Does posterior pericardiotomy reduce the incidence of atrial fibrillation after coronary artery bypass grafting surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether posterior pericardiotomy (PP) reduces the incidence of atrial fibrillation (AF) after coronary artery bypass grafting surgery. Twelve papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. One non-randomized prospective cohort controlled study generated early evidence that PP reduced the rate of postoperative AF and pericardial effusion. The operative details of PP were clearly explained in this paper. The efficacy of this procedure was subsequently examined in five prospective randomized controlled trials performed with some limitations, listed in the table. Meta-analysis of the randomized control trials examined a group of 763 patients (PP = 389, control = 374). It revealed a highly significant reduction in total arrhythmias and AF in the PP group (odds ratio 0.31 and 0.33, respectively). There was a 10.8% AF rate in the PP group (41/379) and a 28.1% AF rate in the control group (108/384). Furthermore, the PP group had a significant reduction in the rate of early and late pericardial effusion (P < 0.001). Moreover, the reduction in the incidence of arrhythmias was significantly associated with the reduction in the incidence of pericardial effusion. Referring to these studies, two guidelines recommend PP to reduce postoperative AF with grade B strength of recommendation. We conclude that PP significantly reduces the incidence of postoperative AF. The number needed to treat to prevent one case of AF is six.