الفهرس 
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Abstract
A lot of factors can alter the outcome of adult cardiac surgeries, many of them relate to the preoperative morbidities of the patients, nature of the pathological condition necessitating surgery, type of surgery the patient will undergo, and surgical and post-surgical complications. Despite its importance, the position of the mediastinal and chest tubes in cardiac surgery is seldomly regarded by most surgeons as an important step to improve the outcome of cardiac surgery. Positioning a posterior tube behind the heart or performing a posterior pericardiotomy helps to efficiently drain the pericardial space after cardiac surgery. Thus, lowering the incidence of postoperative pericardial effusion and its sequalae. Pericardial effusion after cardiac surgery is a common complication reaching up to more than 60% of patients after surgery. The mechanisms behind it are multifactorial and not all of them are completely understood. Postoperative bleeding, the use of anticoagulation after surgery, postpericardiotomy syndrome and the use of a single tube for drainage are among the many reasons that lie behind developing a pericardial effusion. Although a small pericardial effusion is considered self-limited, it may progress and increase in size to be significant. Significant pericardial effusion can lead to very serious and potentially lethal complications. One of these complications is the development of cardiac tamponade which carries fatal outcome if untreated necessitating re-intervention. Another complication of the postoperative pericardial effusion is supraventricular tachyarrhythmia. Postoperative atrial fibrillation (POAF) is considered the most common tachyarrhythmia after cardiac surgery. The incidence of POAF is increasing because of the older ages of cardiac patients. Most studies put the range of the incidence of POAF around 30%. POAF is linked to the development of very serious complications in the postoperative period including stroke, hemodynamic instability, progressing to fatal arrhythmias like ventricular tachycardia and fibrillation, increasing the length of ICU stay and hospital stay, and increasing the overall cost of treatment. The idea of posterior pericardial drainage whether through a posterior pericardial tube or via performing a posterior pericardiotomy incision in cardiac surgery was advised to not only lower the incidence of postoperative pericardial effusion and tamponading but also lowering the incidence of POAF significantly. Although posterior pericardiotomy is not considered a conventional part in cardiac surgery and some surgeons are reluctant to employ it, it is considered a safe, effective and easy to perform procedure to help improve the outcome of the cardiac patient. The aim of this study: - This study aims to evaluate the effects of the position of mediastinal and pleural drains on patients’ outcome in adult cardiac surgery. Patients and methods: This is a prospective randomized study of 148 patients who underwent elective adult cardiac surgery for valve replacement, coronary artery bypass grafting or combined procedures during the period from July 2019 to July 2020. In this study, patients were randomly divided into three groups: - • group I: This group contained 50 patients that were subjected to insertion of two retro-sternal drains in the anterior mediastinum only, with or without a pleural drain if the pleura is opened. No posterior pericardial drainage was offered for this group. • group II: This group included 50 patients in which one retro-sternal drain was inserted in the anterior mediastinum size and another smaller posterior drain behind the heart with or without pleural drain if the pleura is opened. • group III: This group contained 48 Patients and they were subjected to insertion of one retro-sternal drain plus posterior pericardiotomy incision with a left pleural chest tube, posterior pericardiotomy was performed as a longitudinal, 4-cm long incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm. Patients were excluded from our study if they met the exclusion criteria including Redo cases, intraoperative mortality, emergency cases, pediatric cases, patients with renal failure, patients with dysrhythmias, patients needing posterior descending artery grafting, patients with pericardial or pleural diseases, off-pump bypass surgery and patient’s refusal to join the study. All patients had been subjected to preoperative evaluation including the analysis of full history taking, full clinical examination, routine laboratory investigation, coronary angiography in CABG patients in patients with valve lesions if they exceed forty years old, echocardiography, chest X-rays, abdominopelvic ultrasonography. In addition to carotid duplex, venous duplex on the lower limb, thallium scan of the heart, and multi-slice CT angiography to the coronary vessel when needed. Post-operative follow-up of the patient was done with a special concern about continuous ECG monitoring for the early post-operative days, follow up of the amount and characteristics of the tube’s drainage. Echocardiography was performed to detect the presence of pericardial effusion and to detect the amount of the effusion if present. It was performed in the early days after surgery and also performed in the second week or before the discharge of the patient. Numeric Rating Scale (NRS-11) was used for the follow-up of postoperative pain, it is a self-reporting scale for pain where the patient expressed his or her pain on an 11-point scale. Chest X-ray was also performed daily until the removal of the tubes. Results: - - Demographic data: There were no statically significant differences between both groups as regard clinical and demographic data. - The incidence of postoperative pericardial effusion: - The total incidence of early pericardial effusion (occurring in the first postoperative week) was 44.6%. The incidence in group I was 64% of the group’s population, 44% of group II had an early pericardial effusion and only 25% of group III developed an early effusion. The difference between the groups was statistically significant with the lowest incidence of early pericardial effusion in group III (the posterior pericardiotomy group) followed by group II (the posterior retrocardiac tube group). The total incidence of late pericardial effusion (occurring in the second postoperative week) was 33.8%. The incidence was higher in group I and lowest in group III. The incidence in group I was 56%, in group II was 24% and was 20.8% of group III. This difference between the groups was statistically significant with a lower number of patients developing late effusion in groups II and III (the posterior drainage groups). It is also worthwhile noting that the incidence of posterior early and late pericardial effusion was lowest in the posterior drainage groups (groups II and III) and highest in group I with a statistically significant difference. - The incidence of postoperative cardiac tamponade: - Our study had an incidence of 5.4% (a total of 8 cases) for cardiac tamponade. group I had 6 cases, group II had 2 cases and there were no cases with postoperative tamponade in group III. The difference between the groups regarding tamponade was statistically significant. - The incidence of POAF: - In group I, 22 patients (44% of the group) developed POAF. 9 cases of group II (18%) developed POAF and 8 cases of group III (16.7) developed POAF. The total incidence of POAF in our study was 26.4% (a total of 39 cases) The difference between the groups regarding the incidence of POAF was statistically significant with lower incidence in the posterior pericardiotomy group (group III) followed by the posterior tube group (group II). It was also noted that patients with pericardial effusion had a higher tendency to develop POAF. 64.1% of patients with POAF had an early postoperative pericardial effusion. - Postoperative ICU and total hospital stay: - Patients in group I spent longer hours on average in the ICU with 58% of the group population spending more than 48 hours in the ICU. Compared to group II where 30% of the group spent more than 48 hours in the ICU. group III had 25% of its patients spending more than 48 hours in the ICU. This difference was statistically significant with the lowest incidence of patients spending more than 48 hours in the ICU in the posterior pericardiotomy group followed by the posterior tube group. Regarding hospital stay, the mean stay for patients in group I was 12.4 days, it was 9.26 days for group II and 10.5 days for patients in group III. The difference between the groups was statistically significant with patients in the posterior pericardial drainage groups (groups II and III) spending less time overall in the hospital. - 4 patients in group III (8.3% of the group) had a recollection of left-sided pleural effusion that was successfully treated by chest tube reinsertion and these patients didn’t suffer from any further complications. No reintervention for pleural effusion was present in groups I or II. This represented a statistically significant difference between the groups. - No reported cases of phrenic nerve injuries were found in our study population.