Postoperative pericardial effusion, pericardiotomy, and atrial fibrillation: An explanatory analysis of the PALACS trial

Am Heart J. 2023 Jun;260:113-123. doi: 10.1016/j.ahj.2023.03.001. Epub 2023 Mar 18.


Background: In the Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery (PALACS) trial, posterior pericardiotomy was associated with a significant reduction in postoperative atrial fibrillation (POAF) after cardiac surgery. We aimed to investigate the mechanisms underlying this effect.

Methods: We included PALACS patients with available echocardiographic data (n = 387/420, 92%). We tested the hypotheses that the reduction in POAF with the intervention was associated with 1) a reduction in postoperative pericardial effusion and/or 2) an effect on left atrial size and function. Spline and multivariable logistic regression analyses were used.

Results: Most patients (n = 307, 79%) had postoperative pericardial effusions (anterior 68%, postero-lateral 51.9%). The incidence of postero-lateral effusion was significantly lower in patients undergoing pericardiotomy (37% vs 67%; P < .001). The median size of anterior effusion was comparable between patients with and without POAF (5.0 [IQR 3.0-7.0] vs 5.0 [IQR 3.0-7.5] mm; P = .42), but there was a nonsignificant trend towards larger postero-lateral effusion in the POAF group (5.0 [IQR 3.0-9.0] vs 4.0 [IQR 3.0-6.4] mm; P = .06). There was a non-linear association between postero-lateral effusion and POAF at a cut-off at 10 mm (OR 2.70; 95% CI 1.13, 6.47; P = .03) that was confirmed in multivariable analysis (OR 3.5, 95% CI 1.17, 10.58; P = 0.02). Left atrial dimension and function did not change significantly after posterior pericardiotomy.

Conclusions: Reduction in postero-lateral pericardial effusion is a plausible mechanism for the effect of posterior pericardiotomy in reducing POAF. Measures to reduce postoperative pericardial effusion are a promising approach to prevent POAF.

Trial registration: NCT02875405.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Atrial Fibrillation* / epidemiology
  • Atrial Fibrillation* / etiology
  • Atrial Fibrillation* / prevention & control
  • Cardiac Surgical Procedures* / adverse effects
  • Humans
  • Pericardial Effusion* / epidemiology
  • Pericardial Effusion* / etiology
  • Pericardial Effusion* / surgery
  • Pericardiectomy / adverse effects
  • Pericardiectomy / methods
  • Postoperative Complications / epidemiology
  • Postoperative Complications / prevention & control
  • Treatment Outcome

Associated data