PP) in patients undergoing cardiac surgery. The primary endpoint was the incidence of POAF after cardiac surgery. The secondary endpoints were supraventricular arrhythmias, early/late pericardial effusion, pericardial tamponade, pleural effusion, length of hospital/intensive care unit stay, intra-aortic balloon pump use, revision surgery for bleeding, and mortality. RESULTS Twenty-five RCTs comprising 4,467 patients were included in this systematic review and meta-analysis. The overall incidence rate of POAF was 11.7% in the PP group compared with 23.67% in the no PP or control group, with a significant decrease in the risk of POAF following PP (odds ratio [OR] 0.49, 95% confidence interval [CI]: 0.38-0.61). Compared with the control group, the risk of supraventricular tachycardia (OR 0.66, 95% CI: 0.43-0.89), early pericardial effusion (OR 0.32, 95% CI: 0.22-0.46), late pericardial effusion (OR 0.15, 95% CI: 0.09-0.25), and pericardiac tamponade (OR 0.18, 95% CI: 0.10-0.33) were lower in the PP group. CONCLUSIONS PP is an effective intervention for reducing the risk of POAF after cardiac surgery. Also, PP is economically efficient in terms of decreasing the length of hospital stay.
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Affiliation(s)
- Ahmed Abdelaziz
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Abdelrahman H Hafez
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Elaraby
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Merna Raafat Roshdy
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Mohamed Abdelaziz
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Moemen A Eltobgy
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Kasr Al Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Hanaa Elsayed
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed El-Samahy
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Nada Abdallah Elbehbeh
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Kerollos George Philip
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Arwa Mohamed Abdelaty
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Marwa Abdelazim Rizk
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed Al-Tawil
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Hadeer Elsaeed AboElfarh
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Mansoura Manchester Programme for Medical Education, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Alaa Ramadan
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, South Valley University, Qena Governorate, Egypt
| | - Hazem S Ghaith
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Engy A Wahsh
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Department of Clinical Pharmacy, Faculty of Pharmacy, October 6 University, Giza, Egypt
| | - Basel Abdelazeem
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- McLaren Flint Hospital, Flint, MI, USA
- Michigan State University, East Lansing, MI, USA
| | - Badr Fayed
- Cardiothoracic Surgery Department, Faculty of Medicine, Port Said University, Port Said, Egypt
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Charitakis E, Tsartsalis D, Korela D, Stratinaki M, Vanky F, Charitos EI, Alfredsson J, Karlsson LO, Foukarakis E, Aggeli C, Tsioufis C, Walfridsson H, Dragioti E. Risk and protective factors for atrial fibrillation after cardiac surgery and valvular interventions: an umbrella review of meta-analyses. Open Heart 2022; 9:openhrt-2022-002074. [PMID: 36318599 PMCID: PMC9454044 DOI: 10.1136/openhrt-2022-002074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/16/2022] [Indexed: 11/29/2022] Open
Abstract
Objective Postoperative atrial fibrillation (POAF) is a common complication affecting approximately one-third of patients after cardiac surgery and valvular interventions. This umbrella review systematically appraises the epidemiological credibility of published meta-analyses of both observational and randomised controlled trials (RCT) to assess the risk and protective factors of POAF. Methods Three databases were searched up to June 2021. According to established criteria, evidence of association was rated as convincing, highly suggestive, suggestive, weak or not significant concerning observational studies and as high, moderate, low or very low regarding RCTs. Results We identified 47 studies (reporting 61 associations), 13 referring to observational studies and 34 to RCTs. Only the transfemoral transcatheter aortic valve replacement (TAVR) approach was associated with the prevention of POAF and was supported by convincing evidence from meta-analyses of observational data. Two other associations provided highly suggestive evidence, including preoperative hypertension and neutrophil/lymphocyte ratio. Three associations between protective factors and POAF presented a high level of evidence in meta-analyses, including RCTs. These associations included atrial and biatrial pacing and performing a posterior pericardiotomy. Nineteen associations were supported by moderate evidence, including use of drugs such as amiodarone, b-blockers, glucocorticoids and statins and the performance of TAVR compared with surgical aortic valve replacement. Conclusions Our study provides evidence confirming the protective role of amiodarone, b-blockers, atrial pacing and posterior pericardiotomy against POAF as well as highlights the risk of untreated hypertension. Further research is needed to assess the potential role of statins, glucocorticoids and colchicine in the prevention of POAF. PROSPERO registration number CRD42021268268.
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Affiliation(s)
- Emmanouil Charitakis
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
| | - Dimitrios Tsartsalis
- Department of Emergency Medicine, Hippokration Hospital, Athens, Greece
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Dafni Korela
- Department of Cardiology, Venizeleio General Hospital, Heraklion, Greece
| | - Maria Stratinaki
- Department of Cardiology, Venizeleio General Hospital, Heraklion, Greece
| | - Farkas Vanky
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
| | | | - Joakim Alfredsson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
| | - Lars O Karlsson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
| | | | - Constantina Aggeli
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Costas Tsioufis
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Håkan Walfridsson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
| | - Elena Dragioti
- Pain and Rehabilitation Centre and Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
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Kaleda VI, Babeshko SS, Boldyrev SY, Belash SA, Barbuhatti KO. Posterior Pericardiotomy: Should We Perform it in Every Patient? JTCVS Tech 2022; 14:114-116. [PMID: 35967224 PMCID: PMC9366348 DOI: 10.1016/j.xjtc.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/30/2022] [Indexed: 11/22/2022] Open
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Posterior left pericardiotomy for the prevention of atrial fibrillation: evidence from the PALACS trial. Indian J Thorac Cardiovasc Surg 2022; 38:226-228. [PMID: 35221564 PMCID: PMC8857331 DOI: 10.1007/s12055-021-01318-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 12/07/2021] [Accepted: 12/10/2021] [Indexed: 10/19/2022] Open
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Gaudino M, Sanna T, Ballman KV, Robinson NB, Hameed I, Audisio K, Rahouma M, Di Franco A, Soletti GJ, Lau C, Rong LQ, Massetti M, Gillinov M, Ad N, Voisine P, DiMaio JM, Chikwe J, Fremes SE, Crea F, Puskas JD, Girardi L. Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: an adaptive, single-centre, single-blind, randomised, controlled trial. Lancet 2021; 398:2075-2083. [PMID: 34788640 DOI: 10.1016/s0140-6736(21)02490-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/05/2021] [Accepted: 10/12/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Atrial fibrillation is the most common complication after cardiac surgery and is associated with extended in-hospital stay and increased adverse outcomes, including death and stroke. Pericardial effusion is common after cardiac surgery and can trigger atrial fibrillation. We tested the hypothesis that posterior left pericardiotomy, a surgical manoeuvre that drains the pericardial space into the left pleural cavity, might reduce the incidence of atrial fibrillation after cardiac surgery. METHODS In this adaptive, randomised, controlled trial, we recruited adult patients (aged ≥18 years) undergoing elective interventions on the coronary arteries, aortic valve, or ascending aorta, or a combination of these, performed by members of the Department of Cardiothoracic Surgery from Weill Cornell Medicine at the New York Presbyterian Hospital in New York, NY, USA. Patients were eligible if they had no history of atrial fibrillation or other arrhythmias or contraindications to the experimental intervention. Eligible patients were randomly assigned (1:1), stratified by CHA2DS2-VASc score and using a mixed-block randomisation approach (block sizes of 4, 6, and 8), to posterior left pericardiotomy or no intervention. Patients and assessors were blinded to treatment assignment. Patients were followed up until 30 days after hospital discharge. The primary outcome was the incidence of atrial fibrillation during postoperative in-hospital stay, which was assessed in the intention-to-treat (ITT) population. Safety was assessed in the as-treated population. This study is registered with ClinicalTrials.gov, NCT02875405, and is now complete. FINDINGS Between Sept 18, 2017, and Aug 2, 2021, 3601 patients were screened and 420 were included and randomly assigned to the posterior left pericardiotomy group (n=212) or the no intervention group (n=208; ITT population). The median age was 61·0 years (IQR 53·0-70·0), 102 (24%) patients were female, and 318 (76%) were male, with a median CHA2DS2-VASc score of 2·0 (IQR 1·0-3·0). The two groups were balanced with respect to clinical and surgical characteristics. No patients were lost to follow-up and data completeness was 100%. Three patients in the posterior left pericardiotomy group did not receive the intervention. In the ITT population, the incidence of postoperative atrial fibrillation was significantly lower in the posterior left pericardiotomy group than in the no intervention group (37 [17%] of 212 vs 66 [32%] of 208 [p=0·0007]; odds ratio adjusted for the stratification variable 0·44 [95% CI 0·27-0·70; p=0·0005]). Two (1%) of 209 patients in the posterior left pericardiotomy group and one (<1%) of 211 in the no intervention group died within 30 days after hospital discharge. The incidence of postoperative pericardial effusion was lower in the posterior left pericardiotomy group than in the no intervention group (26 [12%] of 209 vs 45 [21%] of 211; relative risk 0·58 [95% CI 0·37-0·91]). Postoperative major adverse events occurred in six (3%) patients in the posterior left pericardiotomy group and in four (2%) in the no intervention group. No posterior left pericardiotomy related complications were seen. INTERPRETATION Posterior left pericardiotomy is highly effective in reducing the incidence of atrial fibrillation after surgery on the coronary arteries, aortic valve, or ascending aorta, or a combination of these without additional risk of postoperative complications. FUNDING None.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA.
| | - Tommaso Sanna
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Karla V Ballman
- Alliance Statistics and Data Center, Weill Medical College of Cornell University, New York, NY, USA
| | - N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Irbaz Hameed
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Giovanni J Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Massimo Massetti
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Niv Ad
- Division of Cardiothoracic Surgery, Washington Adventist Hospital and University of Maryland, Tacoma Park, MD, USA
| | - Pierre Voisine
- Division of Cardiac Surgery, Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Québec City, QC, Canada
| | - J Michael DiMaio
- Department of Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital, Plano, TX, USA
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY, USA
| | - Leonard Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
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Posterior pericardiotomy to prevent new-onset atrial fibrillation after coronary artery bypass grafting: a systematic review and meta-analysis of 10 randomized controlled trials. J Cardiothorac Surg 2021; 16:233. [PMID: 34391454 PMCID: PMC8364072 DOI: 10.1186/s13019-021-01611-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/03/2021] [Indexed: 11/10/2022] Open
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.
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5122] [Impact Index Per Article: 1707.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Abstract
Purpose of Review An overview of recent literature regarding pathophysiology, risk factors, prophylaxis, and treatment of new-onset atrial fibrillation (AF) in post-cardiac surgical patients. Recent Findings AF is the most frequent adverse event after cardiac surgery with significant associated morbidity, mortality, and financial cost. Its causes are multifactorial, and models to stratify patients into risk categories are progressing but a consistent, evidence-based system has not yet been developed. Pharmacologic and surgical interventions to prevent and treat this complication have been an area of ongoing research and recent societal guidelines reflect this. Summary Inconsistencies remain surrounding how to best identify higher-risk AF patients, which interventions should be used to prevent and treat AF, and which patient groups should receive these interventions. The evidence for these available strategies and their place in contemporary guidelines are summarized.
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Rego A, Cheung PC, Harris WJ, Brady KM, Newman J, Still R. Pericardial closure with extracellular matrix scaffold following cardiac surgery associated with a reduction of postoperative complications and 30-day hospital readmissions. J Cardiothorac Surg 2019; 14:61. [PMID: 30876459 PMCID: PMC6419853 DOI: 10.1186/s13019-019-0871-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/17/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND A prospective, multi-center study (RECON) was conducted to evaluate the clinical outcomes of pericardial closure using a decellularized extracellular matrix (ECM) graft derived from porcine small intestinal submucosa. METHODS Patients indicated for open cardiac surgery with pericardial closure using ECM were eligible for the RECON study cohort. Postoperative complications and readmission of the RECON patients were compared to the patient cohort in the Nationwide Readmissions Database (NRD). Inverse probability of treatment weighting was used to control the differences in patient demographics, comorbidities, and risk factors. RESULTS A total of 1420 patients at 42 centers were enrolled, including 923 coronary artery bypass grafting (CABG) surgeries and 436 valve surgeries. Significantly fewer valve surgery patients in the RECON cohort experienced pleural effusion (3.1% vs. 13.0%; p < 0.05) and pericardial effusion (1.5% vs. 2.6%; p < 0.05) than in the NRD cohort. CABG patients in the RECON cohort were less likely to suffer bleeding (1.2% vs. 2.9%; p < 0.05) and pericardial effusion (0.2% vs. 2.2%, p < 0.05) than those in the NRD cohort. The 30-day all-cause hospital readmission rate was significantly lower among RECON patients than NRD patients following both valve surgery (HR: 0.34; p < 0.05) and CABG surgery (HR: 0.42; p < 0.05). In the RECON study, 14.4% of CABG patients and 27.0% of valve patients had postoperative atrial fibrillation as compared to previously reported risks, which generally ranges from 20 to 30% after CABG and from 35 to 50% after valve surgery. CONCLUSIONS Pericardial closure with ECM following cardiac surgery is associated with a reduction in the proportion of patients with pleural effusion, pericardial effusion, and 30-day readmission compared to a nationwide database. TRIAL REGISTRATION NCT02073331 , Registered on February 27, 2014.
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Affiliation(s)
- Alfredo Rego
- South Florida Heart & Lung Institute, 3650 NW 82nd Ave, Doral, FL 33166 USA
| | - Patricia C. Cheung
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA USA
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Shan L, Ge W, Pu Y, Cheng H, Cang Z, Zhang X, Li Q, Xu A, Wang Q, Gu C, Zhang Y. Assessment of three risk evaluation systems for patients aged ≥70 in East China: performance of SinoSCORE, EuroSCORE II and the STS risk evaluation system. PeerJ 2018; 6:e4413. [PMID: 29492345 PMCID: PMC5827670 DOI: 10.7717/peerj.4413] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 02/05/2018] [Indexed: 01/12/2023] Open
Abstract
Objectives To assess and compare the predictive ability of three risk evaluation systems (SinoSCORE, EuroSCORE II and the STS risk evaluation system) in patients aged ≥70, and who underwent coronary artery bypass grafting (CABG) in East China. Methods Three risk evaluation systems were applied to 1,946 consecutive patients who underwent isolated CABG from January 2004 to September 2016 in two hospitals. Patients were divided into two subsets according to their age: elderly group (age ≥70) with a younger group (age <70) used for comparison. The outcome of interest in this study was in-hospital mortality. The entire cohort and subsets of patients were analyzed. The calibration and discrimination in total and in subsets were assessed by the Hosmer-Lemeshow and the C statistics respectively. Results Institutional overall mortality was 2.52%. The expected mortality rates of SinoSCORE, EuroSCORE II and the STS risk evaluation system were 0.78(0.64)%, 1.43(1.14)% and 0.78(0.77)%, respectively. SinoSCORE achieved the best discrimination (the area under the receiver operating characteristic curve (AUC) = 0.829), followed by the STS risk evaluation system (AUC = 0.790) and EuroSCORE II (AUC = 0.769) in the entire cohort. In the elderly group, the observed mortality rate was 4.82% while it was 1.38% in the younger group. SinoSCORE (AUC = .829) also achieved the best discrimination in the elderly group, followed by the STS risk evaluation system (AUC = .730) and EuroSCORE II (AUC = 0.640) while all three risk evaluation systems all had good performances in the younger group. SinoSCORE, EuroSCORE II and the STS risk evaluation system all achieved positive calibrations in the entire cohort and subsets. Conclusion The performance of the three risk evaluation systems was not ideal in the entire cohort. In the elderly group, SinoSCORE appeared to achieve better predictive efficiency than EuroSCORE II and the STS risk evaluation system.
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Affiliation(s)
- Lingtong Shan
- The First Clinical Medical College, Nanjing Medical University, Nanjing, China
| | - Wen Ge
- Department of Cardiothoracic Surgery, Shuguang Hospital affiliated to Shanghai University of TCM, Shanghai, China
| | - Yiwei Pu
- The First Clinical Medical College, Nanjing Medical University, Nanjing, China
| | - Hong Cheng
- Department of Neurology, Jiangsu Province People's Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhengqiang Cang
- The First Clinical Medical College, Nanjing Medical University, Nanjing, China
| | - Xing Zhang
- The First Clinical Medical College, Nanjing Medical University, Nanjing, China
| | - Qifan Li
- The First Clinical Medical College, Nanjing Medical University, Nanjing, China
| | - Anyang Xu
- Department of Chronic and Noncommunicable Disease, Shanghai Changning District Center for Disease Control and Prevention, Shanghai, China
| | - Qi Wang
- The First Clinical Medical College, Nanjing Medical University, Nanjing, China
| | - Chang Gu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai JiaoTong University, Shanghai, China
| | - Yangyang Zhang
- Key Laboratory of Arrhythmias of the Ministry of Education of China, East Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Cardiovascular Surgery, East Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Thoracic and Cardiovascular Surgery, Jiangsu Province People's Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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14
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Examining the impact of active clearance of chest drainage catheters on postoperative atrial fibrillation. J Thorac Cardiovasc Surg 2017; 154:501-508. [DOI: 10.1016/j.jtcvs.2017.03.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 03/01/2017] [Accepted: 03/14/2017] [Indexed: 12/25/2022]
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15
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Gozdek M, Pawliszak W, Hagner W, Zalewski P, Kowalewski J, Paparella D, Carrel T, Anisimowicz L, Kowalewski M. Systematic review and meta-analysis of randomized controlled trials assessing safety and efficacy of posterior pericardial drainage in patients undergoing heart surgery. J Thorac Cardiovasc Surg 2016; 153:865-875.e12. [PMID: 28087110 DOI: 10.1016/j.jtcvs.2016.11.057] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/07/2016] [Accepted: 11/19/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To investigate the potential beneficial effects of posterior pericardial drainage in patients undergoing heart surgery. METHODS Multiple online databases and relevant congress proceedings were screened for randomized controlled trials assessing the efficacy and safety of posterior pericardial drainage, defined as posterior pericardiotomy incision, chest tube to posterior pericardium, or both. Primary endpoint was in-hospital/30 days' cardiac tamponade. Secondary endpoints comprised death or cardiac arrest, early and late pericardial effusion, postoperative atrial fibrillation (POAF), acute kidney injury, pulmonary complications, and length of hospital stay. RESULTS Nineteen randomized controlled trials that enrolled 3425 patients were included. Posterior pericardial drainage was associated with a significant 90% reduction of the odds of cardiac tamponade compared with the control group: odds ratio (95% confidence interval) 0.13 (0.07-0.25); P < .001. The corresponding event rates were 0.42% versus 4.95%. The odds of early and late pericardial effusion were reduced significantly in the intervention arm: 0.20 (0.11-0.36); P < .001 and 0.05 (0.02-0.10); P < .001, respectively. Posterior pericardial drainage significantly reduced the odds of POAF by 58% (P < .001) and was associated with significantly shortened (by nearly 1 day) overall length of hospital stay (P < .001). Reductions in postoperative complications translated into significantly reduced odds of death or cardiac arrest (P = .03) and numerically lower odds of acute kidney injury (P = .08). CONCLUSIONS Posterior pericardial drainage is safe and simple technique that significantly reduces not only the prevalence of early pericardial effusion and POAF but also late pericardial effusion and cardiac tamponade. These benefits, in turn, translate into improved survival after heart surgery.
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Affiliation(s)
- Mirosław Gozdek
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital in Bydgoszcz, Bydgoszcz, Poland; Department of Hygiene, Epidemiology and Ergonomics, Division of Ergonomics and Physical Effort, Collegium Medicum UMK in Bydgoszcz, Bydgoszcz, Poland
| | - Wojciech Pawliszak
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital in Bydgoszcz, Bydgoszcz, Poland
| | - Wojciech Hagner
- Chair and Clinic of Rehabilitation, Faculty of Health Sciences, Nicolaus Copernicus University in Toruń, Toruń, Poland
| | - Paweł Zalewski
- Department of Hygiene, Epidemiology and Ergonomics, Division of Ergonomics and Physical Effort, Collegium Medicum UMK in Bydgoszcz, Bydgoszcz, Poland
| | - Janusz Kowalewski
- Lung Cancer and Thoracic Surgery Department, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - Domenico Paparella
- Division of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy
| | - Thierry Carrel
- Clinic for Cardiovascular Surgery, University Hospital and University of Bern, Bern, Switzerland
| | - Lech Anisimowicz
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital in Bydgoszcz, Bydgoszcz, Poland
| | - Mariusz Kowalewski
- Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital in Bydgoszcz, Bydgoszcz, Poland; Department of Hygiene, Epidemiology and Ergonomics, Division of Ergonomics and Physical Effort, Collegium Medicum UMK in Bydgoszcz, Bydgoszcz, Poland.
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16
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Hu X, Yuan L, Wang H, Li C, Cai J, Hu Y, Ma C. Efficacy and safety of vitamin C for atrial fibrillation after cardiac surgery: A meta-analysis with trial sequential analysis of randomized controlled trials. Int J Surg 2016; 37:58-64. [PMID: 27956113 DOI: 10.1016/j.ijsu.2016.12.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/29/2016] [Accepted: 12/02/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Antioxidant supplement is an option in preventing postoperative atrial fibrillation (AF) after cardiac surgery. However, the benefits and adverse effects of vitamin C have not been well assessed. We aimed to systematically evaluate the efficacy and safety of vitamin C in preventing postoperative AF in adult patients after cardiac surgery. METHODS PubMed, EMBASE, and the Cochrane library databases from inception to September 2016 were searched. Randomized controlled trials (RCTs) that evaluated the efficacy and safety of vitamin C in preventing postoperative AF in adult patients after cardiac surgery were identified. The primary outcome was the incidence of postoperative AF. Secondary outcomes included the length of intensive care unit (ICU) stay, length of hospital stay, and stroke events. RESULTS Eight RCTs incorporating 1060 patients were included. Compared with placebo group, vitamin C treatment was associated with a substantial reduction in postoperative AF (OR, 0.47; 95% CI, 0.36-0.62; evidence rank: moderate), with no significant heterogeneity (I2 44%; P = 0.09). Trial sequential analysis showed that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit, establishing sufficient and conclusive evidence. In addition, vitamin C administration was not associated with any length of stay, including in the ICU (evidence rank: low) and hospital (evidence rank: low), respectively. CONCLUSIONS Short-term treatment with vitamin C is safe, and may reduce the incidence of postoperative AF after cardiac surgery. Future studies as well as more high quality RCTs are still warranted to confirm the effects of different durations of vitamin C on cardiac surgery.
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Affiliation(s)
- Xiaolan Hu
- Department of Anaesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People's Republic of China
| | - Linhui Yuan
- Department of Anaesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People's Republic of China
| | - Hongtao Wang
- Department of Anaesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People's Republic of China
| | - Chang Li
- Department of Anaesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People's Republic of China
| | - Junying Cai
- Department of Anaesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People's Republic of China
| | - Yanhui Hu
- Department of Anaesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People's Republic of China
| | - Changhua Ma
- Department of Anaesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, People's Republic of China.
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