Posterior Left Pericardiotomy for the Prevention of Postoperative Atrial Fibrillation After Cardiac Surgery - PALACS

Contribution To Literature:

The PALACS trial showed that posterior left pericardiotomy during open heart surgery was associated with a reduction in postoperative atrial fibrillation.

Description:

The goal of the trial was to evaluate posterior left pericardiotomy compared with no intervention among patients undergoing open heart surgery.

Study Design

  • Randomization
  • Parallel
  • Stratification

Participants undergoing open heart surgery were randomized to posterior left pericardiotomy (n = 212) versus no intervention (n = 208). Pericardiotomy was performed by making a 4-5 cm vertical incision from the left inferior pulmonary vein to the diaphragm.

  • Total number of enrollees: 420
  • Duration of follow-up: median 6 days
  • Mean patient age: 61 years
  • Percentage female: 24%
  • Percentage with diabetes: 21%

Inclusion criteria:

  • Patients at least 18 years of age undergoing open heart surgery for coronary artery bypass grafting (CABG), aortic valve replacement, and/or aortic repair

Exclusion criteria:

  • History of atrial fibrillation or arrhythmia
  • Mitral or tricuspid surgery
  • Reoperation

Principal Findings:

The primary outcome, postoperative atrial fibrillation, occurred at a rate of 18% in the pericardiotomy group compared with 32% in the no intervention group (p < 0.001).

Secondary outcomes:

  • Operative mortality: 1% in the pericardiotomy group vs. 1% in the no intervention group
  • Major adverse events: 3% in the pericardiotomy group vs. 2% in the no intervention group
  • Pericardial effusion: 12% in the pericardiotomy group vs. 21% in the no intervention group

Interpretation:

Among patients undergoing open heart surgery for CABG, aortic valve replacement, and/or aortic repair, posterior left pericardiotomy was beneficial. Pericardiotomy was associated with a significant reduction in postoperative atrial fibrillation, without increasing the incidence of complications. This trial was adequately powered for a single-center study. A large confirmatory multicenter trial is needed to quantify potential clinical benefits from this intervention.

References:

Gaudino M, Sanna T, Ballman KV, et al., on behalf of the PALACS Investigators. Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: an adaptive, single-center, single-blind, randomized, controlled trial. Lancet 2021;398:2075-83.

Presented by Dr. Mario F. Gaudino at the American Heart Association Virtual Annual Scientific Sessions (AHA 2021), November 14, 2021.

Keywords: AHA Annual Scientific Sessions, AHA21, Arrhythmias, Cardiac, Atrial Fibrillation, Coronary Artery Bypass, Cardiac Surgical Procedures, Pericardial Effusion, Pericardiectomy, Reoperation, Secondary Prevention


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