Posterior Pericardiotomy in MIDCAB Surgery: Surgical Technique and Initial Clinical Experiences

Background: Postoperative atrial fibrillation (POAF) is the most common arrhythmia after CABG. Posterior pericardiotomy (PoP) has been reported to reduce the incidence of POAF after open heart surgery. We therefore developed a technique for PoP in the setting of MIDCAB surgery. Here we describe our technique and report our first clinical results regarding feasibility, safety, and efficacy of the procedure.

Methods: MIDCAB procedure was conducted in a standard manner via left minithoracotomy. To access the heart and carry out the anastomoses a horizontal anterior pericardiotomy was performed. After completion of the anastomoses, the lateral pericardial border was fixed with forceps and pulled upwards. A pair of forceps with a swab at the tip, inserted between the left ventricle and the pericardium, was pushed downwards and laterally. A 4-cm horizontal incision could now be made with a cautery at the exposed posterior pericardium safely, avoiding harm to phrenic nerve and ventricle. A pleural drainage was placed in the left pleural cavity. In-hospital records of 56 patients with MIDCAB surgery between 08/2023 and 08/2024 were reviewed. After excluding patients with preoperative AF, 42 patients were included. Preoperative and intraoperative data were analyzed. The incidence of POAF, the amount of pericardial effusion (PE), and the length of ICU and hospital stay were calculated.

Results: MIDCAB with PoP was performed in 19/42 patients (PoP-MIDCAB). The median (range) age (years) was 62 (39–85) and 68 (53–86) and the mean BMI (kg/m²) was 29 ± 4 and 30 ± 6 in PoP-MIDCAB and MIDCAB, respectively. Mean surgery time (min) was 204 ± 44 and 219 ± 61 in PoP-MIDCAB and MIDCAB, respectively. Median (range) number of grafts was one (1–3) in both groups. No incidence of conversion to CPB/sternotomy, reexploration, or in-hospital death occurred in both groups. Mean ICU stay (hours) was 26 ± 32 and 24 ± 8 and median total hospital stay (days) was 9 (6–21) and 8 (5–16) in PoP-MIDCAB and MIDCAB, respectively. The amount of PE was significantly lower in PoP-MIDCAB compared with MIDCAB (4 ± 3 mm versus 8 ± 6 mm; p = 0.016). The incidence of POAF was higher in the MIDCAB group compared with PoP-MIDCAB (3 versus 1 patient; p = 0.614), but the difference was not significant.

Conclusion: Our technique of PoP in the setting of MIDCAB surgery is a feasible and safe procedure. Furthermore, it has the potential to significantly reduce the amount of PE. It may also lead to lower incidences of POAF. We therefore recommend that this approach be adopted for MICS-CABG (MIDCAB and TCRAT) procedures.

Publication History

Article published online:
11 February 2025