systematic review and meta analysis of randomized controlled trials assessing safety and efficacy of posterior pericardial drainage in patients undergoing heart surgery

Accepted Manuscript Systematic Review and Meta-analysis of Randomized Controlled Trials Assessing Safety and Efficacy of Posterior Pericardial Drainage in Patients Undergoing Heart Surgery Mirosław Gozdek, MD, Wojciech Pawliszak, MD, Wojciech Hagner, MD, PhD, Paweł Zalewski, PhD, Janusz Kowalewski, MD, PhD, Domenico Paparella, MD, PhD, Thierry Carrel, MD, PhD, Lech Anisimowicz, MD, PhD, Mariusz Kowalewski, MD PII: S0022-5223(16)31682-8 DOI: 10.1016/j.jtcvs.2016.11.057 Reference: YMTC 11121 To appear in: The Journal of Thoracic and Cardiovascular Surgery Received Date: September 2016 Revised Date: November 2016 Accepted Date: 19 November 2016 Please cite this article as: Gozdek M, Pawliszak W, Hagner W, Zalewski P, Kowalewski J, Paparella D, Carrel T, Anisimowicz L, Kowalewski M, Systematic Review and Meta-analysis of Randomized Controlled Trials Assessing Safety and Efficacy of Posterior Pericardial Drainage in Patients Undergoing Heart Surgery, The Journal of Thoracic and Cardiovascular Surgery (2017), doi: 10.1016/ j.jtcvs.2016.11.057 This is a PDF file of an unedited manuscript that has been accepted for publication As a service to our customers we are providing this early version of the manuscript The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain ACCEPTED MANUSCRIPT Systematic Review and Meta-analysis of Randomized Controlled Trials Assessing Safety and Efficacy of Posterior Pericardial Drainage in Patients Undergoing Heart Surgery Mirosław Gozdek MD1,2*; Wojciech Pawliszak MD1; Wojciech Hagner MD, PhD3; Paweł Zalewski PhD2; Janusz Kowalewski MD, PhD4; Domenico Paparella MD, PhD5; Thierry Carrel MD, PhD6; Lech Anisimowicz MD, PhD1; Mariusz Kowalewski MD1,2* Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital in Bydgoszcz, Poland; Department of Hygiene, Epidemiology and Ergonomics, Division of Ergonomics and Physical Effort, Collegium Medicum UMK in Bydgoszcz, Poland; 3Chair and Clinic of Rehabilitation, Faculty of Health Sciences, Nicolaus Copernicus University in Toruń, Poland; 4Lung Cancer and Thoracic Surgery Department, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland; 5Division of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy; 6Clinic for Cardiovascular Surgery, University Hospital and University of Bern, Switzerland; SC 10 11 12 13 RI PT M AN U 14 15 16 Correspondence: Mariusz Kowalewski, MD Department of Cardiac Surgery, Dr Antoni Jurasz Memorial University Hospital in Bydgoszcz, POLAND Maria Curie Sklodowska Str 85-094 Bydgoszcz, PL 20 Phone: 0048 502269240 21 Fax: 0048 525854700 22 Email: kowalewskimariusz@gazeta.pl Running title: 24 Wordcount: 27 28 3631 (ref excl.) AC C 25 Posterior pericardial drainage in heart surgery EP 23 26 TE D 17 18 19 29 No relationships that could be construed as a conflict of interest 30 The present contribution did not receive any external funding 31 * - equal contribution ACCEPTED MANUSCRIPT Central Picture M AN U SC RI PT 32 33 Central Picture Legend 35 Pericardial effusion often leads to delayed cardiac tamponade after heart surgery 36 Central Message 37 Posterior pericardial drainage was found to reduce postoperative complications, among others 38 cardiac tamponade and atrial fibrillation In addition, it improved survival after heart surgery 39 Perspective Statement 40 Pericardial effusion may be a source of morbidity following heart surgeries Posterior 41 pericardial drainage allows free escape of the fluid to the pleural space or on the outside via 42 chest tubes Previous studies showed that by reducing the amount of pericardial effusion one 43 can avoid postoperative atrial arrhythmias; whether other postoperative complications may be 44 reduced remains unresolved AC C EP TE D 34 ACCEPTED MANUSCRIPT Abstract 46 Objectives: The objective of the current systematic review and meta-analysis was to 47 investigate the potential beneficial effects of posterior pericardial drainage in patients 48 undergoing heart surgery 49 Methods: Multiple on-line databases and relevant congress proceedings were screened for 50 randomized controlled trials (RCTs) assessing efficacy and safety of posterior pericardial 51 drainage defined as posterior pericardiotomy incision; chest tube to posterior pericardium or 52 both Primary endpoint was in-hospital/30 days cardiac tamponade Secondary endpoints 53 comprised death or cardiac arrest; early- and late pericardial effusion; postoperative atrial 54 fibrillation (POAF); acute kidney injury (AKI); pulmonary complications; length of hospital 55 stay 56 Results: Nineteen RCTs enrolling N=3,425 patients were included Posterior pericardial 57 drainage was associated with a significant 90% reduction of the odds of cardiac tamponade as 58 compared to control group: OR (95%CIs) 0.13 (0.07-0.25); p20 1 cm was considered significant 20mm and compression of the heart Maximum diastolic separation between pericardium and epicardium measured at the level of the tip of the mitral valve leaflet Any effusion >1 cm was considered significant Maximum diastolic separation between pericardium and epicardium measured at the level of the tip of the mitral valve leaflet Any effusion >1 cm was considered significant TE D Asimakopoulos G et al [20] Bakhshandeh AR et al [21,22] Pericardial effusion criteria EP Arbatli H et al [19] Cardiac tamponade (definition; diagnostic criteria) AC C Study [ref] Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an ACCEPTED MANUSCRIPT Effusion ≥10 mm were considered significant Not defined Not defined AF or atrial flutter >30 even after correction of hypoxia and electrolyte imbalance Not defined; NS Effusion ≥10 mm were considered significant NR NR AF or atrial flutter >30 5 Not defined Presence of irregular ventricular rate and absence of consistent P-waves before each QRS complex; persistence not specified Not defined Not defined Absence of consistent P waves before each QRS complex and an irregular ventricular rate; persistence not specified before discharge month after discharge Not defined; persistence not specified Not defined Not defined Not defined 30 3 days after surgery Not defined SC Clinical signs and symptoms in addition to echocardiographic criteria Kaya M et al [31] Kaya M et al [32] Not defined; NS Sadeghpour A et al [36] Not defined; NS Not defined Hemodynamic data and the echocardiographic findings Maximum diastolic separation between pericardium and epicardium measured at the level of the tip of the mitral valve leaflet Any effusion >1 cm was considered significant Not defined; NS EP Not defined; NS AC C Kongmalai P et al [34] Kuralay E et al [35] Not defined M AN U Not defined; NS Kaygin MA et al [33] Echo free space in diastole, small 1020mm, very large >20mm and compression of the heart Echo free space in diastole, small 1020mm, very large >20mm and compression of the heart Echo free space in diastole, small 1020mm, very large >20mm and compression of the heart Any effusion between the epicardial and pericardial surfaces >1 cm in echocardiogram image was considered as significant RI PT Haddadzadeh M et al [29] Kaya M et al [30] Not defined; NS TE D Fawzy H et al [28] Not defined; NS 20 mm, circumferential effusion, large AF, atrial fibrillation; NS, not specified; NR, not reported Not defined, NS effusion measured at 10 postoperative day Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn Not defined; persistence not specified C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an ACCEPTED MANUSCRIPT Two drains in both groups One in the left pleural cavity and the other in the anterior mediastinum Bakhshandeh AR et al [21,22] NR Bolourian AA et al [23] NR Cakalagaoglu C et al [24] Two drains in study and control group in CABG cases: one in the left pleural cavity and the other in the anterior mediastinum Two drains in study and control group in valve cases: anterior mediastinum (or three when left pleural cavity was opened) Pericardium left open anteriorly Two drains in both groups One in the left pleural cavity and the other in the anterior mediastinum TE D M AN U SC Asimakopoulos G et al [20] Ekim H et al [25] Posterior pericardiotomy technique A longitudinal, cm long, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm A longitudinal, cm long, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm A longitudinal, cm long, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein toward the inferior vena cava and diaphragm Incision along the posterior length of left phrenic nerve, to cm long, extending from left inferior pulmonary vein to the diaphragm A longitudinal, cm long, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm RI PT Supplementary Table Chest drainage and posterior pericardiotomy technique Study [ref] Chest drainage technique Arbatli H et al Two drains in both groups One in the left pleural cavity and the other in the anterior [19] mediastinum Lower part of the pericardium left open Two drains in study group: one in the left pleural cavity and the other in the anterior mediastinum One drain in the control group positioned in the anterior mediastinum Eryilmaz S et al [27] Farsak B et al [11] Two drains in study group: one in the anterior mediastinum and the other (thin closed-suction drain system) behind the heart One drain in control group: anterior mediastinum + another drain in both group when left or right pleura was opened Two drains in both groups One in the left pleural cavity and the other in the anterior mediastinum Pericardium left open anteriorly Fawzy H et al [28] Two drains in both groups One in the left pleural cavity and the other in the anterior mediastinum Pericardium left open anteriorly AC C EP Erdil N et al [26] A longitudinal, cm long, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm A longitudinal, cm long, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm NA A longitudinal, cm long, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm A longitudinal, cm long and cm width, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an ACCEPTED MANUSCRIPT Two drains in both groups One in the left pleural cavity and the other in the anterior mediastinum Pericardium left open anteriorly Kaya M et al [30] Two or three drains in study group One in the left pleural cavity and the other in the anterior mediastinum Third drain in 33 patients positioned behind the heart Two drains in control group: One in the left pleural cavity and the other in the anterior mediastinum Pericardium left open (2 cm) Three drains in study group One in the left pleural cavity, one in the anterior mediastinum and the other in the pericardial sac along the right atrium Pericardium was closed Two drains in control group Left pleural cavity and anterior mediastinum Pericardium left open (2 cm) Three drains in study group One in the left pleural cavity, one in the anterior mediastinum and the other in the pericardial sac along the right atrium Proximal anastomoses of the bypass grafts and nearly half of the anterior surface of the heart were covered by pericardium Two drains in control group: left pleural cavity and anterior mediastinum Two drains in both groups One in the left pleural cavity and the other in the anterior mediastinum Pericardium left open anteriorly Kongmalai P et al [34] Kuralay E et al [35] Sadeghpour A et al [36] Zhao J et al [37] SC M AN U NR TE D Kaygin MA et al [33] Two drains in both groups One in the left pleural cavity and the other in the anterior mediastinum Pericardium left open anteriorly NR EP Kaya M et al [32] AC C Kaya M et al [31] A longitudinal, cm long, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm A longitudinal, cm long, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm The left pleural cavity was opened A longitudinal, cm long, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm RI PT Haddadzadeh M et al [29] Two or three drains in study group One in the left or both pleural cavities, one in the anterior mediastinum Two drains in control group: one in the pericardial sac along the right atrium and the other in the anterior mediastinum A longitudinal, cm long, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm A circular, cm long, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm NR A longitudinal, cm long, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm A longitudinal, cm long, incision parallel and posterior to the phrenic nerve, extending from left inferior pulmonary vein to the diaphragm Inverse T, 2,5 cm long in both dimensions (left, right or bilateral window) incision, parallel and posterior to the phrenic nerve, extending from inferior pulmonary vein to the diaphragm CABG, coronary artery bypass grafting; NR, not reported; NA, not applicable Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an ACCEPTED MANUSCRIPT Asimakopoulos G et al [20] Cakalagaoglu C et al [24] Erdil N et al [26] Eryilmaz S et al [27] Farsak B et al [11] Haddadzadeh M et al [29] Kaya M et al [30] 2 3 EP Kaya M et al [31] TE D Fawzy H et al [28] M AN U Ekim H et al [25] Jadad score Other bias SC Bakhshandeh AR et al [21,22] Bolourian AA et al [23] 3 AC C Kaygin MA et al [33] Selective reporting (reporting bias) RI PT Arbatli H et al [19] Kaya M et al [32] Incomplete outcome data (attrition bias) Blinding of outcome assessment (detection bias) Blinding of participants and personnel (performance bias) Study [ref] Allocation concealment (selection bias) Random sequence generation (selection bias) Supplementary Table Publication bias analysis Kongmalai P et al [34] Kuralay E et al [35] Sadeghpour A et al [36] Zhao J et al [37] Cohen’s Kappa high risk of bias 0.89 unclear risk of bias 0.84 0.79 0.84 0.84 low risk of bias Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn 0.89 0.84 C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an ACCEPTED MANUSCRIPT Figure legend sFigure Publication bias analysis ‘Funnel plots’ constructed for studies included in the meta-analysis for the following investigated endpoints: A-cardiac tamponade; B-death or RI PT cardiac arrest; C-early pericardial effusion; D-late pericardial effusion; E-postoperative atrial fibrillation; F-pleural effusion with or without intervention; G-pulmonary complications; Hreoperation for bleeding SC sFigure Forest plot of the comparison between posterior pericardial drainage (intervention) and control group for the total chest drainage volume expressed as mean difference and 95% M AN U Confidence Intervals; IV, inverse variance sFigure Forest plot of the comparison between posterior pericardial drainage (intervention) and control group for the incidence of pleural effusion with or without intervention after heart surgery Odds ratios (OR) and 95% Confidence Intervals (CIs); M-H, Mantel-Haenszel TE D sFigure Forest plot of the comparison between posterior pericardial drainage (intervention) and control group for the prevention of pulmonary complications after heart surgery Odds EP ratios (OR) and 95% Confidence Intervals (CIs); M-H, Mantel-Haenszel sFigure Forest plot of the comparison between posterior pericardial drainage (intervention) AC C and control group for the incidence of reoperation for bleeding after heart surgery Odds ratios (OR) and 95% Confidence Intervals (CIs); M-H, Mantel-Haenszel sFigure Forest plot of the comparison between posterior pericardial drainage (intervention) and control group for prevention of acute kidney injury after heart surgery Peto odds ratios (OR) and 95% Confidence Intervals (CIs) Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an ACCEPTED MANUSCRIPT sFigure Forest plot of the comparison between posterior pericardial drainage (intervention) and control group for the length of ICU stay (A) and overall length of hospital stay (B) expressed as mean difference and 95% Confidence Intervals; IV, inverse variance RI PT sFigure Sensitivity analysis conducted for the primary endpoint after accounting for studies reporting ‘0 events’ The individual and overall estimates are expressed as risk difference and 95% Confidence Intervals; M-H, Mantel-Haenszel SC sFigure Sensitivity subgroup analysis for the comparison between posterior pericardial drainage (intervention) and control group stratified by operative technique conducted for the M AN U primary endpoint The added total number of patients is higher than N=3,425 because of exact same control groups in one study [30] (Odds ratios (OR) and 95% Confidence Intervals (CIs); IV, inverse variance sFigure 10 Sensitivity analysis (influence analysis) for the primary endpoint conducted by TE D deleting each study at a time and repeating the calculations Analysis shows that no single study has influenced the overall effect of the intervention Odds ratios (OR) and 95% AC C EP Confidence Intervals (CIs) Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an ACCEPTED MANUSCRIPT AC C EP TE D M AN U SC RI PT sFigure 1A-H [funnel plots] Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an ACCEPTED MANUSCRIPT TE D M AN U sFigure [pleural effusion with or without intervention] SC RI PT sFigure [total chest drainage volume] AC C EP sFigure [pulmonary complications] Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an ACCEPTED MANUSCRIPT RI PT sFigure [reoperation for bleeding] M AN U SC sFigure [acute kidney injury] AC C EP TE D sFigure 7A-B [length of ICU and hospital stay] Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an ACCEPTED MANUSCRIPT AC C EP TE D sFigure [operative technique] M AN U SC RI PT sFigure [cardiac tamponade RD] Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn