Long-Term Outcomes Associated With Permanent Pacemaker Implantation in Low-Risk Surgical Aortic Valve Replacement

Background

Permanent pacemaker implantation is associated with an increased risk of mortality and heart failure after surgical aortic valve replacement (SAVR).

Objectives

The purpose of this study was to analyze long-term prognosis of permanent pacemaker implantation following SAVR on low-risk patients.

Methods

This nationwide, population-based, observational cohort study included all patients who underwent SAVR in Sweden between 2001 and 2018 with low surgical risk, defined as logistic EuroSCORE I <10% or EuroSCORE II <4%. Patients received a permanent pacemaker implantation within 30 days after SAVR. Main outcomes were all-cause mortality, heart failure hospitalization, and endocarditis. Regression standardization addressed confounding.

Results

We included 19,576 patients with low surgical risk. Of these, 732 (3.7%) patients received a permanent pacemaker within 30 days after SAVR. The mean age was 68 years and 33% were women. We found no difference in all-cause mortality between patients who received a pacemaker compared to those who did not (absolute survival difference at 17 years: 0.1% (95% CI: -3.6% to 3.8%). After 17 years, the estimated cumulative incidence of heart failure in patients who received a pacemaker was 28% (95% CI: 24%-33%) vs 20% (95% CI: 19%-22%) in patients who did not (absolute difference 8.2% [95% CI: 3.8%-13%]). We found no difference in endocarditis between the groups.

Conclusions

We found an increased incidence of heart failure in patients with low surgical risk who received a permanent pacemaker after SAVR. Permanent pacemaker implantation was not associated with all-cause mortality or endocarditis. Efforts should be made to avoid the need for permanent pacemaker following SAVR.

Atrioventricular conduction disorders in aortic valve infective endocarditis

BACKGROUND

Aortic valve infective endocarditis may be complicated by high-degree atrioventricular block in up to 10-20% of cases.

AIM

To assess high-degree atrioventricular block occurrence, contributing factors, prognosis and evolution in patients referred for aortic infective endocarditis.

METHODS

Two hundred and five patients referred for aortic valve infective endocarditis between January 2018 and March 2021 were included in this study. A comprehensive assessment of clinical, electrocardiographic, biological, microbiological and imaging data was conducted, with a follow-up carried out over 1 year.

RESULTS

High-degree atrioventricular block occurred in 22 (11%) patients. In univariate analysis, high-degree atrioventricular block was associated with first-degree heart block at admission (odds ratio 3.1; P=0.015), periannular complication on echocardiography (odds ratio 6.9; P<0.001) and severe biological inflammatory syndrome, notably C-reactive protein (127 vs 90mg/L; P=0.011). In-hospital mortality (12.7%) was higher in patients with high-degree atrioventricular block (odds ratio 4.0; P=0.011) in univariate analysis. Of the 16 patients implanted with a permanent pacemaker for high-degree atrioventricular block and interrogated, only four (25%) were dependent on the pacing function at 1-year follow-up.

CONCLUSIONS

High-degree atrioventricular block is associated with high inflammation markers and periannular complications, especially if first-degree heart block is identified at admission. High-degree atrioventricular block is a marker of infectious severity, and tends to raise the in-hospital mortality rate. Systematic assessment of patients admitted for infective endocarditis suspicion, considering these contributing factors, could indicate intensive care unit monitoring or even temporary pacemaker implantation in those at highest risk.

The impact of permanent pacemaker implantation on long-term survival after cardiac surgery: A systematic review and meta-analysis

OBJECTIVES

The long-term impact of permanent pacemaker (PPM) implantation on survival after cardiac surgery remains ill defined. We aimed to investigate the effect of PPM on survival and explore factors driving outcomes using meta-regression according to the type of surgery.

METHODS

MEDLINE, EMBASE, and the Cochrane Library Central Register of Controlled Trials were searched through October 2023 to identify studies reporting the long-term outcomes of PPM implantation. The primary outcome was all-cause mortality during follow-up. The secondary outcome was heart failure rehospitalization. The subgroup analysis and meta-regression analysis were performed according to the type of surgery.

RESULTS

A total of 28 studies met the inclusion criteria. 183,555 patients (n = 6298; PPM, n = 177,257; no PPM) were analyzed for all-cause mortality, with a weighted median follow-up of 79.7 months. PPM implantation was associated with increased risks of all-cause mortality during follow-up (hazard ratio, 1.22; confidence interval, 1.08-1.38, P < .01) and heart failure rehospitalization (hazard ratio, 1.24; confidence interval, 1.01-1.52, P = .04). Meta-regression demonstrated the adverse impact of PPM was less prominent in patients undergoing mitral or tricuspid valve surgery, whereas studies with a greater proportion with aortic valve replacement were associated with worse outcomes. Similarly, a greater proportion with atrioventricular block as an indication of PPM was associated with worse survival.

CONCLUSIONS

PPM implantation after cardiac surgery is associated with a greater risk of long-term all-cause mortality and heart failure rehospitalization. This impact is more prominent in patients undergoing aortic valve surgery or atrioventricular block as an indication than those undergoing mitral or tricuspid valve surgery.

Optimizing Patient Selection for Physiological Pacing in Bradyarrhythmia: Factors Associated With High Ventricular Pacing Burden

Background

Right ventricular (RV) pacing is established as the most common ventricular pacing (VP) strategy for patients with symptomatic bradyarrhythmia. Some patients with high VP burden suffer deterioration of left ventricular (LV) function, termed pacing-induced cardiomyopathy (PICM). Patients who pace > 20% of the time from the RV apex are at increased risk of PICM, but independent predictors of increased RV pacing burden have not been elucidated in those who have a permanent pacemaker (PPM) inserted for bradyarrhythmia.

Methods

We aimed to identify factors that are associated with increased VP burden > 20%, hence determining those at risk for resultant PICM. In this retrospective cohort study, we identified the most recent 300 consecutive cardiac implantable electronic device (CIED) implants in our center and collected past medical history, electrocardiogram (ECG), echo, medication and pacemaker check data.

Results

A total of 236 individuals met inclusion criteria. Of the patients, 35% had RV pacing burden < 20%, while 65% had VP burden ≥ 20%; 96.2% of patients with complete heart block (CHB) paced > 20% (P = 0.002). Utilization of DDD or VVI (75.2% and 89.2% of patients, respectively) without mode switch algorithms was associated with VP > 20% (P < 0.001). Male or previous coronary artery bypass grafting (CABG) patients also statistically paced > 20%. Other factors trending towards significance included prolonged PR interval, atrial fibrillation or more advanced age.

Conclusion

High-grade atrioventricular (AV) block was associated with an RV pacing burden > 20% over 3 years but this was not consistent in patients with only transient episodes of high-grade AV block. We found a significant association between high VP% and male sex, previous CABG and the absence of mode switching algorithms.

Prognosis of pacing-dependent patients with cardiovascular implantable electronic devices

BACKGROUND

Data on the prognostic significance of pacing dependency in patients with cardiovascular implantable electronic devices (CIEDs) are sparse.

METHODS

The prognostic significance of pacing dependency defined as absence of an intrinsic rhythm ≥ 30 bpm was determined in 786 patients with CIEDs at the authors' institution using univariate and multivariate regression analysis to identify predictors of all-cause mortality.

RESULTS

During 49 months median follow-up, death occurred in 63 of 130 patients with pacing dependency compared to 241 of 656 patients without pacing dependency (48% versus 37%, hazard ratio [HR] 1.34; 95% confidence interval [CI]: 1.02-1.78, P = 0.04). Using multivariate regression analysis, predictors of all-cause mortality included age (HR 1.07; 95% CI: 1.05-1.08, P < 0.01), history of atrial fibrillation (HR 1.32, 95% CI: 1.03-1.69, P < 0.01), chronic kidney disease (HR 1.28; 95% CI: 1.00-1.63, P = 0.048) and New York Heart Association (NYHA) class ≥ III (HR 2.00; 95% CI: 1.52-2.62, P < 0.01), but not pacing dependency (HR 1.15; 95% CI: 0.86-1.54, P = 0.35).

CONCLUSIONS

In contrast to age, atrial fibrillation, chronic kidney disease and heart failure severity as indexed by NYHA functional class III or IV, pacing dependency does not appear to be an independent predictor of all-cause mortality in patients with CIEDs.

Long-Term Atrioventricular Block Following Valve Surgery: Electrocardiographic and Surgical Predictors

BACKGROUND

Bradyarrhythmia requiring pacemaker implantation among patients undergoing valve surgery may occur even after several years, with unclear predictors. Our aim was to investigate the incidence of pacemaker implantation at different follow-up times and identify associated predictors.

METHODS

We conducted a retrospective study evaluating 1046 consecutive patients who underwent valve surgery at the Cardiac Surgery Division of Bologna University Hospital from 2005 to 2010.

RESULTS

During 10 ± 4 years of follow-up, 11.4% of these patients required pacemaker implantation. Interventions on both atrioventricular valves independently predicted long-term pacemaker implantation (SHR 2.1, 95% CI 1.2-3.8, p = 0.014). Preoperative atrioventricular conduction disease strongly predicted long-term atrioventricular block, with right bundle branch block as the major predictor (SHR 7.0, 95% CI 3.9-12.4, p < 0.001), followed by left bundle branch block (SHR 4.9, 95% CI 2.4-10.1, p < 0.001), and left anterior fascicular block (SHR 3.9, 95% CI 1.8-8.3, p < 0.001).

CONCLUSION

Patients undergoing valvular surgery have a continuing risk of atrioventricular block late after surgery until the 12-month follow-up, which was clearly superior to the rate of atrioventricular block observed at long-term. Pre-operative atrioventricular conduction disease and combined surgery on both atrioventricular valves are strong predictors of atrioventricular block requiring pacemaker implantation.

Transcatheter Aortic Valve Implantation and Cardiac Conduction Abnormalities: Prevalence, Risk Factors and Management

Over the last decades, transcatheter aortic valve implantation (TAVI) or replacement (TAVR) has become a potential, widely accepted, and effective method of treating aortic stenosis in patients at moderate and high surgical risk and those disqualified from surgery. The method evolved what translates into a noticeable decrease in the incidence of complications and more beneficial clinical outcomes. However, the incidence of conduction abnormalities related to TAVI, including left bundle branch block and complete or second-degree atrioventricular block (AVB), remains high. The occurrence of AVB requiring permanent pacemaker implantation is associated with a worse prognosis in this group of patients. The identification of risk factors for conduction disturbances requiring pacemaker placement and the assessment of their relation to pacing dependence may help to develop methods of optimal care, including preventive measures, for patients undergoing TAVI. This approach is crucial given the emerging evidence of no worse outcomes for intermediate and low-risk patients undergoing TAVI in comparison to surgical aortic valve replacement. This paper comprehensively discusses the mechanisms, risk factors, and consequences of conduction abnormalities and arrhythmias, including AVB, atrial fibrillation, and ventricular arrhythmias associated with aortic stenosis and TAVI, as well as provides insights into optimized patient care, along with the potential of conduction system pacing and cardiac resynchronization therapy, to minimize the risk of unfavorable clinical outcomes.

Incidence of atrioventricular block after isolated coronary artery bypass grafting: a systematic review and pooled-analysis

Background and objectives

Atrioventricular block (AVB) is a serious complication following coronary artery bypass grafting (CABG) surgery, and its high-grade form may necessitate the implantation of a permanent pacemaker (PPM). AVB is associated with increased morbidity and mortality rates. This study aims to estimate the incidence of AVB and subsequent PPM implantation after isolated CABG surgery.

Material and methods

We searched electronic databases of PubMed, Embase, and Scopus from inception to 18 November 2022. Clinical trials and observational studies reporting the incidence of post-CABG AVB or subsequent PPM implantation in adult patients were included. The total incidence for all included outcomes was calculated using the inverse variance method, and the I2 statistic was reported to evaluate the heterogeneity of studies.

Results

A total of 28 studies met the inclusion criteria. Four studies [3 cohorts, 1 randomized controlled trial (RCT)] reported AVB without specifying its type; one (cohort) reported different degrees of AVB, 20 (12 cohorts, 8 RCTs) reported complete heart block (CHB) (or AVB requiring temporary pacing), and nine (8 cohorts, 1 RCT) reported the number of PPM inserted due to AVB. The pooled incidence of AVB, CHB (or AVB requiring temporary pacing), and PPM due to AVB was 1.16%, 1.73%, and 0.58%, respectively. Meta-regression analysis revealed that age, gender, diabetes, hypertension, hyperlipidemia, or smoking were not significantly associated with AVB, CHB, or PPM implantation.

Conclusion

This study highlights the incidence of AVB and the need for PPM implantation following CABG surgery. The findings emphasize the importance of postoperative monitoring and surveillance to improve patient outcomes.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022377181, identifier PROSPERO CRD42022377181.

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.

Does Pacemaker Implantation After Surgical Aortic Valve Replacement Impact Long-Term Morbidity and Mortality? A Focused Review

Permanent pacing remains a serious complication that can occur in the postoperative period of surgical aortic valve replacement. The reported incidence is variable, and there are many perioperative factors that have been linked with a greater need for permanent pacing. Permanent pacing can also be associated with late lead-related and cardiac complications that can affect late outcome. However, the degree of late dependence on pacemakers is varied, and some studies have shown that a substantial proportion of patients do not need long-term pacing. Some groups have found that permanent pacing was associated with a negative impact on long-term survival in these patients. A common finding among these studies is that the groups of patients with pacemakers had higher preoperative surgical risk and comorbidity status. This makes it difficult to establish whether permanent pacing on its own represents a risk factor for late mortality or whether it is simply a marker that reflects the higher complexity and comorbidities in this group of patients.

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.

Outcomes Following Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement: SWEDEHEART Observational Study

OBJECTIVES

This study was performed to investigate long-term, clinically important outcomes in patients who underwent permanent pacemaker implantation after transcatheter aortic valve replacement (TAVR).

BACKGROUND

The impact of permanent pacemaker implantation after TAVR is unknown, and prior studies have produced conflicting results.

METHODS

In this nationwide, population-based cohort study, the study included all patients who underwent transfemoral TAVR in Sweden from 2008 to 2018 from the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) register. Additional baseline characteristics and information about outcomes were obtained by individual crosslinking with other national health data registers. Unadjusted and multivariable-adjusted analyses were performed using Cox proportional hazards regression.

RESULTS

Of 3,420 patients, 481 (14.1%) underwent permanent pacemaker implantation within 30 days after TAVR. The survival rate at 1, 5, and 10 years was 90.0%, 52.7%, and 10.9% in the pacemaker group and 92.7%, 53.8%, and 15.3% in the nonpacemaker group, respectively (HR: 1.03; 95% CI: 0.88-1.22; P = 0.692). The median follow-up was 2.7 years (interquartile range: 2.5, and maximum 11.8 years). There was no difference in the risk of cardiovascular death (HR: 0.91; 95% CI: 0.71-1.18; P = 0.611), heart failure (HR: 1.23; 95% CI: 0.92-1.63; P = 0.157), or endocarditis (HR: 0.90; 95% CI: 0.47-1.69; P = 0.734) between the groups.

CONCLUSIONS

The study found no difference in long-term survival between patients who did and did not undergo permanent pacemaker implantation after TAVR. As the use of TAVR expands to include younger and low-risk patients with a long life expectancy, it will become increasingly important to understand the impact of permanent pacemaker implantation after TAVR.

Outcomes and periprocedural management of cardiac implantable electronic devices in patients with carcinoid heart disease

BACKGROUND

Carcinoid heart disease (CHD) is a rare complication of hormonally active neuroendocrine tumors that often requires surgical intervention. Data on cardiac implantable electronic device (CIED) implantation in patients with CHD are limited.

OBJECTIVE

The purpose of this study was to evaluate the experience of CIED implantation in patients with CHD.

METHODS

Patients with a diagnosis of CHD and a CIED procedure from January 1, 1995, through June 1, 2020, were identified using a Mayo Clinic proprietary data retrieval tool. Retrospective review was performed to extract relevant data, which included indications for implant, procedural details, complications, and mortality.

RESULTS

A total of 27 patients (55.6% male; mean age at device implant 65.6 ± 8.8 years) with cumulative follow-up of 75 patient-years (median 1.1 years; interquartile range 0.4-4.6 years) were included for analysis. The majority of implanted devices were dual-chamber permanent pacemakers (63%). Among all CHD patients who underwent any cardiac surgery, the incidence of CIED implantation was 12%. The most common indication for implantation was high-grade heart block (66.7%). Device implant complication rates were modest (14.8%). No patient suffered carcinoid crisis during implantation, and there was no periimplant mortality. Median time from implant to death was 2.5 years, with 1-year mortality of 15%.

CONCLUSION

CHD is a morbid condition, and surgical valve intervention carries associated risks, particularly a high requirement for postoperative pacing needs. Our data suggest that CIED implantation can be performed relatively safely. Clinicians must be aware of the relevant carcinoid physiology and take appropriate precautions to mitigate risks.

Permanent pacemaker implantation following mitral valve surgery: a retrospective cohort study of risk factors and long-term outcomes

OBJECTIVES

Conduction disturbances requiring permanent pacemaker (PPM) implantation remain a complication following valvular surgery. PPMs confer the risk of infection, tricuspid valve regurgitation and pacing-induced cardiomyopathy. Literature examining PPM placement in mitral valve surgery (MVS) is limited.

METHODS

Our institutional mitral valve (MV) database was retrospectively reviewed for adult patients undergoing surgery from 2011 to 2019. Patients with preoperative PPM were excluded. Patients were stratified by the receipt of PPM following their index operations. Multivariable logistic regression was performed to determine patient and operative risk factors for PPM. Subgroup analysis was performed on patients who underwent isolated MVS. Kaplan-Meier analysis and a multivariable Cox proportional hazards model were utilized to assess the association between PPM implantation and long-term survival.

RESULTS

A total of 3391 (2991 non-PPM and 400 PPM) patients met the study criteria. Significant predictors of PPM included increased decade of age (odds ratio: 1.23; 95% confidence interval: 1.12-1.35), concomitant aortic (1.44; 1.10-1.90) and tricuspid valve procedures (2.21; 1.64-2.97) and prior history of myocardial infarction (1.48; 1.07-1.86). In the isolated MV repair population, annuloplasty with ring prosthesis was associated with PPM (3.09; 1.19-8.02). Patients in the replacement population did not have significant identifiable risk factors. There was no survival difference found, and postoperative PPM placement was not found to be an independent predictor of mortality.

CONCLUSIONS

Our primary aim was to elucidate predictors for PPM implantation in MVS and found increasing age and concomitant procedures to be risk factors. Receipt of PPM is associated with worse long-term survival but does not independently predict survival. Among patients undergoing isolated MV repair, use of an annuloplasty ring confers a higher risk of PPM compared to an annuloplasty band.

Long-term Outcomes Associated With Permanent Pacemaker Implantation After Surgical Aortic Valve Replacement

IMPORTANCE

Prior studies investigating the long-term clinical outcomes of patients who have undergone permanent pacemaker implantation after aortic valve replacement reported conflicting results.

OBJECTIVE

To investigate long-term outcomes after primary surgical aortic valve replacement among patients who underwent postoperative permanent pacemaker implantation.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included all patients who underwent surgical aortic valve replacement in Sweden from 1997 to 2018. All patients who underwent primary surgical aortic valve replacement in Sweden and survived the first 30 days after surgical treatment were included. Patients who underwent preoperative permanent pacemaker implantation, concomitant surgical treatment for another valve, or emergency surgical treatment were excluded. Patients who underwent concomitant coronary artery bypass grafting or surgical treatment of the ascending aorta were included. Follow-up data were complete for all patients. Data were analyzed from October through December 2020.

EXPOSURES

Patients underwent implantation of a permanent pacemaker or implantable cardioverter defibrillator within 30 days after aortic valve replacement.

MAIN OUTCOMES AND MEASURES

The primary outcome was all-cause mortality.

RESULTS

Among 24 983 patients who underwent surgical aortic valve replacement, 849 patients (3.4%) underwent permanent pacemaker implantation within 30 days after surgical treatment and 24 134 patients (96.6%) did not receive pacemakers in that time. The mean (SD) age of the total study population was 69.7 (10.8) years, and 9209 patients were women (36.9%). The mean (SD) and maximum follow-up periods were 7.3 (5.0) years and 22.0 years, respectively. At 10 years and 20 years after surgical treatment, the Kaplan-Meier estimated survival rates were 52.8% and 18.0% in the pacemaker group, respectively, and 57.5% and 19.6% in the nonpacemaker group, respectively. All-cause mortality was statistically significantly increased in the pacemaker group compared with the nonpacemaker group (hazard ratio [HR], 1.14; 95% CI, 1.01-1.29; P = .03), and so was risk of heart failure hospitalization (HR, 1.58; 95% CI, 1.31-1.89; P < .001). No statistically significant increase was found in the risk of endocarditis in the pacemaker group.

CONCLUSIONS AND RELEVANCE

This study found that there were increased risks of all-cause mortality and heart failure hospitalization among patients who underwent permanent pacemaker implantation after surgical aortic valve replacement, suggesting that these risks are important considerations, especially in an era when transcatheter aortic valve replacement is used in younger patients at lower risk of adverse surgical outcomes. These findings further suggest that future research should investigate how to avoid permanent pacemaker dependency after surgical and transcatheter aortic valve replacement.

Transcatheter aortic valve implantation in low-risk patients: A case of rational over exuberance. The time is not now

BACKGROUND

Review of evidence and concerns, relating to extension of transcatheter aortic valve implantation usage to low-risk patients.

METHODS

Comprehensive literature review was conducted identifying articles relating to transcatheter aortic valve implantation.

RESULTS

Transcatheter aortic valve implantation is effective in patients with aortic stenosis. Currently, long-term durability and cost-effectiveness are unproven, anticoagulation requirement undefined, permanent pacemaker implantation and paravalvular leak rates higher than following surgical aortic valve replacement.

CONCLUSIONS

Current evidence supporting transcatheter aortic valve implantation usage in low-risk patients is insufficient. Extending use now, to this large young patient population is premature, and should be delayed.

Impact of postoperative complications after cardiac surgery on long-term survival

PURPOSE

The impact of postoperative complications on long-term survival is not well characterized. We sought to study the prevalence of postoperative complications after cardiac surgery and their impact on long-term survival.

METHODS

Operative survivors (n = 26,221) who underwent coronary artery bypass grafting (CABG) (n = 13,054, 49.8%), valve surgery (n = 8667, 33.1%) or combined CABG and valve surgery (n = 4500, 17.2%) from 1993 to 2019 were included in the study. Records were reviewed for postoperative complications and long-term survival. Propensity-match analysis was performed between patients who did and did not have a postoperative complication. The associations between postoperative complications and survival were assessed using a Cox-proportional model.

RESULTS

Complications occurred in 17,463 (66.6%) of 26,221 operative survivors. A total of 17 postoperative complications were analyzed. Postoperative blood product use was the commonest (n = 12,397, 47.3%), followed by atrial fibrillation (n = 8399, 32.0%), prolonged ventilation (n = 2336, 8.9%), renal failure (n = 870, 3.3%), reoperation for bleeding (n = 859, 3.3%) and pacemaker/ICD insertion (n = 795, 3.0%). Stroke (hazard ratio [HR]: 1.55; 95% confidence interval [CI]: 1.36-1.77), renal failure (HR: 1.45; 95% CI: 1.33-1.58) and pneumonia (HR: 1.23; 95% CI: 1.11-1.36) had the strongest impact on long-term survival. Long-term survival decreased as the number of postoperative complications increased.

CONCLUSIONS

Postoperative complications after cardiac surgery significantly impact outcomes that extend beyond the postoperative period. Stroke, renal failure, and pneumonia are particularly associated with poor long-term survival.

Tricuspid valve annuloplasty and mitral valve replacement are associated with bradyarrhythmia after mitral valve surgery

INTRODUCTION

Mitral valve surgery has developed into a strong subspecialty of cardiac surgery with operative techniques and outcomes constantly improving. The development of bradyarrhythmias after mitral valve surgery is not completely understood.

METHODS

We investigated a cohort of 797 patients requiring mitral valve surgery with and without concomitant procedures. Incidences and predictors of pacemaker requirement as well as survival were analyzed.

RESULTS

In the complete follow-up period (median follow-up time: 6.09 years [95% confidence interval [CI]: 5.94-6.22 years, maximum 8.77 years) 80 patients (10% of the complete cohort) required pacemaker implantation for bradyarrhythmia. The cumulative rate of pacemaker implantation was 6.4% at 50 days (48 patients) with most (54.2%) requiring pacing for atrioventricular block. Mitral valve replacement (odds ratio [OR]: 1.905; 95% CI: 1.206-3.536; p = .041) and tricuspid ring annuloplasty (OR: 2.348; 95% CI: 1.165-4.730, p = .017) were identified as operative risk factors of pacemaker requirement after mitral valve surgery. Insulin-dependent diabetes mellitus was also identified as a predictor of pacemaker requirement (OR: 4.665; 95% CI: 1.975-11.02; p = .001). There was no difference in survival in the paced and unpaced groups.

CONCLUSIONS

After mitral valve surgery, a relevant subgroup of patients requires pacemaker implantation-most for atrioventricular block. We identified mitral valve replacement and tricuspid ring annuloplasty as significant operative risk factors and insulin-dependent diabetes mellitus as a demographic risk factor. While anatomic relationships help explain the operative risk factors the role of diabetes mellitus is not completely understood.

Relation of Prolonged Pacemaker Dependency After Cardiac Surgery to Mortality

Permanent pacemaker implantation (PPI) represents a rare complication after cardiac surgery, with no uniform agreement on timing and no information on follow-up. A multicenter retrospective study was designed to assess pacemaker dependency (PMD) and long-term mortality after cardiac surgery procedures. Between 2004 and 2016, PPI-patients from 18 centers were followed. Time-to-event data were evaluated with semiparametric regression Cox models and semiparametric Fine and Gray model for competing risk framework. Of 859 (0.90%) PPI-patients, 30% were pacemaker independent (PMI) at 6 months. PMD showed higher mortality compared with PMI (10-year survival 80.1% ± 2.6% and 92.2% +2.4%, respectively, log-rank p-value < 0.001) with an unadjusted hazard ratio for death of 0.36 (95% CI 0.20 to 0.65, p< 0.001 favoring PMI) and an adjusted hazard ratio of 0.19 (95% CI 0.08 to 0.45, p< 0.001 with PMD as reference). Crude cumulative incidence function of restored PMI rhythm at follow-up at 6 months, 1 year and 12 years were 30.5% (95% CI 27.3% to 33.7%), 33.7% (95% CI 30.4% to 36.9%) and 37.2% (95% CI 33.8% to 40.6%) respectively. PMI was favored by preoperative sinus rhythm with normal conduction (SR) (HR 2.37, 95% CI 1.65 to 3.40, p< 0.001), whereas coronary artery bypass grafting and aortic valve replacement were independently associated with PMD (HR 0.63, 95% CI 0.45 to 0.88, p = 0.006 and HR 0.807, 95% CI 0.65 to 0.99, p = 0.047 respectively). Time-to-implantation was not associated with increased rate of PMI. Although 30% of PPI-patients are PMI after 6 months, PMD is associated with higher mortality at long term.

Reduced Permanent Pacemaker Implantation in Patients With Stentless Freedom SOLO Compared With Stented Perimount Magna Aortic Bioprostheses: A Propensity Score Weighted Analysis

OBJECTIVES

Postoperative permanent pacemaker implantation (PPI) after conventional aortic valve replacement (AVR), due to new-onset severe conduction system disorders, is required in approximately 7% of patients. This study investigated the need for PPI after AVR with conventional stented Perimount Magna compared with the Freedom SOLO (FS) stentless valve (Sorin Group, Saluggia, Italy), now LivaNova plc (London, UK) that uses a strictly supra-annular, subcoronary running suture implantation technique, sparing the vulnerable interleaflet triangles in the region of the septum membranaceum.

METHODS

A total of 413 consecutive patients (71.4±9.2 yrs, 178 [43.1%] female) underwent isolated AVR using the stented Perimount Magna (n=264) or the stentless FS (n=149) bioprosthesis. Propensity score weighted analysis was used to account for patient-specific and procedural-specific variables, and to identify the prosthesis-specific need for early postoperative PPI within 30 days of AVR.

RESULTS

Twenty (20) patients required PPI, which was associated with longer intensive care unit (2.1±1.7 vs 1.5±3.0 days, p<0.001) and overall hospital stays (13.8±5.2 vs 10.7±5.3 days, p<0.001) compared with no PPI. Propensity weighted logistic regression including cross-clamp times identified that use of the stented Perimount Magna was associated with increased need for PPI, as compared with the FS, with an odds ratio 5.8 (95% CI, 1.09-30.76; p=0.039).

CONCLUSIONS

After corrections for all plausible confounders, AVR with the stented Perimount valve was associated with an odds ratio of almost 6 for an increased early postoperative need for pacemaker implantation compared with the FS stentless valve. This finding can be explained by the conventional implantation technique, which is potentially associated with mechanical trauma to the conducting system.

Permanent pacemaker implantation after cardiac surgery: Optimization of the decision making process

BACKGROUND

Conduction disturbances necessitating permanent pacemaker (PPM) implantation after cardiac surgery occur in 1% to 5% of patients. Previous studies have reported a low rate of late PPM dependency, but there is lack of evidence that it might be related to implantation timing. In this study, we sought to determine whether PPM implantation timing and specific conduction disturbances as indications for PPM implantation are associated with late pacemaker dependency and recovery of atrioventricular (AV) conduction.

METHODS

Patients with a PPM implanted after cardiac surgery were followed in an outpatient clinic. Two outcomes were assessed: AV conduction recovery and PPM dependency, defined as the absence of intrinsic rhythm on sensing test in VVI mode at 40 bpm.

RESULTS

Of 15,092 patients operated between September 2008 and March 2019, 185 (1.2%) underwent PPM implantation. One hundred seventy-seven of these patients met the criteria for inclusion into this study. Follow-up data were available in 145 patients (82%). Implantation was performed at ≤6 days after surgery in 58 patients (40%) and at >6 days after surgery in 87 patients (60%). The median time from implantation to last follow-up was 890 days (range, 416-1998 days). At follow-up, 81 (56%) patients were not PPM dependent. Multivariable analysis showed that PPM implantation at ≤6 days after surgery is a predictor of being not PPM dependent (odds ratio [OR], 5.40; 95% confidence interval [CI], 2.43-12.04; P < .001) and of AV conduction recovery (OR, 4.96; 95% CI, 2.26-10.91; P < .001). Sinus node dysfunction as indication for PPM implantation was predictive of being not PPM dependent (OR, 6.59; 95% CI, 1.67-26.06; P = .007).

CONCLUSIONS

We recommend implanting a PPM on postoperative day 7 to prevent unnecessary implantations and avoid prolonged hospitalization.

Incidence of permanent pacemaker implantation after valve replacement surgery : Cardiac structure and function at 1-year follow-up

BACKGROUND

Our study aimed to explore the incidence and risk factors of permanent pacemaker implantation (PPI) after valve replacement surgery (VR). The influence of long-term pacemaker dependency on cardiac structure and function at the 1‑year follow-up was also assessed.

METHODS

The demographic and surgical data of all consecutive patients who underwent VR between 2013 and 2016 were collected. Univariate and multivariate analyses were performed to identify variables independently associated with PPI after VR. A 1‑year follow-up was undertaken of patients who underwent dual-chambers pacemaker after VR because of complete atrioventricular block (AVB). Long-term pacemaker dependency and recovery of cardiac structure and function were evaluated.

RESULTS

There were 5320 consecutive patients with VR. The incidence of postoperative PPI was 2.42%. Multivariate analysis indicated that among the 62 patients who underwent PPI due to AVB and sick sinus syndrome, isolated aortic valve replacement (AVR; OR: 2.24, p < 0.05), VR combined with ventricular septal defect (VSD) repair (OR: 6.78, p < 0.05), and VR with aortic root and arch surgery (OR: 4.14, p < 0.05) were independent predictors of PPI after surgery. In total, 89.6% (43/48) of the survivors showed pacemaker dependency. Of these 43 patients, 24 had enlarged left heart before VR. Compared with preoperative values, the left atrial and left ventricular end-diastolic diameter post-PPI decreased significantly, while left ventricular ejection fraction was not significantly different.

CONCLUSION

Isolated AVR, VR concomitant with VSD repair, and VR with aortic root and arch surgery are independent predictors of PPI after VR. The majority of patients do not recover from AVB disorders and there is no significant negative effect on recovery of cardiac structure and function.

Predictors of pacing-dependency in patients with cardiovascular implantable electronic devices

BACKGROUND

Data on the prevalence and predictors for the development of pacing-dependency in patients with cardiovascular implantable electronic devices (CIEDs) are sparse.

METHODS

Pacing-dependency defined as an absence of intrinsic rhythm of ≥ 30 bpm was determined in 802 consecutive patients with CIEDs who visited the documented pacemaker or implantable cardioverter- defibrillator outpatient clinic for routine follow-up.

RESULTS

A total of 131 (16%) patients were found to be pacing-dependent 67 ± 70 months after CIED implant. Multivariate analysis revealed a significant association between pacing-dependency and the following clinical variables: second or third-degree atrioventricular (AV) block at implant (OR = 19.9; 95% CI: 10.9-38.5, p < 0.01), atrial fibrillation at implant (OR = 2.15; 95% CI: 1.16-4.05, p = 0.02), left ventricular ejection fraction (LVEF) ≤ 30% (OR = 2.06; 95% CI: 1.03-4.15, p = 0.04), B-type natriuretic peptide (BNP) > 150 pg/mL (OR = 2.12; 95% CI: 1.16-3.97, p = 0.02), chronic kidney disease (OR = 1.86; 95% CI: 1.08-3.26, p = 0.03), and follow-up duration after implantation > 5 years (OR = 3.29; 95% CI: 1.96-5.64, p < 0.01). None of the remaining clinical variables including age, gender, diabetes mellitus, underlying heart disease, prior cardiac surgery or medication during follow-up including betablockers and amiodarone predicted pacing-dependency.

CONCLUSIONS

Pacing-dependency is associated with second or third-degree AV-block at implant, atrial fibrillation before implant, low LVEF, elevated BNP, chronic kidney disease and follow-up duration after implant.

Common Postcardiothoracic Surgery Arrhythmias

Cardiac arrhythmias are common after cardiac surgery and have profound sequelae. Bradycardias are typically transient and have reversible causes; however, persistent atrioventricular block is an indicator for permanent pacemaker implantation after valvular surgery. Transcatheter aortic valve surgery is associated with even higher rates of permanent pacemaker implantation. Atrial fibrillation, the most common postoperative arrhythmia, is associated with ischemic stroke, myocardial infarction, congestive heart failure, and short-term mortality. Ventricular arrhythmias have extremely high in-hospital mortality, as well as long-term mortality for those who survive the initial event. Implantable cardioverter-defibrillators have been shown to reduce long-term mortality for these patients.

Permanent pacing and conduction recovery in patients undergoing cardiac surgery for active infective endocarditis in an Australian Tertiary Center

BACKGROUND

Postoperative heart block is common among patients undergoing surgery for infective endocarditis (IE). Limited data exists allowing cardiologists to predict who will require permanent pacemaker (PPM) implantation postoperatively. We aimed to determine the rate of postoperative PPM insertion, predictors for postoperative PPM, and describe PPM utilization and rates of device-related infection during follow-up.

MATERIALS AND METHODS

A retrospective analysis was performed of 191 consecutive patients from a single institution who underwent cardiac surgery for IE between 2001 and 2017. Preoperative and operative predictors for postoperative PPM were evaluated using univariate and multivariate logistic regression.

RESULTS

The rate of postoperative PPM implantation was 11% (17/154). The PPM group had more preoperative prolonged PR interval alone (33% vs 12%; P = .03), coexistent prolonged PR and QRS durations (13% vs 2%; P = .01), infection beyond the valve leaflets (82% vs 41%; P = .001), aortic root debridement (65% vs 23%; P = <.001), patch repair (47% vs 20%; P = .01), postoperative prolonged PR interval (50% vs 24%; P = .01), and prolonged QRS duration (47% vs 15%; P = .001). On multivariate analysis, infection beyond the valve leaflets emerged as an independent predictor for postoperative PPM (odds ratio, 1.94, 95% confidence interval, 1.14-3.28; P = .014). A reduction in PPM utilization was observed in five patients while eight patients continued to show significant ventricular pacing with no underlying rhythm at 12 months. There were no device-related infections.

CONCLUSION

Postoperative PPM was required in 11% of patients undergoing surgery for IE over a 16-year period. Infection beyond the valve leaflet was an independent predictor for postoperative PPM insertion.

Bradyarrhythmia development and permanent pacemaker implantation after cardiac surgery

OBJECTIVE:

Bradyarrhythmia is one of the complications that may develop after cardiac surgery. Only a few studies have previously dealt with this concern, and in our study, we investigated the factors affecting the development of atrioventricular block or sinus node dysfunction and the requirement of permanent pacemaker following cardiac surgery.

METHODS:

A total of 62 patients who developed the atrioventricular (AV) block or sinus node dysfunction and required a permanent pacemaker following cardiac surgery were included in the study. Among these, 31 patients were evaluated prospectively, and the information regarding 31 patients was evaluated retrospectively based on hospital records. Demographic, clinical, and surgical information was recorded. Patients were grouped according to the types of procedures, including the coronary artery bypass graft, valve surgery, congenital heart disease, and combinations of these. Patients were evaluated by standard 12-lead electrocardiogram and transthoracic echocardiography preoperatively. The postoperative development of bradyarrhythmia and requirement of permanent pacemaker were evaluated.

RESULTS:

The mean age of patients with preoperative conduction abnormality and wide QRS was statistically significantly higher than those without these disorders. The odds ratio for preoperative conduction abnormality risk in patients over 70 years of age was found as 4.429 (95% confidence interval, 1.40–13.93). There was no gender-related statistically significant difference in terms of left ventricular ejection fraction, left ventricular dilatation, interventricular septum thickness, the time interval from operation to the development of AV block, concomitant diseases, and complication rates.

CONCLUSION:

Preoperative conduction abnormality and wide QRS in patients over 70 years of age was determined as a risk factor.

When to Choose Surgery in the Era of Transcatheter Aortic Valve Replacement

Treatment of severe symptomatic aortic stenosis has undergone significant changes with the advent of transcatheter aortic valve replacement (TAVR). Initially reserved for inoperable patients, these devices have improved; outcomes now rival or outperform surgical treatment. TAVR is recommended for high-risk and certain intermediate-risk patients. As transcatheter aortic valve replacement becomes an option for younger, healthier patients, long-term planning and thoughtful considerations of potential subsequent interventions are paramount. A robust understanding of risks, benefits and expected outcomes with TAVR is critical to provide patients with the best treatment option.

Association of cardiac implantable electronic devices with survival in bifascicular block and prolonged PR interval on electrocardiogram

PURPOSE

Bifascicular block and prolonged PR interval on the electrocardiogram (ECG) have been associated with complete heart block and sudden cardiac death. We sought to determine if cardiac implantable electronic devices (CIED) improve survival in these patients.

METHODS

We assessed survival in relation to CIED status among 636 consecutive patients with bifascicular block and prolonged PR interval on the ECG. In survival analyses, CIED was considered as a time-varying covariate.

RESULTS

Average age was 76 ± 9 years, and 99% of the patients were men. A total of 167 (26%) underwent CIED (127 pacemaker only) implantation at baseline (n = 23) or during follow-up (n = 144). During 5.4 ± 3.8 years of follow-up, 83 (13%) patients developed complete or high-degree atrioventricular block and 375 (59%) died. Patients with a CIED had a longer survival compared to those without a CIED in the traditional, static analysis (log-rank p < 0.0001) but not when CIED was considered as a time-varying covariate (log-rank p = 0.76). In the multivariable model, patients with a CIED had a 34% lower risk of death (hazard ratio 0.66, 95% confidence interval 0.52-0.83; p = 0.001) than those without CIED in the traditional analysis but not in the time-varying covariate analysis (hazard ratio 1.05, 95% confidence interval 0.79-1.38; p = 0.76). Results did not change in the subgroup with a pacemaker only.

CONCLUSIONS

Bifascicular block and prolonged PR interval on ECG are associated with a high incidence of complete atrioventricular block and mortality. However, CIED implantation does not have a significant influence on survival when time-varying nature of CIED implantation is considered.

Frailty as a Risk Factor for Cardiovascular Versus Noncardiovascular Mortality in Older Men: Results From the MrOS Sleep (Outcomes of Sleep Disorders in Older Men) Study

Background

Frailty is associated with greater mortality; however, whether frail patients primarily die of cardiovascular disease (CVD) or non‐CVD causes is unknown.

Methods and Results

We assessed the cause of death in relation to frailty status, measured at baseline, among 3135 community‐dwelling older men in the MrOS Sleep (Outcomes of Sleep Disorders in Older Men) study. Absolute probability and risk of CVD mortality associated with frailty status were estimated with traditional methods that used censoring and newer methods that considered non‐CVD mortality as a competing risk. Of the 3135 men (mean age: 76.4±5.6 years), 475 (15.2%) were frail. During an average follow‐up of 9.2 years, 1275 (40.7%) men died, including 445 (34.9%) from CVD and 828 (64.9%) from non‐CVD causes (2 deaths unadjudicated). Both CVD and non‐CVD mortality risk increased with frailty. Cumulative absolute probability of CVD death at 10 years among frail men was 23.8% (20.2–27.6%) using the competing risk method versus 32.5% (27.3–37.8%) using the traditional Kaplan–Meier method (41.5% [95% confidence interval, 36.9–45.9%] and 48.6% [95% confidence interval, 43.6–53.4%], respectively, for non‐CVD mortality). The multivariable‐adjusted risk of CVD death among frail versus robust men was 1.38 (95% confidence interval, 0.99–1.92) using the competing risk method versus 1.84 (95% confidence interval, 1.35–2.51) using the traditional Cox proportional hazards method.

Conclusions

Among community‐dwelling older men, ≈35% of the deaths were due to CVD. Frail men were at increased risk of CVD death, but ignoring the competing risk of non‐CVD mortality overestimated their long‐term probability and relative risk of CVD death.

Need for Permanent Pacemaker After Surgical Aortic Valve Replacement Reduces Long-Term Survival

BACKGROUND

Permanent pacemaker (PPM) implantation has been touted as an inconsequential complication after transcatheter aortic valve replacement. As transcatheter aortic valve replacement moves to lower risk patients, the long-term implications remain poorly understood; therefore, we evaluated the long-term outcomes of pacemaker for surgical aortic valve replacement patients.

METHODS

A total of 2,600 consecutive patients undergoing surgical aortic valve replacement over the past 15 years were reviewed using The Society of Thoracic Surgeons (STS) institutional database and Social Security death records. Patients were stratified by placement of a PPM within 30 days of surgery. The impact of PPM placement on long-term survival was assessed by Kaplan-Meier analysis and risk-adjusted survival by Cox proportional hazards modeling.

RESULTS

A total of 72 patients (2.7%) required PPM placement postoperatively. Patients requiring PPM had more postoperative complications, including atrial fibrillation (43.1% versus 27.0%, p = 0.003), prolonged ventilation (16.7% versus 5.7%, p < 0.0001), and renal failure (12.5% versus 4.6%, p = 0.002). These led to greater resource utilization including longer intensive care unit stay (89 versus 44 hours, p < 0.0001) and hospital length of stay (9 versus 6 days, p < 0.0001), and higher inflation-adjusted hospital cost ($81,000 versus $47,000, p < 0.0001). Median follow-up was 7.5 years, and patients requiring PPM had significantly worse long-term survival (p = 0.02), even after risk adjustment with STS predicted risk of mortality (hazard ratio 1.48, p = 0.02).

CONCLUSIONS

The need for PPM after aortic valve replacement independently reduces long-term survival. The rate of PPM placement after surgical aortic valve replacement remains very low but dramatically increases resource utilization. As transcatheter aortic valve replacement expands to low-risk patients, the impact of PPM placement on long-term survival warrants close monitoring.

Trends of hospitalizations for syncope/collapse in the United States from 2004 to 2013-An analysis of national inpatient sample

INTRODUCTION

Syncope/collapse is a common reason for emergency department visits, and approximately 30-40% of these individuals are hospitalized. We examined changes in hospitalization rates, in-hospital mortality, and cost of syncope/collapse-related hospital care in the United States from 2004 to 2013.

METHODS

We used the US Nationwide Inpatient Sample (NIS) from 2004 to 2013 to identify syncope/collapse-related hospitalizations using ICD-9, code 780.2, as the principal discharge diagnosis. Data are presented as mean ± SEM.

RESULTS

From 2004 to 2013, there was a 42% reduction in hospitalizations with a principal discharge diagnosis of syncope/collapse from 54,259 (national estimate 253,591) in 2004 to 31,427 (national estimate 156,820) in 2013 (P < 0.0001). The mean length of hospital stays decreased (2.88 ± 0.04 days in 2004 vs. 2.54 ± 0.02 in 2013; P < 0.0001), while in-hospital mortality did not change (0.28% in 2004 vs. 0.18% in 2013; P  =  0.12). However, mean charges (inflation adjusted) for syncope/collapse-related hospitalization increased by 43.6% from $17,514 in 2004 to $25,160 in 2013 (P < 0.0001). The rates of implantation of permanent pacemakers and implantable cardioverter defibrillator remained low during these hospitalizations, and decreased over time (P for both < 0.0001).

CONCLUSIONS

Hospitalization rates for syncope/collapse have decreased significantly in the US from 2004 to 2013. Despite a modest reduction in length of stay, the cost of syncope/collapse-related hospital care has increased.

Outcomes of intermediate-risk patients treated with transcatheter and surgical aortic valve replacement in the Veterans Affairs Healthcare System: A single center 20-year experience

BACKGROUND

Transfemoral transcatheter aortic valve replacement (TAVR) was superior to surgical aortic valve replacement (SAVR) in the placement of aortic transcatheter valves (PARTNER) 2A trial (P2). The generalizability of the trial results to the broader population of patients with intermediate surgical risk remains unknown.

OBJECTIVE

To compare the outcomes of SAVR and TAVR among patients with intermediate surgical risk treated in the VA Healthcare System.

METHODS

We retrospectively analyzed the clinical characteristics and outcomes on all SAVR (1987-2014) and TAVR procedures (2015-2017) performed at the Minneapolis VA Healthcare System. Patients were divided into three groups based on their estimated 30-day mortality risk. The primary outcome was a composite of death or stroke at 30-days.

RESULTS

A total of 1,049 patients underwent SAVR with (n = 468, 45%) or without CABG (n = 581, 55%) and 110 underwent TAVR during the study period. Intermediate-risk patients represented 29.4% and 40% of patients undergoing SAVR and TAVR, respectively. The predicted 30-day mortality risk of intermediate-risk patients was 5.5% for the SAVR group and 5.2% for the TAVR group (P = 0.54). The observed combined rate of stroke or death at 30-days for intermediate-risk patients treated with SAVR and TAVR was 11% and 2.2%, respectively (P = 0.05). The results for SAVR and TAVR at the VA were comparable to the P2 trial and STS database (all P = NS). The results did not change when the analysis was restricted to a more contemporary (2005-2014) surgical cohort or isolated SAVR. The number needed to treat to prevent one death/stroke with TAVR was 10.

CONCLUSIONS

Adoption of TAVR as the preferred treatment modality in intermediate-risk patients may result in significant improvements in morbidity and mortality.

Frequency of Recovery from Complete Atrioventricular Block After Cardiac Surgery

Best timing for permanent pacemaker implantation to treat complete atrioventricular block (AVB) after cardiac surgery is unclear, as late pacemaker dependency was found low in recent observational studies. This study aimed to identify factors associated with spontaneous recovery from AVB. In a prospective and observational cohort, all patients who underwent cardiothoracic surgery during a 14-month-period were included (n = 1,200). Risk factors of postoperative AVB were assessed by logistic regression. Among patients who developed AVB, variables associated with recovery from AVB were assessed by Cox and logistic regression. Overall incidence of postoperative AVB was 6.0%. Risk factors of AVB were age (OR 1.03 [1.00 to 1.06], p = 0.023); female gender (OR 2.06 [1.24 to 3.41], p = 0.005), active endocarditis (OR 3.31 [1.33 to 8.26], p = 0.01), and aortic valve replacement (OR 3.17 [1.92 to 5.25], p <0.001). Among aortic valve replacement, sutureless aortic valve replacement was associated with more AVB (26.7% vs 8.1%, p <0.01). Recovery from AVB occurred in 30 patients (41.7%) in a median period of 3 days [interquartile range = 1;5]. Among patients who would recover from AVB, 90% of patients did so before day 7. None of the studied variable was independently associated with recovery from AVB. In conclusion, identified risk factors of postoperative AVB after cardiac surgery were age, female gender, endocarditis, and aortic valve replacement. Because most patients who would recover did so before day 7, this study validates modern guidelines suggesting permanent pacemaker implantation on day 7.

Impact of prior permanent pacemaker on long-term clinical outcomes of patients undergoing percutaneous coronary intervention

BACKGROUND

The impact of permanent pacemaker (PPM) on long-term clinical outcomes of patients undergoing percutaneous coronary intervention (PCI) has not been studied.

HYPOTHESIS

PPM may increase heart failure (HF) burden on patients undergoing PCI.

METHODS

We recruited consecutive patients undergoing PCI and carried out a nested case-control study. Patients with confirmed PPM undergoing first PCI were identified and matched by age and sex in 1:1 fashion to patients without PPM undergoing first PCI. Clinical data were collected and analyzed. The primary endpoint outcomes were all-cause mortality and hospitalization for HF.

RESULTS

The final analysis included 156 patients. The mean follow-up period was 4.6 ± 2.9 years. The overall all-cause mortality was 21.15%, without significant difference between the 2 groups (21.79% vs 20.51%; P = 0.85). However, the rate of HF-related hospitalization was significantly higher in patients with PPM than in controls (26.92% vs 10.26%; P = 0.008). After adjustment for hypertension, type 2 diabetes mellitus, hyperlipidemia, chronic kidney disease, stroke, left ventricular ejection fraction, brain natriuretic peptide, and acute coronary syndrome (ACS), PCI patients with PPM were still associated with a greater hospitalization rate for HF (odds ratio: 4.31, 95% confidence interval: 0.94-19.80, P = 0.061). Further analysis in the ACS subgroup showed VVI-mode pacing enhanced the risk for HF-associated hospitalization (adjusted odds ratio: 8.27, 95% confidence interval: 1.37-49.75, P = 0.02).

CONCLUSIONS

PPM has no effect on all-cause mortality in patients undergoing first PCI but significantly increases the HF-associated hospitalization rate, especially in ACS patients.

Predictors of Permanent Pacemaker Implantation After Coronary Artery Bypass Grafting and Valve Surgery in Adult Patients in Current Surgical Era

Background

Permanent pacemaker (PPM) implantation after cardiac surgery is required in 0.4-6% of patients depending on cardiac surgery type. PPM implantation in the early postoperative period may reduce morbidity and postoperative hospital stay. We performed a retrospective review of electronic medical records of adult patients with coronary artery bypass grafting (CABG), valve surgery, or both, over a 3-year period. Our aim was to identify predictors of PPM requirements and PPM dependency on follow-up in the current surgical era.

Methods

After exclusion of patients with congenital heart disease, patients who already had a PPM or implantable cardioverter defibrillator (ICD), and patients with an indication for PPM or ICD before surgery, we identified 1,234 adult patients who underwent cardiac surgery between January 2007 and December 2009. A retrospective review of electronic medical records and pacemaker clinic data was performed.

Results

Patients’ mean age was 46.65 ± 16 years, and 59% were males. CABG was performed in 575 (46.6%) cases, aortic valve replacement in 263 (21.3%), mitral valve replacement in 333 (27%), and tricuspid valve replacement in 76 patients (6.2%). Twenty patients (1.6%) required implantation of a PPM postoperatively. Indications for PPM implantation included complete atrioventricular (AV) block in 13 (65%), sick sinus syndrome in three (15%), and atrial fibrillation (AF) with a slow ventricular rate in four (20%). Predictors for PPM requirement by multivariate analysis were the presence of pulmonary hypertension (P-HTN), reoperation, and left bundle branch block (LBBB) (P < 0.05). Late follow-up was available in 18 patients, at 84.5 ± 30 months. Eleven patients (61%) were PPM dependent on long-term follow-up.

Conclusions

Patients at high risk for PPM implantation after cardiac surgery include those with P-HTN, reoperation, and pre-existing LBBB. Of those receiving a PPM, about one-third will recover at least partially at long-term follow-up. We recommend preoperative assessment for risk of requiring postoperative PPM, to counsel patients about this risk and early PPM implantation in high-risk patients who are PPM dependent after surgery.

Transcatheter Aortic Valve Implantation in Lower-Risk Patients With Aortic Stenosis

Transcatheter aortic valve implantation underwent progressive improvements until it became the default therapy for inoperable patients, and a recommended therapy in high-risk operable patients with symptomatic severe aortic stenosis. In the lower-risk patient strata, a currently costly therapy that still has important complications with questionable durability is competing with the established effective and still-improving surgical replacement. This report tries to weigh the clinical evidence, the recent technical improvements, the durability, and the cost-effectiveness claims supporting the adoption of transcatheter aortic valve implantation in intermediate-low risk patients. The importance of appropriate patients’ risk stratification and a more comprehensive approach to estimate that risk are also emphasized in the present report.

Effect of Coronary Artery Bypass Grafting on Left Ventricular Ejection Fraction in Men Eligible for Implantable Cardioverter-Defibrillator

Implantable cardioverter-defibrillator (ICD) therapy for primary prevention of sudden cardiac death is not routinely recommended within 90 days of coronary artery bypass grafting (CABG) because of the possibility of an improvement in left ventricular ejection fraction (EF) to>35% after revascularization. We sought to determine the incidence and predictors of EF improvement to >35% after isolated CABG in patients who had a preoperative EF ≤35%. We studied 375 patients who underwent CABG at a tertiary institution and had an echocardiogram preoperatively and postoperatively. Of these, 74 patients (20%) with a preoperative EF ≤35% were included in this analysis. Improvement in EF was defined as postoperative EF >35%. In the overall study population (n = 74), mean EF improved from 28 ± 6% preoperatively to 36 ± 12% postoperatively (p <0.0001). A total of 38 patients (51%) had postoperative improvement in EF to >35% (mean EF in these patients increased from 30 ± 5% to 46 ± 8%; p <0.0001). Patients with EF improvement had a higher preoperative EF than those with no improvement (30 ± 5% vs 26 ± 7%, p <0.005). Improvement in EF was 5 times more likely in patients with preoperative EF 26% to 35% (odds ratio 4.95, 95% CI 1.73 to 14.1; p = 0.003) than those with preoperative EF ≤25%. Other clinical characteristics were not significantly different between patients with versus without EF improvement. In conclusion, more than half of the ICD-eligible patients who underwent CABG improved their EF to >35% after surgery and became ineligible for a primary prevention ICD. EF improvement was unlikely in patients with preoperative EF <25%.

Pacemaker Dependency after Cardiac Surgery: A Systematic Review of Current Evidence

Background

Severe postoperative conduction disturbances requiring permanent pacemaker implantation frequently occur following cardiac surgery. Little is known about the long-term pacing requirements and risk factors for pacemaker dependency in this population.

Methods

We performed a systematic review of the literature addressing rates and predictors of pacemaker dependency in patients requiring permanent pacemaker implantation after cardiac surgery. Using a comprehensive search of the Medline, Web of Science and EMBASE databases, studies were selected for review based on predetermined inclusion and exclusion criteria.

Results

A total of 8 studies addressing the endpoint of pacemaker-dependency were identified, while 3 studies were found that addressed the recovery of atrioventricular (AV) conduction endpoint. There were 10 unique studies with a total of 780 patients. Mean follow-up ranged from 6–72 months. Pacemaker dependency rates ranged from 32%-91% and recovery of AV conduction ranged from 16%-42%. There was significant heterogeneity with respect to the definition of pacemaker dependency. Several patient and procedure-specific variables were found to be independently associated with pacemaker dependency, but these were not consistent between studies.

Conclusions

Pacemaker dependency following cardiac surgery occurs with variable frequency. While individual studies have identified various perioperative risk factors for pacemaker dependency and non-resolution of AV conduction disease, results have been inconsistent. Well-conducted studies using a uniform definition of pacemaker dependency might identify patients who will benefit most from early permanent pacemaker implantation after cardiac surgery.