Postoperative pericardial effusion on routine echocardiography: A review of incidence, progression, and management

Postoperative pericardial effusion (PPE) is a common finding after cardiac surgery, with reported incidences ranging widely from 2% to 85%. While most effusions resolve spontaneously, a subset progresses to cardiac tamponade requiring urgent intervention. This systematic review evaluated the true incidence of PPE and PPE-related reinterventions based on routine echocardiographic screening, and explored temporal evolution, symptomatology, and perioperative risk factors. A comprehensive search of Embase, PubMed, and Web of Science through May 2025 identified 26 eligible studies including 8,495 patients. Data extraction followed PRISMA guidelines and quality assessment with the JBI checklist. Random-effects meta-analysis demonstrated a pooled PPE incidence of 36% (95% confidence interval (CI) 25-49%), whereas only 3% (95% CI 2-4%) required reintervention, ranging from 2% after CABG to 6% after aortic surgery. Large effusions (> 2 cm) were associated with a substantially higher likelihood of intervention (54% [14-90%]), although spontaneous resolution remained common. Preventive strategies such as posterior pericardiotomy and posterior chest tube placement significantly reduced both PPE incidence and reintervention rates. Despite these findings, interpretation is limited by substantial heterogeneity in study design, definitions, and follow-up protocols. Standardized definitions, structured echocardiographic follow-up, and prospective studies are needed to improve risk stratification and guide clinical decision-making.