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* From Trakya University Medical Faculty, Departments of Cardiovascular Surgery (Drs. Ege, Canbaz, Cikirikcioglu, Sunar, Ozalp, and Duran) and Cardiology (Dr. Tatli), Edirne, Turkey.
Correspondence to: Turan Ege, MD, Trakya University Medicine Faculty, Department of Cardiovascular Surgery, 22030 Edirne, Turkey; e-mail: turanege{at}ttnet.net.tr
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Abstract |
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Materials and methods: Patients undergoing coronary artery bypass grafting were randomized into two groups. At the end of the intervention, an intrapericardial and infracardiac Blake drain was placed in patients in group 1 (n = 97), and an intrapericardial and infracardiac semirigid drain was placed in patients in group 2 (n = 105). In addition, a semirigid drain was placed into mediastinum in all cases. The amount of drainage was calculated at six different time points postoperatively: postoperative 0 to 2 h, postoperative 2 to 4 h, postoperative 4 to 6 h, postoperative 6 to 12 h, postoperative 12 to 24 h, and postoperative 24 to 48 h. The amount of pericardial effusion was estimated by transthoracic echocardiography after the drains were removed.
Results: In all measurements, the amount of drainage from intrapericardial Blake drains was higher, the total amount of drainage being equal to 330.7 ± 29.4 mL and 193.2 ± 19.6 mL in the Blake drain and semirigid drain groups, respectively (p = 0.000) [mean ± SD]. When the drains were removed, the volume of pericardial effusion was 3.86 ± 0.76 mm in Blake drain group and 7.59 ± 1.16 mm in semirigid drain group (p = 0.000). The incidence of postoperative atrial fibrillation was 11.3% in the group with Blake drains, and 23.8% in the group with semirigid drains (p = 0.016).
Conclusion: The more effective drainage obtained with infracardiac Blake drains compared to semirigid drains helps to reduce the amount of postoperative pericardial effusion and the risk of atrial fibrillation.
Key Words: atrial fibrillation • Blake drain • pericardial effusion
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Introduction |
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Other complications arising from cardiac tamponade or pericardial effusion are more prevalent in cases with ineffective postoperative drainage. Among them, atrial fibrillation is an important complication resulting in increased risk of morbidity and mortality, and several surgical techniques have been proposed to avoid from this condition.345 In this study, our aim was to compare the effects of two different drains placed into pericardial sac on the amount of postoperative pericardial effusion.
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Materials and Methods |
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The exclusion criteria were as follows: emergency surgery, vascular surgery, repair for congenital cardiac defect, open of pleural cavity, hyperthyroidism, chronic obstructive pulmonary diseases, preoperative atrial fibrillation, and preoperative use of beta-blockers. In our practice, aspirin, clopidogrel, ticlopidin, and glycoprotein IIb-IIIa inhibitors are discontinued 7 to 10 days prior to an elective CABG procedure.
The study was approved by the ethics committee of our institution, and written informed consent was obtained from patients. Roller pump (Sarns 9000), disposable membrane oxygenators (adult fiber oxygenator; Dideco; Mirandola, Italy), moderate hemodilution (hematocrit value 22 to 24%), and moderate hypothermia (27 to 29°C core temperature) were used for CPB. Anticoagulation was done by heparin (300 IU/kg; Liquemine; Roche; Basel, Switzerland); activated clotting time (ACT) was kept > 480 s, and to maintain this level additional doses were administered when necessary. All operations were performed under CPB, which was established via the cannulation of ascending aorta and right atrium (two-stage cannula). Myocardial protection was provided by antegrade cold hyperkalemic crystalloid cardioplegic solution (Plegisol; Abbott Laboratories; Chicago, IL) [10 mL/kg], and it was repeated at every 20 min. Neutralization of heparin was done by protamine hydrochloride (Protamine 1000; Roche) with a ratio of 1:1.2. Left internal mammary artery was used for arterial grafting in all cases.
The amount of drainage was calculated at six different time points postoperatively: postoperative 0 to 2 h, postoperative 2 to 4 h, postoperative 4 to 6 h, postoperative 6 to 12 h, postoperative 12 to 24 h, and postoperative 24 to 48 h. The ACT value was measured at four different time points (at the end of surgery, postoperative 1 h, postoperative 2 h, and postoperative 4 h) due to the possibility of bleeding resulting from heparin redistribution in the early postoperative period. In our clinic, re-operation is the routine practice in patients with a bleeding volume > 200 mL/h during the last 4 h. The drains with < 20 mL of drainage within last 4 h were removed.
To check for satisfactory drainage, the amount of pericardial effusion was measured by transthoracic echocardiography immediately after the drain was removed (within 10 min). Echocardiographic examinations were performed at supine position by using a commercially available diagnostic system (Sonos 2500; Hewlett-Packard; Andover, MA) equipped with 2.5- to 3.5-MHz transducers. Pericardial fluid was quantified on two-dimensional images of parasternal and apical echocardiographic windows; the maximum width of the echo-free space around the heart at end-diastolic frame was accepted as the measurement reflecting the amount of pericardial effusion.
The patients were continuously monitored by six-lead ECG for 3 days in the ICU. After the patients were transferred to the ward, body temperature, heart rate, and arterial BP were checked every 2 h during the first 2 days, and every 4 h thereafter. If arrhythmia was observed, atrial fibrillation was verified by 12-lead ECG.
Statistical Analysis
The data were expressed as the mean ± SD. The data at different time points were analyzed with variance analysis of repeated measures. Independent-samples t test was used for between-group comparisons. Q-square test was used to compare categorical variables in groups. All analyses were performed using SPSS software for Windows (SPSS; Chicago, IL), and differences were considered statistically significant at a probability level of < 0.05.
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Discussion |
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In our study, Blake drains were used postoperatively to reduce the amount of residual fluid in the pericardial sac. A Blake drain is a round-shaped, flexible, silicon drain with multiple canals. The noncollapsible elongated canals within the drain confer resistance to occlusion due to thrombus formation, and therefore this type drain can maintain its functions for prolonged periods.12 Obney et al1 and Lancey et al2 describe beneficial effects of Blake drains used postoperatively. When Blake drains are used, the patients experience less pain and, as a result, the impairment in respiratory function can be avoided.12 Another desired feature of a drain to be placed into pericardial sac after CABG is the absence of pressure effect on grafts. Blake drains, with their smaller diameters, give confidence to the surgeon with this respect.
Echocardiography is a commonly used and quantitative diagnostic technique for assessing the postoperative pericardial effusion, and thus it has been preferred for this study. In previous studies,345789 the assessment of the amount of pericardial effusion were performed at different time points. The aim of our study was to evaluate the residual fluid in the pericardial sac when the drains were removed and consequently echocardiography was performed immediately after drain removal.
Atrial fibrillation may result in irritability symptoms, heart failure, and thromboembolic complications, and thus necessitates urgent treatment to decrease morbidity and mortality.101112 Although reversal of arrhythmia is important, prevention of atrial fibrillation should be the main focus of attention. Although the reported incidence for atrial fibrillation following CABG is between 10% and 40%, certain factors including age, male gender, preoperative discontinuation of beta-blockers, postoperative fluid and electrolyte balance, and sympathetic activation may influence the development of atrial fibrillation.91314151617 In our department, an incidence of atrial fibrillation following CABG was 18.9% in a retrospective analysis18; in the present study, the incidence was 11.3% in Blake drain group. The decreased amount of pericardial effusion in the Blake drain group may play an important role in this significant reduction in the incidence of atrial fibrillation. In addition, in both groups the patients with atrial fibrillation had higher amounts of fluid in their pericardial sacs, indicating the association between pericardial effusion and atrial fibrillation.
The postoperative incidence of cardiac tamponade is between 0.1% and 6.0%.13 While an incidence of 1.7% was reported for cases with standard drains,2 the frequency of tamponade in the semirigid drain group in this study was 5.7%. The amount of active bleeding, as well as the efficiency of the drain are important factors for the development of cardiac tamponade, since the progression of the tamponade will be accelerated when the clots formed in the drain obstruct the drainage of fluids. In our series, no patients in the Blake drain group had tamponade, whereas the incidence of tamponade was high in the other group, which suggests that the type of drain used is important.
The most important drawback of Blake drains is that their cost is approximately six times higher compared to semirigid drains. However, the decreased risk of postoperative tamponade and atrial fibrillation should probably offset this disadvantage.
The limitations of the present study are the unblinded design and absence of echocardiographic assessment at the late postoperative period. In conclusion, in cardiac surgery infracardiac Blake drains provide more effective postoperative drainage compared to semirigid drains, thus decreasing the amount of pericardial effusion and the risk of atrial fibrillation.
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Footnotes |
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Received for publication October 16, 2003. Accepted for publication June 21, 2004.
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This article has been cited by other articles:
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  N. Roberts, M. Boehm, M. Bates, P. C. Braidley, G. J. Cooper, and T. J. Spyt Two-center prospective randomized controlled trial of Blake versus Portex drains after cardiac surgery. J. Thorac. Cardiovasc. Surg., November 1, 2006; 132(5): 1042 - 1046. [Abstract] [Full Text] [PDF]
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