Permanent pacemaker implantation after aortic valve replacement: Long-term dependency or rhythm recovery?

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.

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.

Indications and predictors for pacemaker implantation after isolated aortic valve replacement with bioprostheses: the CAREAVR study

OBJECTIVES

We sought to study the indications, long-term occurrence, and predictors of permanent pacemaker implantation (PPI) after isolated surgical aortic valve replacement with bioprostheses.

METHODS

The CAREAVR study included 704 patients (385 females, 54.7%) without a preoperative PPI (mean ± standard deviation age 75 ± 7 years) undergoing isolated surgical aortic valve replacement at 4 Finnish hospitals between 2002 and 2014. Data were extracted from electronic patient records.

RESULTS

The follow-up was median 4.7 years (range 1 day to 12.3 years). Altogether 56 patients received PPI postoperatively, with the median 507 days from the operation (range 6 days to 10.0 years). The PPI indications were atrioventricular block (31 patients, 55%) and sick sinus syndrome (21 patients, 37.5%). For 4 patients, the PPI indication remained unknown. A competing risks regression analysis (Fine-Gray method), adjusted with age, sex, diabetes, coronary artery disease, preoperative atrial fibrillation (AF), left ventricular ejection fraction, New York Heart Association class, AF at discharge and urgency of operation, was used to assess risk factors for PPI. Only AF at discharge (subdistribution hazard ratio 4.34, 95% confidence interval 2.34-8.03) was a predictor for a PPI.

CONCLUSIONS

Though atrioventricular block is the major indication for PPI after surgical aortic valve replacement, >30% of PPIs are implanted due to sick sinus syndrome during both short-term follow-up and long-term follow-up. Postoperative AF versus sinus rhythm conveys >4-fold risk of PPI.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02626871.

Patients with bicuspid aortic valves may be associated with infra-hisian conduction disease requiring pacemakers

BACKGROUND

Bicuspid aortic valves (BAVs) are associated with accelerated valvular dysfunction. Increasing rates of conduction system disease are seen in patients with calcific tricuspid aortic valves (TAVs). However, little is known regarding the extent of conduction disorders in BAV patients. We sought to determine the extent of infra-hisian conduction pathology among patients with BAVs undergoing EP studies.

METHODS

We prospectively analyzed patients presenting to the EP laboratory from 2006 to 2017 at our institution. Thirty-three BAV patients had measured HV intervals. Each individual was matched by age and gender to two control patients. Clinical characteristics were collected and compared, and patients followed for outcomes.

RESULTS

The BAV cohort had a mean age of 47.8 ± 17.2 years (range 19-76 years). Indications for referral to the EP lab in the BAV cohort included SVT ablation (n = 16), VT ablation (n = 10), and EP study for syncope, pre-syncope, or palpitations (n = 29). Patients with BAVs had a mean HV interval of 58.7 ms ± 18.6 ms, compared to a mean of 47.2 ms ± 9.6 ms for controls (p value = 0.0001). Over a 10-year follow-up period, 9 BAV patients (27%) went on to require permanent pacing compared to 6 patients (9%) in the control group (p value = 0.03).

CONCLUSION

Compared to patients with TAVs presenting for EP evaluation, individuals with BAVs have longer HV intervals and a significantly increased requirement for pacemaker therapy over long-term follow-up. Closer monitoring of progressive conduction system disease in BAV patients may be warranted.

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.

Immediate and long-term need for permanent cardiac pacing following aortic valve replacement

Introduction: Atrioventricular (AV) node conduction disturbances are common following surgical aortic valve replacement (SAVR), and in some cases the patient needs a permanent pacemaker (PPM) implantation before discharge from hospital. Little is known about the long-term need for PPM and the PPM dependency of these individuals. We determined the incidence of PPM implantation before and after discharge in SAVR patients. Methods: We studied 557 consecutive patients who underwent SAVR for aortic stenosis in Iceland between 2002 and 2016. Timing and indication for PPM were registered, with a new concept, ventricular pacing proportion (VPP), defined as ventricular pacing ≥90% of the time, being used to approximate pacemaker dependency. The median follow-up time was 73 months. We plotted the cumulative incidence of pacemaker implantation, treating death as a competing risk. Results: Of the 557 patients, 22 (3.9%) received PPM in the first 30 days after surgery, most commonly for complete AV block (n = 14) or symptomatic bradycardia (n = 8); Thirty-eight other patients (6.8%) had a PPM implanted >30 days postoperatively, at a median of 43 months after surgery (range 0‒181), most often for AV block (n = 13) or sick-sinus syndrome (n = 10). The cumulative incidence of PPM implantation at 1, 5, and 10 years postoperatively was 5.0%, 9.2%, and 12.3%, respectively. During follow-up, 45.0% of the 60 patients had VPP ≥90%. Conclusion: The cumulative incidence of permanent pacemaker implantation following SAVR was about 12% at 10 years, with every other patient having VPP ≥90% during follow-up. This suggests that AV node conduction disturbances extend significantly beyond the perioperative period.

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.

Performance of the Labcor Dokimos Plus pericardial aortic prosthesis: a single-centre experience

Objectives

In patients with a small aortic annulus, aortic valve replacement (AVR) is frequently associated with high residual pressure gradients. Supra-annular pericardial aortic prostheses are gaining popularity due to the increased effective orifice areas (EOA) and resulting lower gradients. This study reports the clinical and echocardiographic results following implantation of the new supra-annular pericardial aortic prosthesis Dokimos Plus (Labcor, Belo Horizonte, Brazil).

Methods

Between October 2013 and July 2015, 137 patients (41% women, mean age: 74 years) underwent supra-annular AVR with or without concomitant procedures using the Dokimos Plus prosthesis in our department. Transthoracic echocardiography was performed pre- and postoperatively on all patients to assess haemodynamic parameters (gradients, acceleration time [AT], Doppler velocity indices [DVIs] and indexed EOA [EOAI]) and to detect paravalvular leakage (PVL). Data were collected retrospectively from our hospital databases.

Methods

Patients were grouped by prosthesis size: Most patients received 23-mm (57.6%), followed by 21-mm (19%), 25-mm (15.4%) and 27-mm (8%) prostheses. The mean EOAI in all groups was 1.1 ± 0.26 cm 2 /m 2 . Pressure gradients were low in all groups (mean: 8.9 ± 4.4 mmHg; peak: 18.8 ± 6.8 mmHg); AT and DVI were in the normal range according to American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations (mean AT 73.3 ± 29 ms; mean DVI 0.5 ± 0.2). One patient had severe PVL and one presented with central regurgitation, both requiring re-intervention. The mortality rate was 5.1% ( n  = 7); none of the cases was associated with valve insufficiency.

Conclusions

The Dokimos prosthesis showed a satisfactory overall performance, presenting low gradients and DVIs as well as high EOAI. Further investigations are needed to analyse the cases of regurgitation and monitor long-term performance.