Pericardiotomy and Amiodarone for Prophylaxis Against Postoperative Atrial Fibrillation in Cardiac Surgery (PAPPA)

Abstract

Background: Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery, occurring in 30%-50% of patients. Although previous studies have suggested a protective benefit from pericardiotomy and prophylactic amiodarone, these practices have not been widely adopted. The Pericardiotomy and Amiodarone for Prophylaxis against Postoperative Atrial Fibrillation (PAPPA) trial was designed to compare the incidence of POAF in cardiac surgery patients who receive a systematic pharmacosurgical prevention strategy vs standard of care.

Methods: In this prospective, propensity-matched, historically controlled trial, adult patients undergoing isolated coronary artery bypass grafting between 2022 and 2024 received a standardized pharmacosurgical intervention including posterior pericardiotomy and low-dose amiodarone. Outcomes in these patients were compared against those in a population of propensity-matched historical controls who underwent isolated coronary artery bypass grafting between 2019 and 2021. The primary endpoint was POAF incidence.

Results: A total of 204 patients received the treatment protocol and were compared with 902 historical controls; 1:1 propensity matching generated 171 (84%) balanced pairs. The incidence of POAF was significantly lower in the treatment group compared to matched controls (18.1% vs 31.5%, P = .004). There was no statistically significant difference in the incidence of postoperative heart block between the 2 groups (0.6% vs 1.8%, P = .6228). However, fewer patients in the treatment group were discharged on anticoagulants (8.7% vs 14%, P = .1257). No significant differences were observed in 30-day mortality (0.6% in both groups, P > .99) or stroke rates (0.6% vs 1.2%, P = .562).

Conclusions: In adults undergoing cardiac surgery, standardized pharmacosurgical prophylaxis including posterior pericardiotomy and low-dose amiodarone was associated with significantly lower incidence of POAF.