Sinus node dysfunction and related permanent pacemaker implantation after major cardiac surgeries, systematic review, and meta-analysis

High incidence of permanent pacemaker after Cox-maze IV and mitral valve surgery: a nationwide registry-based study

OBJECTIVES

This study evaluated the long-term risk of permanent pacemaker implantation following Cox-maze IV (CMIV) and concurrent mitral valve surgery.

METHODS

A retrospective, nationwide, registry-based analysis was conducted on postoperative permanent pacemaker implantation in 397 patients with symptomatic mitral valve insufficiency and atrial fibrillation who underwent CMIV and mitral valve surgery in Sweden between 2009 and 2017. They were compared to a registry group of 346 patients with atrial fibrillation who underwent mitral valve surgery without surgical ablation during 2014-2017. The follow-up ended on 30 September 2022.

RESULTS

CMIV patients were on average 4 years younger and had lower surgical risk than registry patients. More CMIV patients underwent early (<30 days) pacemaker implantation (13.3% vs. 5.5%, P = 0.002). CMIV patients had a doubled adjusted risk of requiring a pacemaker compared to registry patients after 8 years [HR 1.96, 95% CI 1.27-3.04]. In the CMIV group, 22% (95% CI 18-26%) had a pacemaker by 5 years, increasing to 27% (95% CI 22-31%) by 8 years, compared to 13% (95% CI 10-17%) at both time intervals in the registry group. Atrioventricular block II/III accounted for >60% of early pacemaker indications in both groups, and sinus node dysfunction was the indication for late pacemaker implantation in 48% in the CMIV group.

CONCLUSIONS

Patients undergoing CMIV concomitant with mitral valve surgery have a higher rate of postoperative pacemaker implantation compared to patients with atrial fibrillation undergoing mitral valve surgery alone. Sinus node dysfunction was the main indication for late pacemaker among CMIV patients.

Long-Term Outcomes of Concomitant Modified Cox-Maze and Mitral Surgery

PURPOSE

There are limited data on outcomes of combined Maze and mitral valve procedures beyond 10 years. This study analyzed the efficacy of this operation.

METHODS

Between June 2004 and December 2022, 406 patients underwent mitral surgery concomitant with Maze procedure were evaluated. Rhythm outcomes, predictors of recurrence, and survival were assessed.

RESULTS

The median follow-up period was 100 months. Rheumatic disease was present in 58%. Mitral valve repair was performed in 57.1%. Freedom from atrial fibrillation (AF) at 5, 10, and 15 years was 82.5%, 70.8%, and 52.7%, respectively. Overall survival rates were not different between patients in sinus rhythm (SR) and those who remained in AF (p = 0.172). However, patients in SR experienced fewer neurological complication (p = 0.001). Predictors of AF recurrence included preoperative AF duration (p = 0.005), left atrial diameter (LAD) >50 mm (p <0.001), concomitant tricuspid valve surgery (p = 0.049), and the presence of AF on postoperative day 7 (p <0.001). Factors influencing survival were age >60 years (p <0.001) and a postoperative left ventricular ejection fraction <40% (p <0.001).

CONCLUSIONS

The combined Maze and mitral valve surgery provides significant benefits in managing AF with mitral disease. Predictors of recurrence included AF duration, LAD size >50 mm, associated tricuspid valve disease, and AF on day 7. SR patients had fewer neurological complications.

Pacemaker Implantation Following Heart Transplantation - Incidence and Risk Factors. Single-Center Experience

BACKGROUND

Bradyarrhythmias, requiring pacemaker (PM) implantation, are common complications following orthotopic heart transplantation (HTx). Currently used heart transplantation methods are primarily the bicaval technique and the total heart transplantation technique. The aim of the study was to assess the incidence and risk factors, including donor parameters, of conduction disorders requiring pacing after HTx.

METHODS

A population of 111 (52 ± 13 years, 91 (82%) men) heart recipients was divided into a group requiring PM implantation post-HTx and a group not requiring PM. We compared groups in terms of donor parameters, time of graft ischemia, transport and transplantation, and surgical techniques as the potential risk factors for significant bradyarrhythmias.

RESULTS

Ten of 111 patients with HTx (9%) required PM implantation. The indication in 7 cases was sinus node dysfunction (SND), in 3 patients it was complete atrioventricular block (AV-block). In the PM group, the age of 48 ± 6 vs 40 ± 11 years (P = .0227) and the body mass index (BMI) 28 ± 3 vs 26 ± 4 kg/m2 (P = .0297) of the donor were significantly higher. There was no influence of organ transport time, ischemia time, and transplantation time. All patients requiring PM implantation were transplanted using the bicaval anastomosis: 10 (100%) vs 71 (70%) in the group not requiring PM (P = .044).

CONCLUSIONS

The need for PM implantation post-HTx despite using new techniques is still common, especially in the group operated with the bicaval method. In addition, higher donor's age and BMI are risk factors of PM implantation, what is of importance as qualification criteria of donor hearts have been gradually extended.

Late recognition of cardiac implantable electronic device misplacement in left ventricle: a case report

Background: Cardiac electronic device implantation may be associated with complications. Case Summary: This is a report of inadvertent implantation of implantable cardioverter-defibrillator lead through an unrecognized sinus venosus atrial septal defect into the left ventricle that was not diagnosed early after implantation. Six months later chest x-ray showed an abnormal lead course that was confirmed with echocardiography as to be in the left ventricle. Surgical removal of the implantable cardioverter-defibrillator lead, repair of atrial septal defect, and correction of abnormal pulmonary venous connections were performed. Meanwhile, follow-up of the patient receiving a new dual chamber permanent pacemaker from the contralateral side and discussion of the aforementioned complication are addressed. Conclusion: Early diagnosis of device implantation complication is of paramount importance and prevents potential catastrophic complications.

Different leadless pacemakers working in harmony (Aveir in the atrium/Micra AV2 in the ventricle) in a patient with dextrocardia and double outlet right ventricle after high-risk infected device extraction

INTRODUCTION

Patients with congenital heart disease are at increased risk for requiring cardiac pacing during their lifetime.

METHODS

We present the first described case of using two leadless pacing systems manufactured by separate companies implanted within the same patient to provide atrial and ventricular pacing due to complex congenital anatomy.

RESULTS

A 27-year-old male with dextrocardia with double outlet right ventricle, subaortic ventricular septal defect, and pulmonary stenosis status-post pulmonary valve replacement complicated by ventricular pacing dependence and subsequent atrial pacing dependence after atriotomy-based atypical flutter ablation developed recurrent mediastinitis and pocket infection with erosion despite prolonged antibiotic treatment. Due to atrial and ventricular pacing dependence, a comprehensive congenital care team concluded the need for lead extraction and replacement of pacemaker via leadless peacemaking device. Laser-lead extraction and temporary atrial pacemaker placement was performed. Afterward, a transesophageal echocardiogram guided implantation of both a Micra AV 2 (Medtronic) leadless pacemaker in the interventricular septum within the right ventricle and an Aveir (Abbott) leadless pacemaker in the superior base of the right atrial appendage was performed with successful pacing. Although there is no communication between these devices, atrial-mechanical ventricular pacing was reliable with good implant thresholds, impedances and sensing from both devices.

CONCLUSION

Our case demonstrates the feasibility of using dual leadless pacing modalities to simultaneously pace someone at complex, prohibitive risk for temporary permanent or permanent pacemaker devices.

Retrievable leadless pacemakers (Aveir VR) may be beneficial in adult patients with congenital heart disease

INTRODUCTION

Congenital heart disease may present in up to 1.6 % of newborns. Given high burden of pacing need in adult patients with repaired congenital heart disease and availability of different pacing options, more information on outcomes of newer pacemaker types are needed. Retrievable leadless pacemaker implants in adult congenital patients have not been described.

METHODS

Retrospective review of three Aveir (Abbott) retrievable leadless pacemaker implants were reviewed at the UC Davis Medical Center. All patients underwent implant via femoral access.

RESULTS

All patients had one deployment only, after mapping prior. No complications occurred. Implant thresholds were 0.5 V (V) @0.2msilliseconds (ms) for patients 1 and 2 and 1 V @0.4 ms for patient 3. With impedances between 500 and 1290 Ω. Sensing was 5.5-8 mV (mV). Follow-up occurred up to one year (for two patients) with similar values overall. The predicted longevities of each device were between 22.6 and >25 years.

CONCLUSION

Safety and short-mid-term parameters of retrievable leadless pacemaker implantation is reported in three patients with adult congenital heart disease.

Fragmented QRS, a strong predictor of mortality and major arrhythmic events in patients with nonischemic cardiomyopathy: A systematic review and meta-analysis

Background and Aims

Fragmented QRS (fQRS), which is associated with rhythm disturbances, can predispose the heart to fatal ventricular arrhythmias. Recently, accumulating studies indicates that fQRS is associated with poor prognosis in various types of cardiomyopathies. Therefore, we assessed the association between fQRS with all-cause mortality and major arrhythmic events (MAEs) in patients with nonischemic cardiomyopathy, in this systematic review and meta-analysis study.

Methods

We performed a comprehensive search in databases of PubMed/Medline, EMBASE, and Web of Science from the beginning to December 31, 2022. Published observational studies (cohorts, case-control, or analytical cross-sectional studies) were included that report the prognostic value of fQRS in patients with different types of nonischemic cardiomyopathies for MAEs (sudden cardiac death, sudden cardiac arrest, sustained ventricular tachycardia [VT], ventricular fibrillation [VF], and appropriate shock) and all-cause mortality. We pooled risk ratios (RRs) through raw data and adjusted hazard ratios (aHRs) using "Comprehensive Meta-Analysis" software, Version 2.0.

Results

Nineteen cohort and three analytical cross-sectional studies were included in this meta-analysis involving a total of 4318 subjects with nonischemic cardiomyopathy (1279 with fQRS and 3039 without fQRS). FQRS was significantly associated with an increased risk of all-cause mortality in patients with nonischemic cardiomyopathy (pooled RR: 1.920; 95% confidence interval [CI]: 1.388-2.656, p < 0.0001/pooled HR: 1.729; 95% CI: 1.327-2.251, p < 0.0001). Also, the risk of developing MAEs in the presence of fQRS was significantly increased (pooled RR: 2.041; 95% CI: 1.644-2.533, p < 0.0001/pooled HR: 3.626; 95% CI: 2.119-6.204, p < 0.0001). In the subgroup analysis, the strongest association between fQRS presence and increased MAEs was observed in patients with hypertrophic cardiomyopathy (HCM) (pooled RR: 3.44; 95% CI: 2.07-5.71, p < 0.0001/pooled HR: 3.21; 95% CI: 2.04-5.06, p < 0.0001).

Conclusion

Fragmented QRS could be a prognostic marker for all-cause mortality and MAEs in patients with various types of nonischemic cardiomyopathies, particularly HCM.

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.