Risk factors for pacemaker implantation following aortic valve replacement: a single centre experience

Risk of Pacemaker Implantation After Aortic Root Replacement With and Without Valve Preservation

BACKGROUND

We compared the outcomes of aortic root replacement by composite valve grafts (CVG) and valve-sparing root replacement (VSRR) operations, with an emphasis on postoperative conduction block and the need for permanent pacemaker implantation (PPM).

METHODS

From 1997 to 2023, 1712 consecutive patients underwent ARR by VSRR (501 [29%]) or CVG (1211 [71%]) at a high-volume aortic center.

RESULTS

Patients undergoing CVG were older (59 ± 14 vs 49 ± 14 years, P < .001), with more cardiovascular comorbidities. Compared with CVG, there were more women undergoing VSRR (17% vs. 13%, P = .042) and more patients with connective tissue disease (22% vs 7.3%, P < .001). Multivariable analysis found that the risk for PPM was higher after CVG compared with VSRR (6.5% vs 1.2%; odds ratio [OR], 2.83; 95% CI, 1.23-7.69; P = .024). Other variables associated with PPM include older age (OR, 1.03; 95% CI, 1.01-1.05; P = .006) preoperative renal impairment (OR, 2.69; 95% CI, 1.24-5.6; P = .010), previous operation (OR, 2.76; 95% CI, 1.29-5.62; P = .007), and bicuspid aortic valve (OR, 3.63; 95% CI, 2.13-6.33; P < .001). Among the CVG population, patients who are at increased risk are especially those with some degree of aortic stenosis (OR, 2.06; 95% CI, 1.18-3.61; P = .011). Patients who required PPM had no additive risk for long-term mortality (hazard ratio, 1.01; 95% CI, 0.47-2.17; P = .986); however, they were more likely to have reduced ejection fraction (29.3% vs 16%, P = .014).

CONCLUSIONS

The incidence of PPM after ARR is low, but rates were higher after CVG compared with VSRR.

Ozaki procedure-re-construction of aortic valve leaflets using autologous pericardial tissue: a review

The Ozaki procedure has emerged as a valuable option for treating various aortic valve pathologies. This review article delves into the intricacies of this innovative surgical approach by exploring its adaptation to the complex anatomy and physiology of the aortic root. The diverse etiologies of aortic valve diseases, ranging from congenital anomalies to degenerative changes, make treatment selection a complex challenge. Aortic valve replacement has traditionally been the gold standard, but emerging evidence supports valve repair techniques, emphasizing the importance of preserving native tissue. Nevertheless, issues like lifelong anticoagulation with mechanical valves and patient-prosthetic mismatch remain. The Ozaki procedure offers a compelling alternative by utilizing autologous pericardium or a tissue substitute to construct new aortic valve leaflets. This technique, standardized by Dr. Ozaki in 2007, provides a customizable and adaptable solution. The article highlights the anatomy of the aortic root, emphasizing the critical role of the sinus of Valsalva and interleaflet triangles in maintaining proper valve function. The procedure's unique adaptation to aortic root dynamics allows for reduced mechanical stress during systole and diastole, mimicking the natural valve's behavior. Furthermore, Ozaki leaflets exhibit promising hemodynamics and reduced risks of complications, such as permanent pacemaker implantation and patient-prosthetic mismatch. The use of autologous pericardium in the Ozaki procedure presents advantages, including enhanced tissue strength, minimal immunogenicity, and reduced risk of immune-mediated calcification. These factors contribute to the longevity and resilience of the reconstructed valve. This comprehensive review aims to shed light on the procedure's intricacies, its alignment with aortic root anatomy and physiology, and its potential as a valuable tool in the armamentarium of aortic surgeons.

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.

Surgical management of aortic regurgitation secondary to Behcet's disease

Background

Aortic regurgitation (AR) related to Behcet's disease (BD) is rare, but usually fatal. Perivalvular leakage (PVL) is high if AR related to BD treated with regular AVR. In this study, we report the surgical management of AR secondary to BD.

Methods

Between September 2017 and April 2022, 38 patients with AR secondary to Behcet's disease had surgery in our center. 17 patients did not have a BD diagnosis before surgery, 2 of them were diagnosed during surgery and received Bentall procedure. The remaining 15 patients received conventional AVR. 21 patients were diagnosed as BD before surgery, all of them received modified Bentall procedures. All patients were followed up by regular outpatient visits, transthoracic echocardiogram and CT angiography were performed to evaluate the aorta and aortic valve.

Results

Seventeen patients did not have a BD diagnosis at the time of surgery. Out of them, 15 patients received conventional AVR, and a total of 13 patients suffered PVL after surgery. Twenty-one patients had a BD diagnosis before surgery. They received modified Bentall procedures and IST and steroids were given both pre- and post-surgery. In this group treated with Bentall procedure no patient suffered PVL during follow up.

Conclusions

PVL is a complex scenario after conventional AVR for AR in BD. Modified Bentall procedure seems superior to isolated AVR in these cases. The use of IST and steroids before and after surgery in combination with modified Bentall procedure could have a role in effectively reducing PVL.

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.

Incidence and predictors of permanent pacemaker implantation after surgical aortic v alve replacement: Data of the Netherlands Heart Registration (NHR)

OBJECTIVE

Permanent pacemaker implantation (PPI) after surgical aortic valve replacement (SAVR) remains a frequent complication. Predictors, however, have been mainly investigated in single-center studies. Therefore, nationwide data were used to identify patients-and procedural risk factors for postoperative PPI.

MATERIALS AND METHODS

Data were retrospectively collected from the Netherlands Heart Registration (NHR). Patients enrolled in the NHR undergoing isolated SAVR from 2013 to 2019 were analyzed. Primary endpoint was in-hospital PPI during hospitalization after SAVR.

RESULTS

From the NHR database, 5600 patients with symptomatic aortic valve stenosis were included in the study. Crude incidence of post-SAVR PPI was 4.0%. Backward regression analysis identified previous cardiac surgery (odds ratio [OR]: 1.80; 95% confidence interval [CI]: 1.18-2.76), extra-corporeal circulation time (OR: 1.01; 95% CI: 1.00-1.01), vasopressor use (OR: 2.66; 95% CI: 1.79-3.96) and in-hospital cardiac conduction abnormalities (OR: 4.48; 95% CI: 3.36-5.98) as potential predictors for PPI. Across the time, PPI after SAVR significantly increased (OR: 1.11; 95% CI: 1.03-1.21).

CONCLUSIONS

From this nationwide analysis, PPI after SAVR remains a low but increasingly frequent complication. Several predictive factors for postoperative PPI after SAVR have been identified and might be useful for patient informed consent about potential adverse event rate.

What Can We Learn from the Past by Means of Very Long-Term Follow-Up after Aortic Valve Replacement?

Background: Studies on very long-term outcomes after aortic valve replacement are sparse. Methods: In this retrospective cohort study, long-term outcomes during 25.1 ± 2.8 years of follow-up were determined in 673 patients who underwent aortic valve replacement with or without concomitant coronary artery bypass surgery for severe aortic stenosis and/or regurgitation. Independent predictors of decreased long-term survival were determined. Cumulative incidence rates of major adverse events in patients with a mechanical versus those with a biologic prosthesis were assessed, as well as of major bleeding events in patients with a mechanical prosthesis under the age of 60 versus those above the age of 60. Results: Impaired left ventricular function, severe prosthesis–patient mismatch, and increased aortic cross-clamp time were independent predictors of decreased long-term survival. Left ventricular hypertrophy, a mechanical or biologic prosthesis, increased cardiopulmonary bypass time, new-onset postoperative atrial fibrillation, and the presence of symptoms did not independently predict decreased long-term survival. The risk of major bleeding events was higher in patients with a mechanical in comparison with those with a biologic prosthesis. Younger age (under 60 years) did not protect patients with a mechanical prosthesis against major bleeding events. Conclusions: Very long-term outcome data are invaluable for careful decision-making on aortic valve replacement.

Atrioventricular Block after Tricuspid Valve Surgery

Tricuspid valve (TV) surgery is associated with a high risk of postoperative pacemaker requirement. We set out to identify the incidence of atrioventricular block (AVB) after TV surgery and determine whether atrioventricular conduction recovers within time.We investigated pre/intra- and postoperative predictors of AVB in patients who underwent tricuspid valve surgery (not only isolated TV surgery) at our institution between 2004 and 2017. Patients who had pacemakers prior to surgery were excluded.One year after surgery, 5.8% of the surviving cohort had received a pacemaker due to AVB. In the complete follow-up time, 33 out of 505 patients required pacemaker implantation because of AVB. Of the 37 patients who presented to the intensive care unit postoperatively with AVB III, 14 (38%) underwent pacemaker implantation for AVB, and 20 (54%) did not require a pacemaker. AVB III at ICU admission was identified as a predictor of pacemaker implantation (OR: 9.7, CI: 3.8-24.5, P < 0.001). TV endocarditis was also identified as a predictor (OR: 12.4, CI: 3.3-46.3, P < 0.001). Eleven out of 32 patients (34%) with tricuspid endocarditis required a pacemaker for AVB. The mean ventricular pacing burden within the first 5 years after pacemaker implantation was 79%.The issue of AVB after TV surgery is significant. Both the initial rhythm after surgery and etiology of the tricuspid disease can help predict pacemaker requirement. Within the first 5 years after surgery, the ventricular pacing burden remains high without relevant rhythm recovery.

Predictors of Pacemaker Insertion Post-Sutureless (Perceval) Aortic Valve Implantation

INTRODUCTION

The use of rapid deployment sutureless aortic valve replacement (AVR) has become a viable alternative to conventional AVR especially in intermediate and high-risk patients. However, sutureless AVR has been associated with increased rates of permanent pacemaker (PPM) implantation compared with conventionally implanted aortic valve prostheses. The aim of this study was to determine predictive factors for complete heart block requiring insertion of a PPM post-AVR with a Perceval S sutureless valve (LivaNova, London, UK). Such knowledge will help to improve patient counselling, selection and management of patients undergoing sutureless AVR.

METHODOLOGY

A retrospective cohort study assessed all patients who underwent insertion of the Perceval sutureless aortic valve prosthesis between July 2015 and September 2019. Medical records were reviewed for demographic, preoperative electrocardiograph (ECG), and operative features related to postoperative PPM implantation and follow-up in the electrophysiology clinic.

RESULTS

One hundred and thirty (130) patients without pre-existing PPM underwent sutureless AVR (66.9% male, average age 74.4±6.6 years). Fifty-seven (57) underwent concomitant cardiac surgical procedures. Eight (8) patients underwent redo cardiac surgery. Nineteen (19) of the 130 (14.6%) patients required insertion of a PPM during their postoperative course. Factors associated with PPM insertion were right bundle branch block (overall n=15, PPM vs No PPM: 8/19 vs 7/111 [42.1 % vs. 6.31 %; p<0.01]), longer QRS duration 113.32ms±22.24 ms vs 100.52±20.96 ms (p=0.017) and longer PR Interval 185.166±42.38 ms vs 169.23±25.70 ms (p=0.03).

CONCLUSION

Insertion of rapid deployment sutureless aortic valves in the setting of pre-existing right bundle branch block, prolonged QRS complex and longer PR intervals is associated with increased risk of postoperative PPM requirement. These factors should be considered when preoperatively counselling and postoperatively managing patients when balloon expandable sutureless valves are used.

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.

Conduction disturbances following surgical aortic valve replacement with a rapid-deployment bioprosthesis

BACKGROUND

The implantation of rapid-deployment aortic valves may interfere with the conduction system of the heart. This study evaluates the occurrence and predictive factors of conduction anomalies in patients undergoing surgical aortic valve replacement (SAVR) with a rapid-deployment balloon-expandable bioprosthesis in a single-center, real-world experience.

METHODS

Between May 2010 and April 2019, 700 consecutive patients were included in a prospective, ongoing database with a longitudinal follow-up preoperatively, at discharge, and at 3 months, 1 year, 3 years, and 5 years postoperatively. Thirty-seven patients (5.3%) had a permanent pacemaker at baseline and were excluded from further analysis, leaving 663 patients for analysis. Assessment of conduction anomalies was performed by electrocardiography (ECG) monitoring and repeated 12-lead ECG during the hospital stay and at postoperative follow-ups.

RESULTS

Preoperatively, 126 patients (19.0%) presented with different conduction disturbances. New permanent pacemaker implantation (PPI) occurred in 61 patients during the first 14 days (cumulative incidence, 9.4%). The indication for PPI was complete atrioventricular block in 47 cases (77%). Preoperative conduction anomalies, such as right bundle branch block, as well as operative characteristics (concomitant procedures) were found to be independent predictors for new PPI. One-year survival was 98% in patients with new early PPI and 96% in those without new early PPI (P = .60).

CONCLUSIONS

The PPI rate was in the range of previous reports for rapid-deployment prostheses. PPI did not have a significant influence on short- to intermediate-term survival. Case selection with exclusion of patients presenting with baseline conduction disturbances may decrease the rate of new PPIs after SAVR with rapid-deployment balloon-expandable bioprostheses.

Incidence and Risk Factors for Permanent Pacemaker Implantation Following Mitral or Aortic Valve Surgery

BACKGROUND

Risk factors for post-operative conduction disturbances after cardiac valve surgery requiring a permanent pacemaker (PPM) are poorly characterized.

OBJECTIVES

The aim of this study was to investigate the timing and risk factors for PPM implantation after mitral or aortic valve surgery.

METHODS

All patients who underwent open aortic or mitral valve surgery between January 1996 and December 2014 were reviewed using New York State's mandatory hospital discharge database. Patients with prior cardiac surgery or pre-existing PPM were excluded. The primary endpoint was PPM implantation within 1 year.

RESULTS

Among 77,882 patients, 63.8% (n = 49,706) underwent aortic valve replacement (AVR), 18.9% (n = 14,686) underwent mitral valve replacement (MVR), 10.5% (n = 8,219) underwent mitral valve repair (MVr), 5.4% (n = 4,202) underwent AVR plus MVR, and 1.4% (n = 1,069) underwent AVR plus MVr. The 1-year PPM implantation rate was 4.5% after MVr, 6.6% after AVR, 9.3% after AVR plus MVr, 10.5% after MVR, and 13.3% after AVR plus MVR (p < 0.001). Across all groups, the majority of PPMs were implanted during the index hospitalization (79.9%). MVr was associated with the lowest risk for PPM and AVR plus MVR with the highest risk. Older age, history of arrhythmias, pre-operative conduction disturbances, and concomitant index procedures were associated with increased risk for PPM during the index hospitalization. Conversely, beyond 30 days, chronic comorbidities were associated with increased risk for PPM.

CONCLUSIONS

Conduction disturbances requiring PPM remain a common adverse event after valve surgery. Identifying patients at risk for PPM will help facilitate perioperative planning and inform clinical decision making regarding post-operative rhythm surveillance.

Incidence and causes of pacemaker implantation during postoperative period of aortic valve replacement with rapid deployment prosthesis

BACKGROUND

Aortic stenosis is currently the most frequently occurring valve pathology. Developments, such as transcatheter prostheses and rapid deployment prostheses, allow for the offer of a valve replacement to higher risk patients, but these techniques are linked with a higher need for a permanent pacemaker during the immediate postoperative period.

METHODS

We studied the incidence and the factors associated with permanent pacemaker implantation after aortic valve replacement with Edwards Intuity rapid deployment prosthesis.

RESULTS

Between October 2012 and December 2016, the Edwards Intuity prosthesis was implanted in 71 patients (68% male, 75.3 ± 5 years old). Six patients (8%) required a permanent pacemaker during immediate postoperative period. Univariate analysis showed that a history of acute myocardial infarction (AMI) (P = .046, B = 7.5, 95% CI [1.039-54.1]) and preoperative amiodarone (P = .009, B = 31.5; 95% CI [2.32-426]) were associated with a higher need for a pacemaker during the postoperative period.

CONCLUSIONS

The incidence of permanent pacemaker implantation during the immediate postoperative period of aortic valve replacement with Edwards Intuity prosthesis was 8%, a value which is within the limits reported for conventional aortic prostheses. Preoperative amiodarone treatment and previous AMI may increase the need for a pacemaker during the postoperative period of these aortic prostheses.

Anesthetic challenges in a pregnant patient with post mitral valve replacement, complete heart block, and coagulopathy coming for emergency cesarean section: A case report

A 24-year-old primigravida with a history of rheumatic heart disease and prosthetic mitral valve on oral anticoagulation who was lost follow-up during the third trimester presented with premature rupture of membranes. On evaluation, she had new-onset complete heart block. She was temporarily paced but developed cardiac failure. Anesthetic challenges and management of this parturient with post mitral valve replacement, complete heart block, and warfarin-induced coagulopathy for emergency cesarean delivery are discussed in this case report. Ours is the first case report of a pregnant patient with new onset of complete heart block during pregnancy several years after mitral valve replacement.

The del Nido versus cold blood cardioplegia in aortic valve replacement: A randomized trial

OBJECTIVES

To compare the cardioprotective efficacy of a solution that requires only a single infusion at the start of the ischemic duration versus a solution that requires multiple infusions.

METHODS

Aortic valve replacement was performed for 150 patients, who were randomized into the del Nido (DN) cardioplegia group or the cold blood (CB) cardioplegia group. The DN cardioplegia was delivered every 90 minutes and the CB cardioplegia was delivered every 20 to 30 minutes, or whenever cardiac activity was observed. The primary endpoints were electrical cardiac activity during crossclamp, ventricular fibrillation during reperfusion, and postoperative troponin and creatine kinase (CK-MB isoenzyme) at 24 and 48 hours.

RESULTS

Electrical activity during crossclamp occurred in 29 (39.7%) patients in the DN group versus 34 (45.3%) patients in the CB group (adjusted P = 1.0). The number of procedures with ventricular fibrillation after removing the crossclamp was 41 (54.7%) in the CB group versus 17 (22.7%) in the DN group (adjusted P = .001; relative risk, 2.41). Troponin values appeared to be lower in the DN group (median, 223.10; interquartile range, 168.35-364.77 pg/mL vs 285.5; 196.20-419.45 pg/mL at 24 hours and 159.60; 125.42-217.20 pg/mL vs 201.60; 160.62-268.45 pg/mL at 48 hours) and CK-MB (median, 14.94; interquartile range, 12.16-20.39 ng/mL vs 17.43; 13.66-22.43 ng/mL at 24 hours and 6.19; 4.41-7.63 ng/mL vs 7.38; 4.74-10.20 ng/mL at 48 hours), but no significance was found.

CONCLUSIONS

The del Nido cardioplegia protocol is an acceptable alternative for cold blood cardioplegia in patients undergoing aortic valve replacement.

Predictors of paravalvular aortic regurgitation after surgery for Behcet's disease-related severe aortic regurgitation

Background

Behcet’s disease (BD)-related aortic regurgitation (AR) is known to be associated with paravalvular leakage (PVL) after successful aortic valve (AV) surgery. This study aimed to determine predictors of PVL after successful AV surgery in BD patients. We retrospectively collected data of 35 patients (42.1 ± 9.1 years, 27 men) who underwent surgery for severe BD-related AR at two tertiary centers. The diagnosis was established based on echocardiographic, surgical, and/or pathological findings in conjunction with the International Study Group criteria for BD. A total of 76 cases of AV surgery in 35 patients were analyzed.

Results

A median follow-up duration was 8.0 years (interquartile range, 5.4–14.3 years). PVL developed in 18 patients (51.4%) within 2 years after the first surgery. Six patients who met the diagnostic criteria for BD did not develop PVL, in whom 5 patients took immunosuppressive therapy (IST). However, 4 of 9 patients (44.4%) who did not meet the diagnostic criteria developed PVL, in whom four (44.4%) patients took IST. On multivariable analysis, postoperative IST and concomitant aortic root replacement (ARR) were two independent predictors for less PVL development (HR 0.38, 95% CI 0.17–0.89, p = 0.025 for postoperative IST; HR 0.17, 95% CI 0.08–0.36, p < 0.001 for concomitant ARR). Preoperative IST use did not determine PVL development (p = 0.75).

Conclusions

Postoperative, but not preoperative, IST and concomitant ARR were independent predictors of less development of PVL. Special attention is required for early diagnosis BD-related AR, especially in patients not satisfying the current diagnostic criteria.

Electronic supplementary material

The online version of this article (10.1186/s13023-019-1083-8) contains supplementary material, which is available to authorized users.

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.

Updated clinical indications for transcatheter aortic valve implantation in patients with severe aortic stenosis: expert opinion of the Italian Society of Cardiology and GISE

: The introduction of percutaneous treatment of severe aortic stenosis with transcatheter aortic valve implantation (TAVI) remains one of the greatest achievements of interventional cardiology. In fact, TAVI emerged as a better option than either medical therapy or balloon aortic valvuloplasty for patients who cannot undergo surgical aortic valve replacement (SAVR) or are at high surgical risk. Recently, increased operator experience and improved device systems have led to a worldwide trend toward the extension of TAVI to low-risk or intermediate-risk patients. In this expert opinion paper, we first discuss the basic pathophysiology of aortic stenosis in different settings then the key results of recent clinical investigations on TAVI in intermediate-risk aortic stenosis patients are summarized. Particular emphasis is placed on the results of the nordic aortic valve intervention, placement of aortic transcatheter valves (PARTNER) 2 and Surgical Replacement and Transcatheter Aortic Valve Implantation Randomized trials. The PARTNER 2 was the first large randomized trial that evaluated the outcome of TAVI in patients at intermediate risk. The PARTNER 2 data demonstrated that TAVI is a feasible and reasonable alternative to surgery in intermediate-risk patients (Society of Thoracic Surgeons 4-8%), especially if they are elderly or frail. There was a significant interaction between TAVI approach and mortality, with transfemoral TAVI showing superiority over SAVR. Moreover, we examine the complementary results of the recently concluded Surgical Replacement and Transcatheter Aortic Valve Implantation trial. This prospective randomized trial demonstrated that TAVI is comparable with surgery (primary end point 12.6% in the TAVI group vs. 14.0% in the SAVR group) in severe aortic stenosis patients deemed to be at intermediate risk. We review the most relevant clinical evidence deriving from nonrandomized studies and meta-analyses. Altogether, clinical outcome available data suggest that TAVI with a newer generation device might be the preferred treatment option in this patient subgroup. Finally, the differences between the latest European and American Guidelines on TAVI were reported and discussed. The conclusion of this expert opinion article is that TAVI, if feasible, is the treatment of choice in patients with prohibitive or high surgical risk and may lead to similar or lower early and midterm mortality rates compared with SAVR in intermediate-risk patients with severe aortic stenosis.

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.

Atrial Fibrillation is Associated with Increased Pacemaker Implantation Rates in the Placement of AoRTic Transcatheter Valve (PARTNER) Trial

Atrial fibrillation (AF) is associated with worse outcomes in many cardiovascular diseases. There are few data examining pacemaker implantation rates and indications in patients with AF who undergo transcatheter aortic valve replacement (TAVR). To examine the impact of AF on the incidence of and indications for pacemakers in patients undergoing TAVR, we evaluated data of 1723 patients without pre-existing pacemakers who underwent TAVR in the Placement of AoRTic TraNscathetER Valve (PARTNER) trial. Permanent pacemaker implantation rates and indications were compared in groups based on baseline and discharge heart rhythm: sinus rhythm (SR) vs. AF. 1211 patients manifested SR at baseline/SR at discharge (SR/SR), 105 SR baseline/AF discharge (SR/AF), and 407 AF baseline/AF discharge (AF/AF). Patients who developed and were discharged with AF (SR/AF) had the highest rates of pacemaker implantation at 30 days (13.7% SR/AF vs. 5.4% SR/SR, p=0.0008 and 5.9% AF/AF, p=0.008) and 1 year (17.7% SR/AF vs. 7.1% SR/SR, p=0.0002 and 8.1% AF/AF, p=0.0034). Conversion from SR to AF by discharge was an independent predictor of increased pacemaker implantation at 30 days (HR 2.19 vs. SR/SR, 95% CI 1.23-3.93, p=0.008) and 1 year (HR 1.91 vs. SR/SR, 95% CI 1.33-3.80). Pacemaker indications differed between groups, with relatively more implanted in the AF groups for sick sinus syndrome (SSS) versus AV block. In conclusion, conversion to AF is an independent predictor of permanent pacemaker implantation in TAVR patients. Indications differ depending on heart rhythm, with patients in AF manifesting clinically significant tachy-brady syndrome versus AV block.

Histological topography of the atrioventricular node and its extensions in relation to the cardiothoracic surgical landmarks in normal human hearts

BACKGROUND

Atrioventricular (AV) nodal injury which results in cardiac conduction disorders is one of the potential complications of heart valve surgeries and radiofrequency catheter ablations. Understanding the topography of the AV conduction system in relation to the tricuspid and mitral valves will help in reducing these complications.

METHODS

A tissue block of 3cmx4cm, which contain the AV node, bundle of His and the AV nodal extensions, was excised at the AV septal junction in 20 apparently normal human hearts. The block was divided into three equal segments through vertical incisions perpendicular to the insertion of the septal leaflet of the tricuspid valve. Each segment was processed and stained with H&E and Gomori to study the different parts of the AV conduction system.

RESULTS

The lower pole of the AV node was located vertically above the tricuspid septal leaflet (TSL) in 100% (20/20) of cases and at the level of the muscular interventricular septum in 65% (13/20) of cases. The upper pole of the compact AV node was located at the level of the mitral valve leaflet (MVL) in 50% (10/20) of cases. The penetrating bundle of His was seen at the level of the TSL, while the branching bundle of His was situated 1.9±1.5 mm inferior to the TSL. The right and left posterior extensions of the AV node spanned from the MVL to 2.9±1.3 mm above the TSL.

CONCLUSIONS

A rectangular area (2.5 mm × 12 mm) in the Koch's triangle was devoid of AV nodal tissue and could be labeled as a safe area with no risk of conduction defects during valve surgeries. Information on the separation of AV nodal extensions from the TSL, MVL and muscular interventricular septum may play a crucial role in guiding and improving the safety of radiofrequency ablations.

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.

A Meta-Analysis Examining Differences in Short-Term Outcomes between Sutureless and Conventional Aortic Valve Prostheses

Objective

Sutureless aortic valve prostheses are anchored by radial force in a mechanism similar to that of transcatheter aortic valve implantation. Transcatheter aortic valve implantation is associated with an increased permanent pacemaker (PPM) requirement in a significant proportion of patients. We undertook a meta-analysis to examine the incidence of PPM insertion associated with sutureless compared with conventional surgical aortic valve replacement.

Methods

A systematic review was conducted in accordance with the Prisma guidelines.1 All searches were performed on August 10, 2014. Studies between 2007 and 2014 were included in the search.

Results

A total of 832 patients were included in the sutureless group and 3,740 in the conventional group. Aortic cross-clamp (39.8 vs 62.4 minutes; P < 0.001) and cardiopulmonary bypass (64.9 vs 86.7 minutes; P = 0.002) times were shorter in the sutureless group. Permanent pacemaker implantation rate was higher in the sutureless cohort (9.1% vs 2.4%; P = 0.025).

Conclusions

Sutureless aortic valve prostheses are associated with significantly shorter cardiopulmonary bypass and aortic cross-clamp times and a higher incidence of PPM insertion than conventional. Further investigation of the prognostic significance is required.

Shock Management for Cardio-surgical ICU Patients - The Golden Hours

Postoperative shock following cardiac surgery is a serious condition with a high morbidity and mortality. There are four types of shock: cardiogenic, hypovolemic, obstructive and distributive and these can occur alone or in combination. Early identification of the underlying diseases and understanding of the mechanisms at play are key for successful management of shock. Prompt resuscitation measures are necessary to reverse the shock state and avoid permanent organ dysfunction or death. In this review, the authors focus on the management during the first 6 hours of shock (the 'golden hours'). They discuss how to optimise preload, vascular tone, contractility, heart rate and oxygen delivery. The review incorporates the findings of recent trials on early goal-directed therapy and includes practical recommendations in areas in which the evidence is scare or controversial. While the review focuses on cardio-surgical patients, the suggested treatment algorithms might be usefully expanded to other critically ill patients with shock arising from other causes.

Transcatheter versus surgical aortic valve replacement: a systematic review and meta-analysis of randomised and non-randomised trials

Introduction

Many patients deemed inoperable for surgical aortic valve replacement (SAVR) have been treated successfully by transcatheter aortic-valve replacement (TAVR). This meta-analysis is designed to evaluate the performance of TAVR in comparison with SAVR.

Methods

A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, the Cochrane library, Google Scholar, Science Direct and Web of Science. Original data were abstracted from each study and used to calculate a pooled OR and 95% CI.

Results

Among three randomised controlled trials (RCTs), differences between the two cohorts were not statistically significant for the frequency of stroke (OR=1.94, 95% CI=0.813 to 4.633), incidence of myocardial infarction (MI), (OR=0.765, 95% CI=0.05 to 11.76) 30-day mortality rate, 1-year mortality rate (0.82, 95% CI=0.62 to 1.09) and acute kidney injury incidence rate. The non-RCTs demonstrated that the TAVR group had an amplified frequency aortic regurgitation at discharge (OR=5.465, 95% CI=3.441 to 8.680). While differences between the two cohorts were not statistically significant for the incidence of MI (OR=0.697, 95% CI=0.22 to 2.21), stroke (OR=0.575, 95% CI=0.263 to 1.259), acute renal failure requiring haemodialysis (OR=0.943, 95% CI=0.276 to 3.222), 30-day mortality (OR=0.869, 95% CI=0.621 to 1.216) and the need for a pacemaker (OR=1.832, 95% CI=0.869 to 3.862), a lower incidence of patients needing transfusion (OR=0.349, 95% CI=0.121 to 1.005) and new-onset atrial fibrillation (OR=0.296, 95% CI=0.124 to 0.706) was seen in the TAVR group.

Conclusions

Randomised and observational evidence adjusted on the baseline patient’s characteristics finds a similar risk for 30 days mortality, 1-year mortality, stroke, MI and acute kidney injury in TAVR and SAVR.

Aortic dissection one year after aortic valve replacement

Acute aortic dissection after aortic valve replacement is rare. A 57-year-old man presented with an acute type A aortic dissection 1 year after aortic valve replacement, which originated from the previous aortotomy site. He underwent a Bentall procedure. Postoperatively, he developed complete heart block requiring permanent pacemaker implantation. During aortic valve replacement, risk factors for aortic dissection (diameter of the aorta and fragility and thinness of the aortic wall) should be assessed. Prophylactic aortic root replacement should be undertaken if the aortic root is more than 45 mm in diameter.

Transcatheter aortic valve implantation-induced left bundle branch block: causes and consequences

Transcatheter aortic valve implantation (TAVI) is an alternative treatment option for patients with severe aortic valve stenosis who do not qualify for surgical aortic valve replacement (AVR). Besides its proven clinical benefits, one of the complications of TAVI is the creation of conduction abnormalities, like left bundle branch block (LBBB). New LBBB occurs between 7 and 65% of cases, numbers that differ considerably between devices. In this review, we discuss the possible causes and the clinical significance of TAVI-induced LBBB. Several device- and procedural-related factors seem responsible for the development of LBBB, of which depth of implantation and balloon-annulus diameter ratio are the most important ones. TAVI-induced LBBB negatively affects cardiac function and hospitalization, but its impact on mortality is subject of debate. Future research and registries should implement strict diagnostic criteria for LBBB together with recording of its timing and persistence.

Predictors of temporary epicardial pacing wires use after valve surgery

Background

Although temporary cardiac pacing is infrequently needed, temporary epicardial pacing wires are routinely inserted after valve surgery. As they are associated with infrequent, but life threatening complications, and the decreased need for postoperative pacing in a group of low risk patients; this study aims to identify the predictors of temporary cardiac pacing after valve surgery.

Methods

A retrospective analysis of data collected prospectively on 400 consecutive valve surgery patients between May 2002 and December 2012 was performed. Patients were grouped according to avoidance or insertion of temporary pacing wires, and were further subdivided according to temporary cardiac pacing need. Multiple logistic regression was used to determine the predictors of temporary cardiac pacing.

Results

170 (42.5%) patients did not have insertion of temporary pacing wires and none of them needed temporary pacing. 230 (57.5%) patients had insertion of temporary pacing wires and among these, only 55 (23.9%) required temporary pacing who were compared with the remaining 175 (76.1%) patients in the main analysis. The determinants of temporary cardiac pacing (adjusted odds ratios; 95% confidence interval) were as follows: increased age (1.1; 1.1, 1.3, p = 0.002), New York Heart Association class III- IV (5.6; 1.6, 20.2, p = 0.008) , pulmonary artery pressure ≥ 50 mmHg (22.0; 3.4, 142.7, p = 0.01), digoxin use (8.0; 1.3, 48.8, p = 0.024), multiple valve surgery (13.5; 1.5, 124.0, p = 0.021), aorta cross clamp time ≥ 60 minutes (7.8; 1.6, 37.2, p = 0.010), and valve annulus calcification (7.9; 2.0, 31.7, p = 0.003).

Conclusion

Although limited by sample size, the present results suggest that routine use of temporary epicardial pacing wires after valve surgery is only necessary for high risk patients. Preoperative identification and aggressive management of predictors of temporary cardiac pacing and the possible modulation of intraoperative techniques can decrease the need of temporary cardiac pacing. Prospective randomized controlled studies on a larger number of patients are necessary to draw solid conclusions regarding the selective use of temporary epicardial pacing wires in valve surgery.

Atrioventricular block as the initial presentation of calcified bicuspid aortic valve

BACKGROUND

Bicuspid aortic valve (BAV) is one of the most common and important congenital heart disorders in adults. If a patient with congenital disorders is not diagnosed early, the patient's disease may progress to a severe condition and thus diagnosis of the main disorder will be rendered difficult.

CASE REPORT

A 34 year-old male patient referred to a referral medical care unit for cardiac electrophysiological study with cardiac shock due to complete heart block 3 months ago and he underwent Dual-Chamber permanent pacemaker (PPM) implantation. Thick and calcified bicuspid AV with invasion to interventricular septum, moderate to severe valve insufficiency (AI), severe aortic valve stenosis (AS), and dilated ascending aorta were observed at his echocardiography. Aortic valve replacement (AVR), aneurysm of ascending aorta, root replacement with tube graft (Bentall Procedure), and also a 3 chambers intracardiac defibrillator (ICD) were used. After 2 weeks of operation, he was discharged and at the first post-hospitalization visit (1 week later), his cardiovascular condition was acceptable.

CONCLUSION

Thick calcified aortic root is a less studied and potential contributing risk factor for AV block after AVR. Therefore, in candidates of aortic valve replacement, considering conductive disorders, especially in patients with calcified valve, is mandatory. Irreversible AV block requiring PPM implantation is a rare condition following AVR.