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Farina J, Biffi M, Folesani G, Di Marco L, Martin S, Zenesini C, Savini C, Ziacchi M, Diemberger I, Martignani C, Pacini D. Long-Term Atrioventricular Block Following Valve Surgery: Electrocardiographic and Surgical Predictors. J Clin Med 2024; 13:538. [PMID: 38256672 PMCID: PMC10816093 DOI: 10.3390/jcm13020538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/08/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
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.
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Affiliation(s)
- Jacopo Farina
- Cardiology Unit, Arcispedale Sant’Anna, Azienda Ospedaliero-Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Mauro Biffi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (M.B.); (M.Z.); (I.D.); (C.M.)
| | - Gianluca Folesani
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.F.); (L.D.M.); (S.M.); (C.S.); (D.P.)
| | - Luca Di Marco
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.F.); (L.D.M.); (S.M.); (C.S.); (D.P.)
| | - Sofia Martin
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.F.); (L.D.M.); (S.M.); (C.S.); (D.P.)
| | - Corrado Zenesini
- Epidemiology and Statistic Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy;
| | - Carlo Savini
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.F.); (L.D.M.); (S.M.); (C.S.); (D.P.)
| | - Matteo Ziacchi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (M.B.); (M.Z.); (I.D.); (C.M.)
| | - Igor Diemberger
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (M.B.); (M.Z.); (I.D.); (C.M.)
| | - Cristian Martignani
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (M.B.); (M.Z.); (I.D.); (C.M.)
| | - Davide Pacini
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.F.); (L.D.M.); (S.M.); (C.S.); (D.P.)
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Tindale A, Cretu I, Haynes R, Gomez N, Bhudia S, Lane R, Mason MJ, Francis DP. How robust are recommended waiting times to pacing after cardiac surgery that are derived from observational data? Europace 2023; 25:euad238. [PMID: 37539864 PMCID: PMC10430344 DOI: 10.1093/europace/euad238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/08/2023] [Accepted: 08/01/2023] [Indexed: 08/05/2023] Open
Abstract
AIMS For bradycardic patients after cardiac surgery, it is unknown how long to wait before implanting a permanent pacemaker (PPM). Current recommendations vary and are based on observational studies. This study aims to examine why this variation may exist. METHODS AND RESULTS We conducted first a study of patients in our institution and second a systematic review of studies examining conduction disturbance and pacing after cardiac surgery. Of 5849 operations over a 6-year period, 103 (1.8%) patients required PPM implantation. Only pacing dependence at implant and time from surgery to implant were associated with 30-day pacing dependence. The only predictor of regression of pacing dependence was time from surgery to implant. We then applied the conventional procedure of receiver operating characteristic (ROC) analysis, seeking an optimal time point for decision-making. This suggested the optimal waiting time was 12.5 days for predicting pacing dependence at 30 days for all patients (area under the ROC curve (AUC) 0.620, P = 0.031) and for predicting regression of pacing dependence in patients who were pacing-dependent at implant (AUC 0.769, P < 0.001). However, our systematic review showed that recommended optimal decision-making time points were strongly correlated with the average implant time point of those individual studies (R = 0.96, P < 0.001). We further conducted modelling which revealed that in any such study, the ROC method is strongly biased to indicate a value near to the median time to implant as optimal. CONCLUSION When commonly used automated statistical methods are applied to observational data with the aim of defining the optimal time to pacing after cardiac surgery, the suggested answer is likely to be similar to the average time to pacing in that cohort.
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Affiliation(s)
- Alexander Tindale
- National Heart and Lung Institute, Imperial College London, London W12 0HS, UK
- Department of Cardiology, Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, Hill End Road, London UB9 6JH, UK
| | - Ioana Cretu
- College of Engineering, Design and Physical Sciences, Brunel University London, Kingston Lane, Uxbridge UB8 3PH, UK
| | - Ross Haynes
- Department of Cardiology, Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, Hill End Road, London UB9 6JH, UK
| | - Naomi Gomez
- Department of Cardiology, Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, Hill End Road, London UB9 6JH, UK
| | - Sunil Bhudia
- Department of Cardiothoracic Surgery, Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, Hill End Road, London UB9 6JH, UK
| | - Rebecca Lane
- Department of Cardiology, Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, Hill End Road, London UB9 6JH, UK
| | - Mark J Mason
- Department of Cardiology, Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, Hill End Road, London UB9 6JH, UK
- College of Engineering, Design and Physical Sciences, Brunel University London, Kingston Lane, Uxbridge UB8 3PH, UK
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, London W12 0HS, UK
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El Diasty M, Davies M, Fernandez AL, Ribeiro I, Payne D, Petsikas D. Does Pacemaker Implantation After Surgical Aortic Valve Replacement Impact Long-Term Morbidity and Mortality? A Focused Review. Tex Heart Inst J 2022; 49:487617. [PMID: 36252278 PMCID: PMC9632401 DOI: 10.14503/thij-20-7518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Mohammad El Diasty
- Cardiac Surgery Department, Kingston Health Science Centre, Kingston, Ontario, Canada
| | - Mark Davies
- Cardiology Department, Oxford University Hospital, Oxford, United Kingdom
| | - Angel L. Fernandez
- Cardiovascular Surgery Department, University Hospital, Santiago de Compostela, Spain
| | - Igo Ribeiro
- Cardiac Surgery Department, Kingston Health Science Centre, Kingston, Ontario, Canada
| | - Darrin Payne
- Cardiac Surgery Department, Kingston Health Science Centre, Kingston, Ontario, Canada
| | - Dimitri Petsikas
- Cardiac Surgery Department, Kingston Health Science Centre, Kingston, Ontario, Canada
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Servito M, Khoury W, Payne D, Baranchuk A, El Diasty M. Long-term impact of permanent cardiac pacing after surgical aortic valve replacement: systematic review and meta-analysis. Expert Rev Cardiovasc Ther 2022; 20:81-86. [DOI: 10.1080/14779072.2022.2031981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Maria Servito
- Faculty of Medicine, Queen’s University, Kingston, ON, Canada
| | - William Khoury
- Faculty of Medicine, Queen’s University, Kingston, ON, Canada
| | - Darrin Payne
- Division of Cardiac Surgery, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Adrian Baranchuk
- Division of Cardiology, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Mohammad El Diasty
- Division of Cardiac Surgery, Kingston Health Sciences Centre, Kingston, ON, Canada
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Glaser N, Persson M, Dalén M, Sartipy U. Long-term Outcomes Associated With Permanent Pacemaker Implantation After Surgical Aortic Valve Replacement. JAMA Netw Open 2021; 4:e2116564. [PMID: 34255050 PMCID: PMC8278270 DOI: 10.1001/jamanetworkopen.2021.16564] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Natalie Glaser
- Department of Cardiology, Stockholm South General Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Michael Persson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrik Sartipy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
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Navaratnarajah M, Luthra S, Ohri S. Transcatheter aortic valve implantation in low-risk patients: A case of rational over exuberance. The time is not now. Asian Cardiovasc Thorac Ann 2021; 29:836-847. [PMID: 34034507 DOI: 10.1177/02184923211018589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
| | - Suvitesh Luthra
- Department of Cardiac Surgery, Southampton University Hospital, Southampton, UK
| | - Sunil Ohri
- Department of Cardiac Surgery, Southampton University Hospital, Southampton, UK
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Krane M, Boehm J, Prinzing A, Ziegelmueller J, Holfeld J, Lange R. Excellent Hemodynamic Performance After Aortic Valve Neocuspidization Using Autologous Pericardium. Ann Thorac Surg 2020; 111:126-133. [PMID: 32540439 DOI: 10.1016/j.athoracsur.2020.04.108] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/27/2020] [Accepted: 04/20/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Aortic valve neocuspidization (AVNeo) for trileaflet aortic valve reconstruction using autologous pericardium (Ozaki procedure) offers an alternative treatment modality to overcome drawbacks of conventional prosthetic aortic valve replacement. METHODS Between October 2016 and April 2019, 103 patients underwent surgery. Mean follow-up was 426 ± 270 days. Aortic stenosis was the leading diagnosis in 80 patients (77.7%) and aortic regurgitation in 23 (22.3%), respectively. Mean age was 54.0 ± 16.4 years (range, 13.8-78.5). A bicuspid valve was found in 81 patients (78.6%). Transthoracic echocardiography was performed at discharge and at 6 to 12 months after surgery. During AVNeo surgery valve sizing for an Abbott/St Jude Trifecta bioprosthesis (virtually implanted Trifecta bioprosthesis; St Jude Medical, St Paul, MN) was performed to compare pressure gradients and effective orifice area with published data. RESULTS Trileaflet aortic valve reconstruction was achieved in all patients. In 38 patients neocommissures were created (36.9%). Mean cross-clamp time was 135 ± 20 minutes. Four patients underwent reoperation; the overall freedom from reoperation was 96.1%. Echocardiographic 6- to 12-months follow-up after surgery was available in 93.8% of patients and did not show any change in hemodynamic parameters compared with discharge. Comparison between AVNeo and virtually implanted Trifecta Bioprosthesis revealed a significantly lower mean pressure gradient (8.5 ± 3.7 mm Hg vs 10.2 ± 2.0 mm Hg, P < .001) and higher mean effective orifice area (2.2 ± 0.7 cm2 vs 2.1 ± 0.4 cm2, P = .037) for AVNeo. CONCLUSIONS AVNeo shows low reoperation rates after surgery within the first 2 years. The hemodynamic performance is excellent, and the effective orifice area and mean pressure gradient remain stable within the first year.
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Affiliation(s)
- Markus Krane
- Department of Cardiovascular Surgery, German Heart Center Munich, Technical University Munich, Munich, Germany; Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center, Technical University Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Johannes Boehm
- Department of Cardiovascular Surgery, German Heart Center Munich, Technical University Munich, Munich, Germany; Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center, Technical University Munich, Munich, Germany.
| | - Anatol Prinzing
- Department of Cardiovascular Surgery, German Heart Center Munich, Technical University Munich, Munich, Germany; Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center, Technical University Munich, Munich, Germany
| | - Johannes Ziegelmueller
- Department of Cardiovascular Surgery, German Heart Center Munich, Technical University Munich, Munich, Germany; Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center, Technical University Munich, Munich, Germany
| | - Johannes Holfeld
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Center Munich, Technical University Munich, Munich, Germany; Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center, Technical University Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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