Elsevier

Heart Rhythm

Volume 19, Issue 9, September 2022, Pages 1442-1449
Heart Rhythm

Clinical
Ablation
Permanent pacemaker implantation after valve and arrhythmia surgery in patients with preoperative atrial fibrillation

https://doi.org/10.1016/j.hrthm.2022.04.007Get rights and content

Background

Among patients referred for cardiac surgery, atrial fibrillation (AF) is a common comorbidity and a risk factor for postoperative arrhythmias (eg, sinus node dysfunction, atrioventricular heart block), including those requiring permanent pacemaker (PPM) implantation.

Objective

The purpose of this study was to evaluate the prevalence and long-term survival of postoperative PPM implantation in patients with preoperative AF who underwent valve surgery with or without concomitant procedures.

Methods

Presented analysis pertains to the HEIST (HEart surgery In atrial fibrillation and Supraventricular Tachycardia) registry. During the study period, 11,949 patients underwent valvular (aortic, mitral, or tricuspid valve replacement or repair) surgery and/or surgical ablation (SA) and were stratified according to postoperative PPM status.

Results

PPM implantation after surgery was necessary in 2.5% of patients, with significant variation depending on the type of surgery (from 1.1% in mitral valve repair to 3.3% in combined mitral and tricuspid valve surgery). In a multivariate logistic regression model, tricuspid intervention (P <.001), cardiopulmonary bypass time (P = .024), and endocarditis (P = .014) were shown to be risk factors for PPM. Over long-term follow-up, PPM was not associated with increased mortality compared to no PPM (hazard ratio 0.96; 95% confidence interval 0.77–1.19; P = .679). SA was not associated with PPM implantation. However, SA improved survival regardless of PPM status (log rank P <.001).

Conclusion

In patients with preoperative AF, the need for PPM implantation after valve surgery or SA is not an infrequent outcome, with SA not affecting its prevalence but actually improving long-term survival.

Introduction

Postoperative conduction abnormalities requiring permanent pacemaker (PPM) implantation can be induced after cardiac surgery.1 Their prevalence is strongly related to the area of the procedure, with interventions in proximity to elements of the conduction system bearing the greatest risk.2 This anatomic dependency results in a significant heterogeneity in the reported PPM implantation incidence, starting from 1%–3% in coronary artery bypass surgeries, followed by 10%–15% in surgical valve replacement, and reaching >30% in transcatheter valve interventions.1,3 Several analyses have linked postoperative PPM implantation to a prolonged hospital length of stay, as well as increased morbidity and mortality.2,4

Atrial fibrillation (AF) is a common comorbidity among patients with myocardial ischemia and valvular disease.5,6 AF may facilitate left atrial annulus dilation leading to mitral regurgitation.7 At the same time, mitral valve insufficiency and a consequent regurgitant jet result in left atrial enlargement, which may trigger AF.8 Finally, AF shares risk factors such as age, hypertension, or diabetes mellitus with other cardiovascular diseases.6 Patients with underlying AF have an increased risk of symptomatic bradycardia due to rhythm and rate control medications.9 During disease progression (ie, sinus node and atrial wall remodeling), bradycardia may lead to excess associated morbidity, development of sick sinus node syndrome, and/or atrioventricular block (AVB).10 AF is a poor prognostic marker in both surgical and nonsurgical settings and is an established risk factor for postoperative PPM implantation.1,2

Besides anatomic and physiological considerations, AF is more often becoming a subject for surgical ablation (SA), another claimed risk factor for postoperative PPM.11 Yet, SA is not a single unified procedure. Although surgical pulmonary vein (PV) isolation has been shown to be effective for maintaining sinus rhythm (SR), the most effective ablation treatment for AF isolates the PVs and the left atrial posterior wall. Cox–maze III, also known as the cut-and-sew technique, offers nearly 100% effectiveness in resolving AF but because of its complexity is now seldom performed.12 Cox–maze IV uses new energy sources (bipolar radiofrequency and cryothermy) to create ablation lines that impede electrical impulses around the most important structures (PVs, mitral and tricuspid valve annuli, venae cavae, and appendages). Left atrial appendage occlusion may be further performed. Cardiology societies recommend concomitant SA at the time of other surgical procedure to restore SR (class IA)13 and to improve survival (class IIa)14 after mitral and coronary surgery.15,16

The current analysis aimed to assess the incidence of PPM implantation after valve surgery, with or without concomitant procedures, and its effect on long-term survival among patients with preoperative AF and in a subpopulation undergoing concomitant SA.

Section snippets

Methods

The study is an analysis of the HEIST (HEart surgery In atrial fibrillation and Supraventricular Tachycardia) Registry (ClinicalTrials.gov Identifier: NCT 04860882). Data of AF patients undergoing surgery between January 1, 2011, and December 31, 2020, were collected from 8 tertiary centers in Poland, The Netherlands, and Italy. Only valve operations with or without concomitant procedures (coronary artery bypass graft [CABG], aortic surgery, left atrial appendage occlusion, SA) and standalone

PPM implantation after cardiac surgery

Overall, 11,949 patients with preoperative AF who had undergone a valvular procedure and/or SA were identified. Of these patients, 295 (2.5%) had a PPM implanted postoperatively. The study flowchart is shown in Figure 1. Patients in the PPM group had a significantly higher EuroSCORE II (3.72 vs 3.21; P = .002), more frequently had from endocarditis (7.8% vs 3.7%) (P = .001), and more often had previously undergone cardiac surgery (11.5% vs 7.9%; P = .030). Table 1 summarizes baseline

Discussion

The current analysis of the HEIST Registry showed the following. (1) PPM implantation is a relatively frequent postoperative complication among patients with AF, with an incidence of 2.5%. (2) Postoperative PPM implantation did not influence long-term survival (HR 0.96; 95% CI 0.77–1.19; P = .679). (3) Concomitant SA among patients with preoperative AF did not increase the risk for PPM implantation. (4) Long-term SA survival benefit was observed regardless of PPM implantation status. (5)

Conclusion

In patients with preoperative AF, the need for PPM implantation after valve surgery or SA is not an infrequent outcome, with SA not affecting its prevalence but actually improving long-term survival.

Acknowledgment

The authors acknowledge the work of all the members of Thoracic Research Centre (www.trc.org.pl).

References (22)

  • N. Glaser et al.

    Long-term outcomes associated with permanent pacemaker implantation after surgical aortic valve replacement

    JAMA Netw Open

    (2021)
  • Cited by (3)

    • Atrial fibrillation ablation improves late survival after concomitant cardiac surgery

      2023, Journal of Thoracic and Cardiovascular Surgery
      Citation Excerpt :

      Second, the number of PPM implantations might be underestimated, because reimbursement policy favors PPM implantation after an index hospitalization for borderline indications; together with the fact that the exact timing of PPM implantation was not available in the registry, PPM implantation in the current analysis should be regarded as one occurring during index hospitalization. Lower rates of PPM observed in the SA group require further investigation, although one recent analysis showed SA was not prognostic of PPM after valve and arrhythmia surgery.35 Third, certain detailed baseline and operative data such as AF type and duration, ablation energy source, ablation duration, and additional ablation lines are not recorded.

    Funding Sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

    Disclosures: The authors have no conflicts of interest to disclose. ClinicalTrials.gov Identifier: NCT 04860882.

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