Assessment of the need pacemaker implantation following aortic valve replacement with combined cardiac surgery

Aim. To evaluate the risk factors for the development of cardiac conduction disorders and to determine their significance in temporary and permanent pacemaker implantation in patients after surgical aortic valve replacement and other combined cardiac surgical interventions.
Material and methods. The analysis of patients who underwent surgical aortic valve replacement and other combined cardiac surgical interventions for the period from January 2018 to May 2023 in Krasnoyarsk Regional Clinical Hospital was performed.
Results. The correlation between the occurrence of atrioventricular block (AVB) of II-III degree and sinus node dysfunction (SND) that required temporary pacemaker and permanent pacemaker implantation in patients after surgical prosthesis of aortic valve and other combined cardiac surgical interventions was determined. After AVR and other combined cardiac interventions atrial fibrillation (AF) was detected in 107 (44.6%) patients, left bundle branch block (LBBB) and right bundle branch block (RBBB) in 8 (3.3%) patients, and first-degree AV block in 12 (5.0%) patients. The need for temporary pacemaker after surgical prosthetic aortic valve and other combined cardiac surgical interventions was in 79 (45.4%) patients. 76 (96.2%) patients underwent TCP within 2 days after surgical treatment and 3 (3.8%) patients within 72 hours. According to single-factor analysis, 4 important reasons for required temporary pacemaker were identified: atrial fibrillation (OR=2,47, 95% CI=1,31-4,46, p=0,005), age older than 58.5 years (OR=2,52, 95% CI=1,29-4,93, p=0,006), glomerular filtration rate less than 77 ml/min (OR=2,12, 95% CI =1,08-4,17, p=0,028) and atrial tachycardia (OR=8,00, 95% CI=1,04-67,92, p=0,046). Рermanent pacemaker implantation was performed in 12 (6.7%) patients, 11 (91.7%) due to complete AVB and 1 (8.3%) patient due to SVD development. Pacemaker implantation after cardiac surgery was performed in 8 (66.7%) patients from 5 to 8 days, 3 (25.0%) patients from 10 to 15 days, and 1 (8.3%) patient after 23 months. According to regression analysis, a significant sign indicating a high risk of pacemaker implantation — presence of baseline left bundle branch block (OR= 6,32, 95% CI=1,09-36,70, p=0.020).
Conclusion. The identified risk factors for conduction disturbances after aortic valve replacement and other cardiac surgical interventions can be used for timely conduction and implantation of a permanent pacemaker.

1. Rosillo N, Vicent L, Martín de la Mota Sanz D, et al. Time trends in the epidemiology of nonrheumatic aortic valve disease in Spain, 2003-2018. Rev Esp Cardiol (Engl Ed). 2022;75(12):1020-8. DOI:10.1016/j.rec.2022.06.005.

2. Chatterjee A, Kazui T, Acharya D. Growing prevalence of aortic stenosis — Question of age or better recognition? Int J Cardiol. 2023;388:131155. DOI:10.1016/j.ijcard.2023.131155.

3. Whelton SP, Jha K, Dardari Z, et al. Prevalence of Aortic Valve Calcium and the Long-Term Risk of Incident Severe Aortic Stenosis. JACC Cardiovasc Imaging. 2024;17(1):31-42. DOI:10.1016/j.jcmg.2023.02.018.

4. Aluru JS, Barsouk A, Saginala K, et al. Valvular Heart Disease Epidemiology. Med Sci (Basel). 2022;10(2):32. DOI:10.3390/medsci10020032.

5. Aslam S, Patsalides MA, Stoma S, et al. Aortic valve intervention rates in patients of different ethnicity with severe aortic stenosis in Leicestershire, UK. Open Heart. 2023;10(1):e002266. DOI:10.1136/openhrt-2023-002266.

6. Hibino M, Pandey AK, Hibino H, et al. Mortality trends of aortic stenosis in high-income countries from 2000 to 2020. Heart. 2023;109(19):1473-8. DOI:10.1136/heartjnl-2023-322397.

7. Iung B, Arangalage D. Community burden of aortic valve disease. Heart. 2021;107(18):1446-7. DOI:10.1136/heartjnl-2021-319560.

8. Chetrit M, Khan MA, Kapadia S. State of the Art Management of Aortic Valve Disease in Ankylosing Spondylitis. Curr Rheumatol Rep. 2020;22(6):23. DOI:10.1007/s11926-020-00898-4.

9. Lee HJ, Kim HK. Natural History Data in Symptomatic Severe Aortic Stenosis Alerts Cardiologists to the Dangers of No Action. Korean Circ J. 2019;49(2):170-2. DOI:10.4070/kcj.2018.0344.

10. Vahanian A, Beyersdorf F, Praz F, et al. ; ESC/EACTS Scientific Document Group. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2022;43(7):561-632. DOI:10.1093/eurheartj/ehab395. Erratum in: Eur Heart J. 2022;43(21):2022. DOI:10.1093/eurheartj/ehac051.

11. Marcoff L, Gillam LD. Aortic Stenosis: Risk Stratification and Timing of Surgery. Curr Cardiol Rep. 2023;25(3):89-95. DOI:10.1007/s11886-022-01835-w.

12. Dalén M, Persson M, Glaser N, Sartipy U. Permanent pacemaker implantation after On-X surgical aortic valve replacement: SWEDEHEART observational study. BMJ Open. 2021;11(11):047962. DOI:10.1136/bmjopen-2020-047962.

13. Yanagisawa H, Tabata M. Modified annular suturing technique for minimizing postoperative pacemaker use after surgical aortic valve replacement. Gen Thorac Cardiovasc Surg. 2021;69(2):254-9. DOI:10.1007/s11748-020-01450-y

14. Généreux P, Cohen DJ, Pibarot P, et al. Cardiac Damage and Quality of Life After Aortic Valve Replacement in the PARTNER Trials. J Am Coll Cardiol. 2023;81(8): 743-52. DOI:10.1016/j.jacc.2022.11.059.

15. Coti I, Schukro C, Drevinja F, et al. Conduction disturbances following surgical aortic valve replacement with a rapid-deployment bioprosthesis. J Thorac Cardiovasc Surg. 2021;162(3):803-11. DOI:10.1016/j.jtcvs.2020.01.083.

16. Hwang YM, Kim J, Lee JH, et al. Conduction disturbance after isolated surgical aortic valve replacement in degenerative aortic stenosis. J Thorac Cardiovasc Surg. 2017;154(5):1556-65.e1. DOI:10.1016/j.jtcvs.2017.05.101.

17. Klapkowski A, Pawlaczyk R, Kempa M, et al. Complete atrioventricular block after isolated aortic valve replacement. Kardiol Pol. 2016;74(9):985-93. DOI:10.5603/KP.a2016.0038.

18. Miyauchi M, Imamura T. Predictors of permanent pacemaker implantation following surgical aortic valve replacement. J Card Surg. 2021;36(11):4443. DOI:10.1111/jocs.15903.

19. Ram E, Peled Y, Sarantsev I, et al. Impact of pre-existing right or left bundle branch block on patients undergoing surgical aortic valve replacement. Eur J Cardiothorac Surg. 2022;62(4):ezac105. DOI:10.1093/ejcts/ezac105.

20. Gill R, Meghrajani V, Ali S, Riasat M. Delayed Onset Atrioventricular Block After Surgical Aortic Valve Replacement: A Rare Entity. Cureus. 2022;14(6):e25606. DOI:10.7759/cureus.25606.

21. Biancari F, Pykäri J, Savontaus M, et al. Early and late pace-maker implantation after transcatheter and surgical aortic valve replacement. Catheter Cardiovasc Interv. 2021;97(4):560-8. DOI:10.1002/ccd.29177.

22. Stolbikov YuYu, Matyushin GV, Protopopov AV, et al. Incidence of atrioventricular conduction disturbances and need for pacemaker implantation in patients after endovascular aortic valve replacement. Sibirskij nauchnyj medicinskij zhurnal = Siberian Scientific Medical Journal. 2024;44(6):225-30. (In Russ.). DOI:10.18699/SSMJ20240624.

23. Hwang YM, Kim J, Nam GB, et al. Pacemaker dependency after transcatheter aortic valve replacement compared to surgical aortic valve replacement. Medicine (Baltimore). 2021;100(22):e26123. DOI:10.1097/MD.0000000000026123.

24. Ravaux JM, Van Kuijk SM, Di Mauro M, et al. ; Cardiothoracic Surgery Registration Committee of the Netherlands Heart Registration. Incidence and predictors of permanent pacemaker implantation after surgical aortic valve replacement: Data of the Netherlands Heart Registration (NHR). J Card Surg. 2021;36(10): 3519-27. DOI:10.1111/jocs.15803.