Tricuspid valve surgery in implantable cardiac electronic device-related endocarditis: Repair or replace?

BACKGROUND: The aim of this study was to investigate lead endocarditis-related tricuspid valve regurgitation, to identify underlying causes, and to report our surgical approaches to tricuspid valve endocarditis. METHODS: Between March 2010 and August 2016, medical records of a total of 43 patients (23 males, 20 females; mean age: 63.2±13.6 years; range 48 to 72 years) who underwent tricuspid valve surgery for severe tricuspid regurgitation caused by lead endocarditis, which was previously placed as an implantable cardiac electronic device were reviewed. We removed all systems including infected leads and generators, revised infected wounds and tissues, performed tricuspid valve surgery for lead endocarditis, and applied long-term intravenous antibiotic regimen for the culprit agent, as confirmed by the culture. RESULTS: Of 43 patients, 18 underwent tricuspid valve repair and 25 underwent tricuspid valve replacement for lead endocarditisrelated severe tricuspid valve regurgitation. During followup (range, 2 to 62 months), two patients required temporary mechanical support due to postoperative acute right heart failure, while eight patients died due to sepsis (n=6; 14%) and stroke (n=2; 4.6%) in the early postoperative period. The remaining patients showed significant improvement in signs and symptoms of heart failure. CONCLUSION: Our study results suggest that incompetent experience and inaccurate decision for valve repair may result in delayed valve replacement and prolonged operation time.

Comparison of aortic cross-clamping versus beating heart surgery in tricuspid valve repair.

BACKGROUND: The aim of this study was to evaluate the clinical outcomes of tricuspid valve repair using aortic cross-clamping versus using beating heart surgery. METHODS: A total of 208 patients (67 males, 141 females; mean age 61.5±9.2 years; range, 29 to 81 years) who underwent concomitant cardiac surgery and tricuspid valve repair between January 2007 and January 2016 at a single center were included. Two surgical strategies for tricuspid valve repair with aortic cross-clamping (n=102) or on beating heart (n=106) were compared. Primary endpoints were in-hospital mortality and the rate of permanent pacemaker placement after surgery. Secondary endpoints were cross-clamp and cardiopulmonary bypass times, postoperative inotropic support, temporary pacemaker requirement, and residual tricuspid regurgitation at discharge and at one year. RESULTS: Overall hospital mortality was 7% (n=14) (cross-clamping 7% vs. beating heart 7%; p>0.05). The mean cross-clamp and cardiopulmonary bypass times were significantly longer in the aortic cross-clamping group (p=0.0001). Also, a higher number of patients in this group needed inotropic support (78/102) than the beating heart group (57/106) (p<0.05). The rate of postoperative left bundle branch block was higher in the cross-clamping group (14% vs. 5%, respectively; p<0.05). The rate of permanent pacemaker placement was also significantly higher in the cross-clamping group than the beating heart group (11.8% vs. 2.8%, respectively; p<0.05). At discharge, residual >2 tricuspid regurgitation was more commonly seen in the cross-clamping group (16% vs. 3%, respectively; p=0.0023). At one year of follow-up, residual >2 tricuspid regurgitation was present in 22 patients (23%) in the aortic crossclamping group and in eight patients (8%) in the beating heart group (p=0.0048). CONCLUSION: Tricuspid valve repair on beating heart offers less inotropic support and a lower rate of postoperative permanent pacemaker placement requirement and residual tricuspid regurgitation, although both techniques yield similar postoperative clinical outcomes. These results support the use of tricuspid valve repair on a beating heart in concomitant left-sided valvular heart surgery.

Effects of Preoperative Tricuspid Valve Diameters on Early Postoperative Surgical Outcomes in Patients Undergoing Tricuspid Valve Surgery.

BACKGROUND: Many of the previous studies on tricuspid valve surgery were on the materials that were used and the advantages and disadvantages of them. In this study, effects of preoperative tricuspid valve diameter on early postoperative outcomes were investigated. Methods: A total of 43 patients who underwent tricuspid valve repair surgery with the ring between the years 2012-2014 were included in this study. Tricuspid valve diameters and other cardiac functions of patients undergoing tricuspid intervention were evaluated with transthoracic echocardiography.Patients included in this study were divided into 2 groups: those with minimal, minimal-to-1st degree and 1st-degree tricuspid valve regurgitation found on thoracic echocardiography in the early postoperative period were considered as having a successful tricuspid repair (Group 1). Those with 1st-2nd degree and higher degrees of tricuspid regurgitation were considered as having an unsuccessful tricuspid repair (Group 2).The relationship between tricuspid valve dimensions and early tricuspid valve regurgitation was assessed with the help of preoperative, intraoperative, and postoperative data. RESULTS: Thirty patients (Group 1) were found to have a successful tricuspid valve repair in the postoperative period. The mean annulus diameter of the tricuspid valve at end-diastole in patients from Group 1 was similar to Group 2 (4.24 ± 0.44 cm versus 3.99 ± 0.40; P = .080). Also, tricuspid valve end-systolic diameter in Group 1 was similar to patients in Group 2 (3.59 ± 0.38 cm versus 3.42 ± 0.33 cm; P = .151). Conclusion: A direct relationship was not found between tricuspid valve diameter and post-operative development of moderate to severe regurgitation in tricuspid valve surgery in this study.

A Retrospective Analysis of Surgical Femoral Artery Closure Techniques: Conventional versus Purse Suture Technique.

BACKGROUND: Different techniques have been reported for the exploration and repair of femoral artery (FA) in patients who undergo minimally invasive cardiac surgery (MICS) and endovascular aortic surgery. We used a modified approach alternative to the conventional technique (group CT) since May 2013, which specifies a shorter groin incision and diamond-shaped hemostatic purse sutures for arteriotomy closure without the requirement of cross-clamping (group PT [purse suture technique]) and evaluated early outcomes and the complication profiles of the 2 techniques for femoral access. METHODS: In our clinic, between May 2011 and December 2015, 503 FA cannulations were performed on 345 patients who underwent MICS (n = 109, mean age 64.1 ± 17.6 years, female/male ratio 71/38), endovascular abdominal aneurysm repair (n = 158, mean age 71.3 ± 10.2 years, female/male ratio 63/95), thoracal endovascular aneurysm repair (n = 50, mean age 65.0 ± 15.3 years, female/male ratio 15/35), and transaortic valve implantation (n = 28, mean age 80.8 ± 5.9 years, female/male ratio 13/15). A total of 295 FAs were exposed via mini incision and were repaired with the PT. We compared the duration of femoral closure (FC), wound infection, and vascular complications including bleeding hematoma, thromboembolic and ischemic events, pseudoaneurysm, seroma, surgical reintervention rates, delayed hospital stay for groin complications, and existence of postoperative local luminal narrowing (LLN) at the intervention site over 25% for both groups. RESULTS: FC time (CT 14.9 ± 3.16 min, PT 6.5 ± 1.12 min, P < 0.0001), bleeding hematoma frequency (CT 6.2%, PT 1.7%, P = 0.01), and prolonged hospital stay for groin complications (CT 14.9%, PT 3.4%, P < 0.0001) were significantly lower in the PT group. Rate of technical success (CT 80.3%, PT 87.4%, P = 0.03) and event-free patient (CT 66.1%, PT 77.5%, P = 0.03) were significantly better in the PT group. There were no differences between groups in terms of ischemic events, wound infection rates, development of pseudoaneurysm and seroma, surgical reintervention rates, and LLN of FA over 25% at 6-month duplex evaluation. CONCLUSIONS: The comparison of the 2 approaches revealed the advantages of the PT in terms of bleeding hematoma and shortening in FC time and the length of hospital stay. We suggest performing a smaller skin incision for FA access and utilizing purse sutures, which allows completing the procedure without cross-clamping, thus providing a favorable approach and excellent comfort for the surgeon.

Primary Left Cardiac Angiosarcoma with Mitral Valve Involvement Accompanying Coronary Artery Disease.

We report here on a 43-year-old female patient presenting with non-ST elevation myocardial infarction, severe mitral regurgitation, and mild mitral stenosis secondary to encroachment of the related structures by a primary cardiac angiosarcoma. A coronary angiography revealed significant stenosis in the left main and left circumflex arteries and at exploration, the tumour was arising from posterior left atrial free wall, invading the posterior mitral leaflet, and extending into all of the pulmonary veins and pericardium. Therefore, no further intervention was performed, except for left internal mammarian artery to left anterior descending artery anastomosis and biopsy. As far as we know, this case is unique with respect to its presentation.

A Rare Cause of Acute Abdomen: Perforation of Double Meckel's Diverticulum.

Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract. In this report, we aimed to represent a case of intestinal perforation, caused by double Meckel's diverticulum, which is a very rare entity in surgical practice. The patient was a 20-year-old Caucasian man, admitted to hospital with complaints of abdominal pain, nausea, and vomitting during the last 3 days. Physical examination indicated tenderness, rebound, and guarding in the right lower quadrant of abdomen. Abdominal X-ray revealed a few air-liquid levels in the left upper quadrant. In the operation, 2 Meckel's diverticula were observed, one at the antimesenteric side, at 70 cm distance to the ileocecal valve, approximately in 3 cm size, and the other between the mesenteric and antimesenteric sides, approximately in 5 cm size. The first one had been perforated at the tip and wrapped with omentum. A 30 cm ileal resection, including both diverticula with end-to-end anastomosis, was performed. The diagnosis of symptomatic Meckel's diverticulum is considerably hard, especially when it is complicated. Diverticulectomy or segmentary resections are therapeutic options. In patients with acute abdomen clinic, Meckel's diverticulum and its complications should be kept in mind, and the intestines should be observed for an extra diverticulum for caution although it is a very rare condition.

Improvement of functional recovery of donor heart following cold static storage with doxycycline cardioplegia.

Injury to the donor heart during cold preservation has a negative impact on graft survival before transplantation. This study aims to examine whether doxycycline, known as an MMP-2 inhibitor, has a positive effect on donor heart preservation via its antioxidant action when added to standard preservation solution. Hearts were obtained from 3-month-old male Wistar rats and randomly divided into three groups: hearts stored for 1 h at 4 °C (1) with doxycycline preservation solution (DOX cardioplegia) with low Ca(2+); (2) with standard cardioplegia with low Ca(2+); and (3) unstored hearts. All hearts were perfused in working mode, arrested at 37 °C, removed from the perfusion system, reattached in Langendorff perfusion system, and converted to working mode for 1 h. At the end of the storage period, hearts preserved in DOX cardioplegia had significantly less weight gain than those preserved in the standard cardioplegia. DOX cardioplegia-induced preservation resulted in significantly higher heart rates and better recovery quality during reperfusion in aortic flow compared to the standard cardioplegia group. Recovery in the left ventricular function and Lambeth Convention Arrhythmia scores during 1 h reperfusion were also significantly better in the DOX cardioplegia group. Biochemical data showed that DOX cardioplegia prevented an increase in MMP-2 activity and blocked apoptosis through increased activity of the pro-survival kinase Akt in the donor heart homogenates. DOX cardioplegia also led to a balanced oxidant/antioxidant level in the heart homogenates. This is the first study to report that cardioplegia solution containing doxycycline provides better cardioprotection via the preservation of heart function, through its role in controlling cellular redox status during static cold storage.

The efficacies of modified mechanical post conditioning on myocardial protection for patients undergoing coronary artery bypass grafting.

BACKGROUND: Coronary artery bypass grafting (CABG) with cardioplegic cardiac arrest and cardiopulmonary bypass (CPB) is associated with myocardial injury. The aim of this study was to investigate whether a modified mechanical post-conditioning (MMPOC) technique has a myocardial protective effect by enhancing early metabolic recovery of the heart following revascularization. METHODS: A prospective, randomized trial was conducted at a single-center university hospital performing adult cardiac surgery. Seventy-nine adult patients undergoing first-time elective isolated multivessel coronary artery bypass grafting were prospectively randomized to MMPOC or control group. Anesthetic, cardiopulmonary bypass, myocardial protection, and surgical techniques were standardized. The post reperfusion cardiac indices, inotrope use and biochemical-electrocardiographic evidence of myocardial injury were recorded. The incidence of postoperative complications was recorded prospectively. RESULTS: Operative characteristics, including CPB and aortic cross-clamp time, were similar between the two groups (p>0.05). The MMPOC group had lower troponin I and other cardiac biomarkers level post CPB and postoperatively, with greater improvement in cardiac indices (p<0.001). MMPOC shortened post surgery hospitalization from 9.1 ± 2.1 to 7.5 ± 1.6 days (p<0.001). CONCLUSIONS: MMPOC technique promotes early metabolic recovery of the heart during elective CABG, leading to better myocardial protection and functional recovery.

Effects of prophylactic indomethacin treatment on postoperative pericardial effusion after aortic surgery.

OBJECTIVE: This prospective, randomized study assessed the prophylactic effects of indomethacin treatment on pericardial effusion after aortic surgery. METHODS: Eighty-five patients were found eligible to participate in this double-blind study. Patients were assigned to a control group receiving oral placebo or to an indomethacin group receiving 25 mg oral indomethacin 3 times daily for 7 days preoperatively. After aortic surgery, patients were followed up clinically and evaluated for pericardial effusion with transthoracic echocardiography on the first and seventh postoperative days during hospitalization and at the second and sixth weeks after discharge. RESULTS: The demographic and the operative data were similar between groups. The surgical interventions included Bentall procedure in 63 patients, valve-sparing procedures in 7 patients, and supracoronary ascending aorta replacement in 15 patients. Hemiarch replacement was performed in 16 patients. No patient in either group had pericardial effusion after the first postoperative day. At the end of the first week, however, 2 patients had pericardial effusion, at the end of the second week after discharge, 3 patients had pericardial effusion, and at the end of the sixth week after discharge, 4 patients had PEs. One of the patients who had PE at the end of the sixth week received indomethacin; the others were all in the control group, a significant difference (P=.019). Five patients underwent transthoracic echocardiographically guided pericardiocentesis; 4 underwent surgical pericardiocentesis. CONCLUSIONS: Indomethacin may have beneficial effects on the outcomes and incidence of postoperative pericardial effusion after aortic surgery.

Micronized purified flavonoid fraction in pretreating CABG patients.

The aim of the present study was to determine whether oral pretreatment with micronized purified flavonoid fraction (Daflon) has beneficial effects on cardiac function and outcome after cardiac operations. This prospective, randomized trial enrolled 43 patients who had an impaired preoperative left ventricular ejection fraction of less than 0.50 (mean, 0.45 +/- 0.04) and a mean New York Heart Association functional class status of 2.30 +/- 0.74; all were scheduled for elective coronary artery bypass grafting. Patients who were randomized to the Daflon group (n=21) received oral Daflon 500 mg (6 tablets daily for 4 days, followed by 2 tablets for 3 days) preoperatively. Outcome variables included perioperative hemodynamic data, inotropic requirements, morbidity, and death, as well as cardiac ischemia and various outcome markers. Hemodynamic and biochemical data were collected before induction of anesthesia, perioperatively before starting cardiopulmonary bypass, immediately after bypass, and at the 24th postoperative hour. There was only 1 death (in the Daflon group). During the post-cardiopulmonary bypass period, troponin I and lactate dehydrogenase levels were significantly lower in the Daflon group. Also, the New York Heart Association status of the patients in the Daflon group was significantly lower postoperatively. Differences between the 2 groups in lengths of stay in the intensive care unit and hospital, inotropic requirements, and left ventricular ejection fraction levels did not reach statistical significance. Orally administered Daflon might provide better outcomes for patients who have impaired cardiac function before undergoing cardiac operations that require cardiopulmonary bypass.

Native valve Brucella endocarditis.

OBJECTIVE: Brucellosis is frequently seen in Mediterranean and Middle East countries, including Turkey. We report the medical and surgical management of 31 cases of native endocarditis. MATERIAL AND METHOD: Thirty-one patients were admitted to our clinic with suspected Brucella Endocarditis. The diagnosis was established by either isolation of Brucella species, or the presence of antibodies. Following preoperative antibiotic therapy patients underwent valve replacement with excessive tissue debridement. Patients were followed up with Brucella titers, blood cultures, and echocardiography. RESULTS: On admission all patients were febrile and mostly dyspneic (NYHA Class 3 or 4). The blood tests were normal except for elevated ESR, CRP and serological tests. The aortic valve was involved in 19 patients, mitral valve in 7 patients, and both valves in 5. After serological confirmation of BE, antibiotic therapy was maintained. Twenty-five of the patients received rifampicine, doxycycline, and cotrimaxozole; 2 of them received a combination of rifampicine, streptomycin, and doxycycline; and 4 of them received rifampicine, tetracycline, and cotrimaxozole. Tissue loss in most of the affected leaflets and vegetations were presenting all patients. Valve replacements were performed with mechanical and biologic prostheses. All the patients were afebrile at discharge but received the antibiotics for 101, 2+/-16, 9 days. The follow-up was 37, 1+/-9, 2 months. DISCUSSION: In our retrospective study, combination of adequate medical and surgical therapy resulted in declined morbidity and mortality rate. The valve replacement with aggressive debridement is the most important part of the treatment, which should be supported with efficient preoperative and long term postoperative medical treatment.

Vacuum-assisted closure and bilateral pectoralis muscle flaps for different stages of mediastinitis after cardiac surgery.

PURPOSE: To assess the results of bilateral pectoralis major muscle flaps (BPMMF) and vacuum-assisted closure (VAC) at different stages of postcardiac surgery mediastinitis. METHODS: Of 65 patients with a deep sternal wound infection (DSWI) after cardiac surgery, 33 with a stable sternum were treated with VAC (59.3 +/- 11.7 years of age) and 32 with an unstable sternum or osteomyelitis (63.3 +/- 9.8 years of age) were treated with early BPMMF and continuous irrigation. Delayed BPMMF reconstruction was necessary in six VAC patients. RESULTS: The overall incidence of DSWI was 1.04% within the study period. Deep sternal wound infection was diagnosed 15.9 +/- 10.8 days (range 5-62 days) after surgery. Diabetes was more common in the BPMMF group than in the VAC group (P = 0.046). Hospital mortality after treatment was 4.6% (n = 3) overall. Causes of death were septic multiorgan failure and respiratory failure. The infective pathogens were methicillin-resistant Staphylococcus aureus (MRSA; n = 2) and Acinetobacter species (n = 1). The median hospital stay was 29 days (range 15-110 days). After 6 months, only one recurrent sternal infection had occurred in the VAC group. CONCLUSIONS: Early BPMMF is an effective surgical treatment for DSWI in patients with an unstable sternum and osteomyelitis. VAC may be considered for patients without osteomyelitis but a stable sternum, or as adjuvant therapy in patients with comorbidity.

Mid-segment harvesting of right internal thoracic artery decreases sternal ischemia.

OBJECTIVE: We aimed to preserve sternal vascularity better by harvesting only midsegment of the right internal thoracic artery (RITA) than using conventional bilateral internal thoracic artery (BITA) harvesting method, and we evaluated the sternal vascularity with single photon emission computed tomography (SPECT). METHODS: In this prospective clinical randomized investigation, 135 patients undergoing coronary artery bypass surgery (CABG) were divided into three groups: Full-RITA group who had a full length of both ITA as a graft for CABG (n=45); mid-RITA group - a midsegment of RITA and left internal thoracic artery (LITA) (n=45); and non-RITA group who had only LITA (n=45). Before and after surgery, all patients underwent a bone scan with single photon emission computed tomography (SPECT) to evaluate the sternal vascular activity. Comparisons of variables were performed by Chi-square, ANOVA, Tukey HSD and paired t test as appropriate. The Bonferroni correction was applied for multiple comparisons. RESULTS: Postoperative early scans (6.9+/- 0.9 days) showed a reduction of blood flow in the both sides of the sternum compared with the preoperative scans (p<0.001). In full-RITA group, there was no significant difference between left and right hemi-sternum (0.56+/- 0.04 and 0.55+/- 0.02 respectively). However, in mid-RITA and non-RITA groups, right hemi-sternum showed significantly better vascularity than left hemi-sternum in the early postoperative period (p<0.001). Three patients (6.6%) with diabetes mellitus in full-RITA group had sternal infection; one of them was deep sternal infection with dehiscence. In mid-RITA group, there was only two patients who had superficial infection (4.4%) and in non-RITA group there was no infection (p=0.234). CONCLUSION: Mid-RITA harvesting technique can be preferred to preserve sternal vascularity better than conventional technique. By improving new techniques and methods, more acceptable sternal complications could be achieved than full-RITA technique.

Multiple hydatid cystectomy of the heart necessitating LIMA to LAD anastomosis in a young patient.

Cardiac hydatid disease is very rare, even in endemic regions. Clinical manifestations included chest pain, anaphylactic shock, constrictive pericarditis, congestive heart failure, and arterial embolism. Surgery is the exclusive therapy, where the cysts are excised during open-heart surgery. The surgical approach therefore must be performed carefully, given the potential complications that surgery may bring. Because of the risk of potentially lethal complications, early diagnosis and definitive treatment are important. A 32-year-old male patient was admitted with chest pain, weight loss, lethargy, and dizziness. On the transesophageal echocardiography study, a cystic mass (2.5 x 3 x 4.5 cm in dimension adjacent to the left ventricular posterior wall) that was divided into two by a septum was noted. Diagnosis of hydatidosis was confirmed with serologic tests (ELISA and indirect immunofluorescence). Echinococcosis, also known as hydatid disease, is common in several regions of the world, for example, the Mediterranean countries, the Middle East, South America, and East Africa. While performing pericystectomy in the anterior left ventricular wall, we noticed that there were three cysts, contrary to the preoperative diagnosis pointing a single one, and it was impossible to effectively complete the procedure without compromising anterosuperiorly displaced left anterior descending artery (LAD). We decided to go on bypass, arrest the heart, and complete the pericystectomy at the cost of injuring LAD and grafting the left internal mammary artery to LAD. Microscopic examination of the cyst showed a germinal layer and an avascular, eosinophilic, chitinous layer that confirmed the diagnosis of hydatid cyst. The patient was discharged on the fifth postoperative day on albendazole medication.

Effects of carbamazepine on spinal cord ischemia.

BACKGROUND: Prophylactic treatment with carbamazepine has been shown to reduce the cerebral damage and neurologic deficit in ischemic conditions. A randomized controlled study based on a rabbit model was designed to study the effect of carbamazepine on a spinal cord ischemic reperfusion injury. METHODS: Thirty New Zealand rabbits were randomly assigned to 1 of the 2 groups (n = 15 per group): group I (control group) and group II (carbamazepine group). Spinal cord ischemia was induced by infrarenal aortic crossclamp for 25 minutes in both groups. Functional evaluation with the Tarlov score during a 2-day observation period and histopathologic assessment of the lumbar spinal cord were performed. Changes in spinal cord morphology were observed with hematoxylin-eosin staining and electron microscopy. Gray matter damage was assessed on the basis of the number of normal neurons in the ventral horn. RESULTS: Diffuse destruction of gray matter with moderate to severe vacuolization and essentially no normal ganglion cells was observed in the spinal cord of rabbits in the control group, whereas specimens of rabbits assigned to the carbamazepine group showed ganglion cells with normal nuclei and cytoplasm (P < .0001). Neurologic impairment was significantly attenuated in the carbamazepine group compared with the Tarlov scores of the control group (P < .0001 at day 2). CONCLUSION: Carbamazepine may protect the spinal cord from ischemic reperfusion injury that is associated with ameliorated neurologic and histopathologic results.

Coexistence of left-sided inferior vena cava, deep vein thrombosis of the upper and lower extremities and prothrombotic polymorphisms in a young patient: a case report.

A literature review suggests an interaction between an anomaly of the inferior vena cava and thrombophilia in the pathogenesis of deep vein thrombosis. Genetic thrombotic abnormalities have been found in some of the subjects having venous thromboembolic diseases. We report a case of a young man presenting with venous thrombosis of the upper and lower extremities, left-sided vena cava inferior and with combination of heterozygosity of the mutation of the genes Methylenetetrahydrofolate reductase 677 and Factor V 1691.

Report of the anatomic variation of the brachial artery in a patient undergoing transradial cardiac catheterization.

The arterial pattern of the upper limb is one of the systems that shows a large number of variations in the adult human body. Most of these variations occur in either the radial or ulnar artery; brachial artery variations are less common. In this case report we describe the anomaly in the formation of the brachial artery system. Appreciation of variations in the upper extremity vasculature is essential to prevent injury, particularly in patients undergoing arteriography.

Effect of posterior pericardial drainage on the incidence of pericardial effusion after ascending aortic surgery.

OBJECTIVE: Pericardial effusion and cardiac tamponade after ascending aortic surgery are higher than anticipated after cardiac surgery. We evaluated a thin closed-suction drain system to prevent posterior pericardial effusion in patients undergoing ascending aortic surgery. METHODS: One hundred forty patients who underwent ascending aortic surgery were prospectively randomized into group A and group B. In group A (n = 70) we used a 32F drain placed anteriorly overlying the heart and a 16F thin drain placed retrocardially. In group B (n = 70) only a 32F drain placed anteriorly was used. In group A we removed the large drain on the first postoperative day and continued drainage with the thin drain until the drainage was less than 50 mL in a 24-hour period. In group B we removed the drain after the first postoperative day when the drainage was less than 50 mL in an 8-hour period. Preoperative, perioperative, and postoperative parameters of the patients were compared. RESULTS: No significant posterior pericardial effusion and late cardiac tamponade developed in patients in group A. In group B 10 (14.3%) patients experienced significant posterior pericardial effusion and 4 (5.7%) patients experienced late cardiac tamponade; the incidence of significant pericardial effusion in group B was significantly higher (P = .001). Postoperative new-onset atrial fibrillation developed in 6 (10.4%) patients in group A and in 18 (32.7%) patients in group B (P = .03). CONCLUSIONS: We demonstrated that effective posterior drainage is important to prevent posterior pericardial effusion, and use of a thin drain placed retrocardially appears to be sufficient for these results.