Partial Cardiac Denervation to Prevent Postoperative Atrial Fibrillation After Coronary Artery Bypass Grafting - pCAD-POAF

Nov 27, 2024
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Author/Summarized by Author:
Amit Saha, MD
Summary Reviewer:
Anthony A. Bavry, MD,MPH,FACC
Trial Sponsor:
National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, and Chinese Academy of Medical Sciences
Date Published:
11/17/2024
Original Posted Date:
11/27/2024
References

Contribution To Literature:

The pCAD-POAF trial showed that in patients undergoing isolated CABG, intraoperative partial cardiac denervation reduced the incidence of postoperative AF by almost 50% without increased morbidity or mortality.

Description:

The goal of the trial was to determine the efficacy and safety of partial cardiac denervation to reduce the risk of postoperative atrial fibrillation (POAF) following coronary artery bypass grafting (CABG).

Study Design

  • Single-center
  • Randomized
  • Single-blind

Patients undergoing CABG with no history of AF were randomized in a 1:1 fashion to undergo intraoperative partial cardiac denervation (n = 215) or CABG only (n = 215). Partial cardiac denervation was performed by complete excision of the ligament of Marshall and the epicardial fat pad along Waterston’s groove, both of which contain autonomic nerves and ganglia. POAF was defined as supraventricular tachycardia lasting >30 seconds on continuous telemetry or 12-lead electrocardiogram within 6 days postoperatively.

  • Total number of enrollees: 430
  • Duration of follow-up: 30 days
  • Mean patient age: 62 years
  • Percentage female: 18%

Inclusion criteria:

  • Age ≥18 years
  • Isolated, elective CABG surgery on or off cardiopulmonary bypass (CPB)

Exclusion criteria:

  • Emergent surgery
  • Any prior cardiac surgery
  • Additional concurrent cardiac surgery with CABG (e.g., valvular or aortic surgery)
  • History of AF
  • Preoperative vasoactive or mechanical support
  • Any antiarrhythmic except beta-blockers ≤2 weeks prior

Other salient features/characteristics:

  • Prior myocardial infarction (MI): 40%
  • Prior stroke: 17%
  • Median left ventricular ejection fraction (LVEF): 63%
  • Median left atrial diameter: 36 mm
  • Preoperative beta-blocker use: 87%
  • On-pump CABG: 41%

Principal Findings:

The primary outcome, POAF incidence at 6 days, for CABG plus partial cardiac denervation vs. CABG only, was: 18.1% vs. 31.6% (risk ratio 0.57, 95% confidence interval 0.41-0.81, p = 0.001).

Secondary outcomes for CABG plus partial cardiac denervation vs. CABG only:

  • Perioperative blood transfusion: 15.4% vs. 20.5%, p = 0.17
  • Mean postoperative hospital length of stay (LOS): 6.8 vs. 7.3 days, p = 0.09
  • Median hospital-associated cost: $3,909.20 vs. $4,052.90 (USD), p = 0.05
  • Delayed pericardial effusion at 30 days: 0.5% vs. 0.9%, p > 0.99
  • Composite of stroke, MI, coronary revascularization, and all-cause mortality at 30 days: 0.5% vs. 0.5%, p > 0.99

Intraoperative characteristics for CABG plus partial cardiac denervation vs. CABG only:

  • CPB time: 102 vs. 107 minutes
  • Aortic cross-clamp time: 73 vs. 73 minutes
  • Total operative time: 228 vs. 234 minutes

Interpretation:

Several prior studies have demonstrated mixed efficacy of perioperative intervention on the atrial epicardial fat pads during cardiac surgery to prevent POAF. pCAD-POAF is the largest such study to date and demonstrated a substantial reduction in POAF following isolated CABG. Whereas various techniques including injection of calcium chloride or botulinum toxin have been described, surgical excision in the current trial was not only effective but also simple to learn and resulted in no difference in CPB, cross-clamp, or total operative time. No subgroup interactions were observed after stratifying by risk factors for POAF, including increased age, CPB use, depressed preoperative LVEF, or increased left atrial size.

Although there were no adverse safety signals with positive trends in LOS and hospital-associated costs, the long-term effects of partial cardiac denervation, especially future AF and stroke risk, deserve further study. Replication in multicenter cohorts and in other cardiac surgeries is also necessary to confirm the generalizability of these promising findings.

References:

Yang Z, Tiemuerniyazi X, Xu F, et al. Partial Cardiac Denervation to Prevent Postoperative Atrial Fibrillation After Coronary Artery Bypass Grafting: The pCAD-POAF Randomized Clinical Trial. JAMA Cardiol 2024;Nov 17:[Epublished].

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias

Keywords: Atrial Fibrillation, Coronary Artery Bypass, Denervation


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