Permanent pacemaker implantation rates following cardiac surgery in the modern era

Types of Complications and Associated Factors in Patients Undergoing Permanent Cardiac Pacemaker Implantation: A Systematic Review

Background

Permanent Pacemaker (PPM) implantation is essential in treating cardiac arrhythmias and conduction disorders, especially in patients with heart failure. Although PPM has been proven to improve quality of life and prolong life expectancy in patients with cardiac conduction disorders, post implantation complications still often occur.

Purpose

This study aimed to identify types of complications and associated predictors in patients undergoing PPM implantation.

Methods

This review used a systematic review design and follows the guidelines of the Cochrane Handbook for Systematic Reviews and the Preferred Reporting Item for Systematic Reviews and Meta-analysis (PRISMA). The database used was PubMed, CINAHL: Medline Ultimate, ScienceDirect, Scopus, and search engines: Google Scholar. Articles with observational designs and RCTs in English were included without limitation of publication year.

Results

This review analyzed 15 articles. The analysis showed that there are five categories of factors which influences the incidence of complications in patients after PPM implantation: demographic, pre-existing clinical, comorbid disease, procedural, operator experience, and activity factors. The complications that are most frequently reported are generator erosion, pacemaker infection, pneumothorax, atrial lead displacement, battery depletion, and even death after PPM implantation.

Conclusion

There are many incidents of complications and factors that influence complications in patients after PPM placement. The reported complications underscore the importance of careful patient selection and procedure execution to minimize risks. Healthcare providers should emphasize patients with risk factors to provide targeted monitoring and management. Integrating a multidisciplinary approach involving cardiologists, nephrologists, surgeons, and the nursing team is essential to optimizing patient care and improving clinical outcomes.

High hemoglobin-to-red cell distribution width ratio reduces adverse events in patients with pacemaker implantation

BACKGROUND

The prognostic significance of the hemoglobin-to-red blood cell distribution width (Hb/RDW) ratio in patients undergoing pacemaker implantation (PMI) remains uncertain. Our study aimed to explore the prospective relationship between the Hb/RDW ratio and the risk of major cardiovascular events (MCEs) in Chinese patients with PMI.

METHODS

A total of 595 patients with permanent PMI were enrolled. Patients were divided into the high-Hb/RDW (≥ 9.1 g/L per percent) and the low-Hb/RDW (< 9.1 g/L per percent) groups according to the levels of the Hb/RDW ratio using the receiver operating characteristic curve. The primary outcome was the composite MCEs including heart failure hospitalization, myocardial infarction, stroke, and all-cause death, presented as hazard ratios (HR) with 95% confidence intervals (CI) estimated by the Cox Proportional Hazards models, propensity score (PS) adjusted, and inverse probability weighting (IPW) analyses, respectively.

RESULTS

During the median 2-year follow-up period, 95 (16%) MCEs were identified among the 595 patients with PMI Patients with a high Hb/RDW ratio exhibited a lower risk of MCEs compared to those with a low Hb/RDW ratio (adjusted HR: 0.456; 95% CI: 0.376-0.848). In additional analyses with different statistical models, the multivariate-adjusted HR was 0.592 (95% CI: 0.380-0.920) for the PS-adjusted analysis and 0.444 (95% CI: 0.271-0.729) for the IPW, respectively. There were no interactions between subgroups and Hb/RDW in our analysis.

CONCLUSION

High levels of the Hb/RDW ratio were linked to a lower risk of composite MCEs. The Hb/RDW ratio was a better predictor of MCEs than Hb or RDW alone.

Incidence, Risk Factors, and Outcomes Associated With Permanent Pacemaker Implantation Following Tricuspid Valve Surgery

BACKGROUND

Data regarding permanent pacemaker (PPM) implantation following tricuspid valve surgery (TVS) are limited. We sought to evaluate its incidence, risk factors, and outcomes.

METHODS AND RESULTS

Medicare beneficiaries who underwent TVS from 2013 to 2020 were identified. Patients who underwent TVS for endocarditis were excluded. The primary exposure of interest was new PPM after TVS. Outcomes included all-cause mortality and readmission with endocarditis or heart failure on follow-up. Among the 13 294 patients who underwent TVS, 2518 (18.9%) required PPM placement. Risk factors included female sex (relative risk [RR], 1.26 [95% CI, 1.17-1.36], P<0.0001), prior sternotomy (RR, 1.12 [95% CI, 1.02-1.23], P=0.02), preoperative second-degree heart block (RR, 2.20 [95% CI, 1.81-2.69], P<0.0001), right bundle-branch block (RR, 1.21 [95% CI, 1.03-1.41], P=0.019), bifascicular block (RR, 1.43 [95% CI, 1.06-1.93], P=0.02), and prior malignancy (RR, 1.23 [95% CI, 1.01-1.49], P=0.04). Tricuspid valve (TV) replacement was associated with a significantly higher risk of PPM implantation when compared with TV repair (RR, 3.20 [95% CI, 2.16-4.75], P<0.0001). After a median follow-up of 3.1 years, mortality was not different in patients who received PPM compared with patients who did not (hazard ratio [HR], 1.02 [95% CI, 0.93-1.12], P=0.7). PPM placement was not associated with a higher risk of endocarditis but was associated with a higher risk of heart failure readmission (HR, 1.28 [95% CI, 1.14-1.43], P<0.001).

CONCLUSIONS

PPM implantation frequently occurs after TVS, notably in female patients and patients undergoing TV replacement. Although mortality is not increased, it is associated with higher rates of heart failure rehospitalization.

The prevalence of permanent pacemaker implantation after open-heart surgeries; eight years of experience in Tehran heart center

BACKGROUND

We aimed to evaluate the prevalence of permanent pacemaker implantation (PPI) among open-heart surgery patients.

METHODS

We reviewed data from 23 461 patients undergoing open-heart surgeries between 2009 and 2016 in our heart center in Iran. A total of 18 070 patients (77%) had coronary artery bypass grafting (CABG), 3 598 (15.3%) valvular surgeries, and 1 793 (7.6%) congenital repair procedures. Finally, 125 patients who received PPI following open-heart surgeries were enrolled in our study. We defined the demographic and clinical characteristics of all these patients.

RESULTS

PPI was required in 125 (0.53%) patients with an average age of 58 ± 15.3 years. The average hospitalization time after surgery and waiting time for PPI were 19.7 ± 10.2 and 11.4 ± 6.5 days, respectively. Atrial fibrillation was the dominant pre-operative cardiac conduction abnormality (29.6%). Also, the primary indication for PPI was complete heart block in 72 patients (57.6%). Patients in the CABG group were significantly older (P = 0.002) and were more likely to be male (P = 0.030). The valvular group longer bypass and cross-clamp times and had more left atrial abnormalities. In addition, the congenital defect group was younger and had longer ICU stay times.

CONCLUSIONS

Based on our study findings, PPI was required in 0.53% of patients following open-heart surgery due to damage to the cardiac conduction system. The current study paves the way for future investigations to identify possible predictors of PPI in patients undergoing open-heart surgeries.

Meta-Analysis Comparing Valve-in-Valve Transcatheter Mitral Valve Replacement Versus Redo Surgical Mitral Valve Replacement in Degenerated Bioprosthetic Mitral Valve

Valve-in-valve transcatheter mitral valve replacement (ViV-TMVR) and redo surgical mitral valve replacement (redo-SMVR) are 2 treatment strategies for patients with bioprosthetic mitral valve dysfunction. We conducted a systematic review and meta-analysis to compare the outcomes of ViV-TMVR versus redo-SMVR. We searched PubMed, EMBASE, Cochrane, and Google Scholar for studies comparing outcomes of ViV-TMVR versus redo-SMVR in degenerated bioprosthetic mitral valves. We used a random-effects model to calculate odd ratios (ORs) with 95% confidence intervals (CIs). Outcomes included in-hospital, 30-day, 1-year, and 2-year mortality, stroke, bleeding, acute kidney injury, arrhythmias, permanent pacemaker insertion, and hospital length of stay (LOS). A total of 6 observational studies with 707 subjects were included. The median follow-up was 2.7 years. Despite their older age and greater co-morbidity burden, patients who underwent ViV-TMVR had a similar in-hospital mortality (OR 0.52, 95% CI 0.22 to 1.23, p = 0.14), 30-day mortality (OR 0.65, 95% CI 0.36 to 1.17, p = 0.15), 1-year mortality (OR 0.97, 95% CI 0.63 to 1.49, p = 0.89), and 2-year mortality (OR 1.17, 95% CI 0.65 to 2.13, p = 0.60) compared with redo-SMVR. ViV-TMVR was associated with significantly lower periprocedural complications, including stroke, bleeding, acute kidney injury, arrhythmias, and permanent pacemaker insertion, and shorter hospital LOS than redo-SMVR. In conclusion, ViV-TMVR was associated with better outcomes than redo-SMVR in patients with degenerated bioprosthetic mitral valves, including lower complication rates and shorter hospital LOS, with no significant difference in mortality rates. Large-scale randomized trials are needed to mitigate biases and confirm our findings.

Techniques to aid prediction of pacing dependence at 30 days in patients requiring pacemaker implantation after cardiac surgery

Permanent pacemaker (PPM) implantation occurs in up to 5 % of patients after cardiac surgery but there is little consensus on how long to wait between surgery and PPM insertion. Predicting the likelihood of a patient being pacing dependent 30 days after implant can aid with this timing decision and avoid unnecessary observation time waiting for intrinsic conduction to recover. In this paper, we introduce a new approach for the prediction of PPM dependency at 30 days after implant in patients who have undergone recent cardiac surgery. The aim is to create an automatic detection model able to support clinicians in the decision-making process. We first applied Synthetic Minority Oversampling Technique (SMOTE) and Bayesian Networks (BN) to the dataset, to balance the inherently imbalanced data and create additional synthetic data respectively. The six resultant datasets were then used to train four different classifiers to predict pacing dependence at 30 days, all using the same testing set. The Bagged Trees classifier achieved the best results, reaching an area under the receiver operating curve (AUC) of 90 % in the train phase, and 83 % in the test phase. The overall classification performance was clearly enhanced when using SMOTE and synthetic data created with BN to create a combined and balanced dataset. This technique could be of great use in answering clinical questions where the original dataset is imbalanced.

Redo Surgical Mitral Valve Replacement Versus Transcatheter Mitral Valve in Valve From the National Inpatient Sample

Background Redo mitral valve surgery is required in up to one-third of patients and is associated with significant mortality and morbidity. Valve-in-valve transcatheter mitral valve replacement (ViV TMVR) is less invasive and could be considered in those at prohibitive surgical risk. Studies on comparative outcomes of ViV TMVR and redo surgical mitral valve replacement (SMVR) remain limited. Our study aimed to investigate the real-world outcomes of the above procedures using the National Inpatient Sample database. Methods and Results We analyzed National Inpatient Sample data using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) from September 2015 to December 2018. A total of 495 and 2250 patients underwent redo ViV TMVR and SMVR, respectively. The patients who underwent ViV TMVR were older (77 versus 68 years, P<0.01). Adjusted mortality was higher in the redo SMVR group compared with the ViV TMVR group (7.6% versus <2.8%, P<0.01). Perioperative complications were higher among patients undergoing redo SMVR including blood transfusions (38% versus 7.6%, P<0.01) and acute kidney injury (36.7% versus 13.9%, P<0.01). Cost of care was higher (USD$57 172 versus USD$52 579, P<0.01), length of stay was longer (10 versus 3 days, P<0.01), and discharge to home was lower (20.3% versus 64.6%, P<0.01) in the SMVR group compared with the ViV TMVR group. Conclusions ViV TMVR is associated with lower mortality, periprocedural morbidity, and resource use compared with patients undergoing redo SMVR. ViV TMVR may be a viable option for some patients with mitral prosthesis dysfunction. Studies evaluating long-term outcomes and durability of ViV TMVR are needed. A patient-centered approach by the heart team, local institutional expertise, and careful preprocedure planning can help decision-making about the choice of intervention for the individual patient.