Research Spotlight: Combining Surgery and Medication to Prevent Postoperative Atrial Fibrillation in Cardiac Surgery

Adham Makarem, MD, MPH, and Asishana A. Osho, MD, MPH, both of the Mass General Brigham Heart and Vascular Institute, are the lead and senior authors of a paper published in Annals of Thoracic Surgery, “Pericardiotomy and Amiodarone for Prophylaxis Against Postoperative Atrial Fibrillation in Cardiac Surgery (PAPPA).”

Q: How would you summarize your study for a lay audience?

Atrial fibrillation (AF) — an irregular heart rhythm — is one of the most frequent complications after open-heart surgery, affecting up to half of patients. It can lead to serious consequences like stroke, extended hospital stays, and the need for blood thinners.

In the Pericardiotomy and Amiodarone for Prophylaxis against Postoperative Atrial Fibrillation (PAPPA) trial, we tested a new approach to prevent AF by combining a minor surgical technique with a short course of medication. The surgical procedure, called posterior pericardiotomy, helps drain fluid from around the heart, reducing irritation that can trigger AF. At the same time, a low-dose, short-term regimen of amiodarone — a medication that helps maintain a steady heartbeat — offers additional protection.

We studied patients at Massachusetts General Hospital (MGH) who received this combined strategy and compared their outcomes to similar patients who did not. Our results suggest that this dual approach may significantly reduce the risk of developing AF after heart surgery.

Q: What question(s) were you investigating?

We aimed to determine whether pairing a minor surgical procedure with a short-term medication plan could help prevent AF following heart surgery. Specifically, we wanted to know if this dual method could reduce the risk of this common complication and improve patient outcomes compared to standard care.

Q: What methods or approach did you use?

The PAPPA trial was conducted at MGH and included adult patients who underwent coronary artery bypass grafting (CABG) between 2022 and 2024. These individuals received a standardized protocol that incorporated both the surgical and medication elements.

To evaluate the effectiveness of this combined approach, we compared their outcomes to patients who had the same surgery between 2019 and 2021 but did not receive the intervention. We used a matching technique to ensure both groups were similar in terms of age, health status, and surgical characteristics.

Patients were continuously monitored for signs of AF using electrocardiograms (ECGs). We also tracked key clinical outcomes such as stroke, heart block, the need for blood thinners, and death within 30 days post-surgery.

Q: What did you find?

Patients who received the intervention had a significantly lower rate of postoperative AF — 18% compared to 32% in the comparison group — representing nearly a 50% reduction in risk.

Importantly, this benefit did not come with added risks. Rates of stroke, heart block and death were similar between both groups. Additionally, fewer patients in the intervention group required blood thinners at discharge or continued amiodarone therapy, suggesting potential advantages for recovery, reduced medication burden, and overall safety.

Q: What are the implications?

Our findings suggest that this combined strategy can safely and effectively reduce the risk of developing AF after heart surgery. For patients, this means fewer heart rhythm disturbances, lower stroke risk, shorter hospital stays, and reduced reliance on long-term medications.

If implemented more broadly, this method could help thousands of individuals recover more smoothly after bypass surgery, while also decreasing readmissions and improving overall outcomes.

Q: What are the next steps?

While our findings are promising and highlight the potential of this approach, further research is essential to support broader adoption. The next steps include validating these results in larger, multi-center populations to confirm its effectiveness across diverse patient populations and clinical settings.

We also plan to investigate how much each component — surgical and pharmaceutical — contributes to the overall benefit, and whether either one alone might be sufficient. Another priority is developing personalized risk scores to identify patients most likely to develop AF, allowing for tailored prevention.

Finally, long-term follow-up will help determine whether this method reduces stroke risk, rehospitalizations and healthcare costs over time. These efforts could support its integration into routine cardiac care and promote more individualized treatment plans.

Authorship: In addition to Makarem and Osho, Mass General Brigham authors include Dane Paneitz, MD, Tracy Winship, Ruby Singh, Jordan P. Bloom, Motahar Hosseini, Arminder S. Jassar, Antonia Kreso, Nathaniel Langer, Serguei Melnitchouk, Eriberto Michel, Seyed Alireza Rabi, Oluwaseun Akeju, David D’Alessandro, and Thoralf M. Sundt.

Paper cited: Makarem, A., et al. “Pericardiotomy and Amiodarone for Prophylaxis Against Postoperative Atrial Fibrillation in Cardiac Surgery (PAPPA).” Annals of Thoracic Surgery. DOI: 10.1016/j.athoracsur.2025.05.045

Funding: Asishana A. Osho reports that financial support was provided by the Society of Black Academic Surgeons (SBAS), the Executive Committee on Research (ECOR) at Massachusetts General Hospital and a faculty research award to study principal investigator (A.A. Osho) from Intuitive Surgical.

Disclosures: The authors have no conflicts of interest to disclose.