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 electrocardiostimulation (TECS) and permanent pacemaker implantation (PI) 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 “Regional Clinical Hospital” Krasnoyarsk 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 TCP after surgical prosthetic AoC 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).

PEC 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, Elola FJ, Moreno G, Bueno H. Time trends in the epidemiology of nonrheumatic aortic valve disease in Spain, 2003-2018. Rev Esp Cardiol (Engl Ed). 2022 Dec;75(12):1020-1028. English, Spanish. DOI: 10.1016/j.rec.2022.06.005. Epub 2022 Jun 2. PMID: 35662678.

2. Chatterjee A, Kazui T, Acharya D. Growing prevalence of aortic stenosis - Question of age or better recognition? Int J Cardiol. 2023 Oct 1;388:131155. DOI: 10.1016/j.ijcard.2023.131155. Epub 2023 Jul 8. PMID: 37429442.

3. Whelton SP, Jha K, Dardari Z, Razavi AC, Boakye E, Dzaye O, Verghese D, Shah S, Budoff MJ, Matsushita K, Carr JJ, Vasan RS, Blumenthal RS, Anchouche K, Thanassoulis G, Guo X, Rotter JI, McClelland RL, Post WS, Blaha MJ. Prevalence of Aortic Valve Calcium and the Long-Term Risk of Incident Severe Aortic Stenosis. JACC Cardiovasc Imaging. 2024 Jan;17(1):31-42. DOI: 10.1016/j.jcmg.2023.02.018. Epub 2023 May 10. PMID: 37178073; PMCID: PMC10902718.

4. Aluru JS, Barsouk A, Saginala K, Rawla P, Barsouk A. Valvular Heart Disease Epidemiology. Med Sci (Basel). 2022 Jun 15;10(2):32. DOI: 10.3390/medsci10020032. PMID: 35736352; PMCID: PMC9228968.

5. Aslam S, Patsalides MA, Stoma S, Alfuhied A, Nelson CP, Squire IB, Lawson CA, Khunti K, McCann GP, Singh A. Aortic valve intervention rates in patients of different ethnicity with severe aortic stenosis in Leicestershire, UK. Open Heart. 2023 May;10(1):e002266. DOI: 10.1136/openhrt-2023-002266. PMID: 37156572; PMCID: PMC10173973.

6. Hibino M, Pandey AK, Hibino H, Verma R, Aune D, Yanagawa B, Takami Y, Bhatt DL, Attizzani GF, Pelletier MP, Verma S. Mortality trends of aortic stenosis in high-income countries from 2000 to 2020. Heart. 2023 Sep 13;109(19):1473-1478. DOI: 10.1136/heartjnl-2023-322397. PMID: 37208159.

7. Iung B, Arangalage D. Community burden of aortic valve disease. Heart. 2021 Sep;107(18):1446-1447. DOI: 10.1136/heartjnl-2021-319560. Epub 2021 Jun 14. PMID: 34127542.

8. Chetrit M, Khan MA, Kapadia S. State of the Art Management of Aortic Valve Disease in Ankylosing Spondylitis. Curr Rheumatol Rep. 2020 May 14;22(6):23. DOI: 10.1007/s11926-020-00898-4. PMID: 32410005.

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 Feb;49(2):170-172. DOI: 10.4070/kcj.2018.0344. Epub 2018 Nov 7. PMID: 30468037; PMCID: PMC6351281.

10. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W; ESC/EACTS Scientific Document Group. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2022 Feb 12;43(7):561-632. doi: 10.1093/eurheartj/ehab395. Erratum in: Eur Heart J. 2022 Jun 1;43(21):2022. DOI: 10.1093/eurheartj/ehac051. PMID: 34453165.

11. Marcoff L, Gillam LD. Aortic Stenosis: Risk Stratification and Timing of Surgery. Curr Cardiol Rep. 2023 Mar;25(3):89-95. DOI: 10.1007/s11886-022-01835-w. Epub 2023 Feb 14. PMID: 36787025.

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 Nov 18;11(11):e047962. DOI: 10.1136/bmjopen-2020-047962. PMID: 34794986; PMCID: PMC8603281.

13. Yanagisawa H, Tabata M. Modified annular suturing technique for minimizing postoperative pacemaker use after surgical aortic valve replacement. Gen Thorac Cardiovasc Surg. 2021 Feb;69(2):254-259. DOI: 10.1007/s11748-020-01450-y. Epub 2020 Jul 29. PMID: 32725475.

14. Généreux P, Cohen DJ, Pibarot P, Redfors B, Bax JJ, Zhao Y, Prince H, Makkar RR, Kapadia S, Thourani VH, Mack MJ, Nazif TM, Lindman BR, Babaliaros V, Russo M, McCabe JM, Gillam LD, Alu MC, Hahn RT, Webb JG, Leon MB, Arnold SV. Cardiac Damage and Quality of Life After Aortic Valve Replacement in the PARTNER Trials. J Am Coll Cardiol. 2023 Feb 28;81(8):743-752. DOI: 10.1016/j.jacc.2022.11.059. PMID: 36813373.

15. Coti I, Schukro C, Drevinja F, Haberl T, Kaider A, Kocher A, Laufer G, Andreas M. Conduction disturbances following surgical aortic valve replacement with a rapid-deployment bioprosthesis. J Thorac Cardiovasc Surg. 2021 Sep;162(3):803-811. DOI: 10.1016/j.jtcvs.2020.01.083. Epub 2020 Feb 19. PMID: 32204909.

16. Hwang YM, Kim J, Lee JH, Kim M, Hwang J, Kim JB, Jung SH, Choo SJ, Nam GB, Choi KJ, Chung CH, Lee JW, Kim YH. Conduction disturbance after isolated surgical aortic valve replacement in degenerative aortic stenosis. J Thorac Cardiovasc Surg. 2017 Nov;154(5):1556-1565.e1. DOI: 10.1016/j.jtcvs.2017.05.101. Epub 2017 Jun 15. PMID: 28712585.

17. Klapkowski A, Pawlaczyk R, Kempa M, Jagielak D, Brzeziński M, Rogowski J. Complete atrioventricular block after isolated aortic valve replacement. Kardiol Pol. 2016;74(9):985-93. DOI: 10.5603/KP.a2016.0038. Epub 2016 Apr 4. PMID: 27040012.

18. Miyauchi M, Imamura T. Predictors of permanent pacemaker implantation following surgical aortic valve replacement. J Card Surg. 2021 Nov;36(11):4443. DOI: 10.1111/jocs.15903. Epub 2021 Aug 7. PMID: 34363418.

19. Ram E, Peled Y, Sarantsev I, Jamal T, Kogan A, Raanani E, Sternik L. Impact of pre-existing right or left bundle branch block on patients undergoing surgical aortic valve replacement. Eur J Cardiothorac Surg. 2022 Sep 2;62(4):ezac105. DOI: 10.1093/ejcts/ezac105. PMID: 35167678.

20. Gill R, Meghrajani V, Ali S, Riasat M. Delayed Onset Atrioventricular Block After Surgical Aortic Valve Replacement: A Rare Entity. Cureus. 2022 Jun 2;14(6):e25606. DOI: 10.7759/cureus.25606. PMID: 35795512; PMCID: PMC9250352.

21. Biancari F, Pykäri J, Savontaus M, Laine M, Husso A, Virtanen M, Maaranen P, Niemelä M, Mäkikallio T, Tauriainen T, Eskola M, Raivio P, Valtola A, Juvonen T, Airaksinen J. Early and late pace-maker implantation after transcatheter and surgical aortic valve replacement. Catheter Cardiovasc Interv. 2021 Mar;97(4):E560-E568. DOI: 10.1002/ccd.29177. Epub 2020 Aug 7. PMID: 32767643.

22. Stolbikov Yu.Yu., Matyushin G.V., Protopopov A.V., Samokhvalov E.V., Ishchenko O.P., Kobanenko V. O. 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(x):xxx–xxx. DOI: в печати. (In Russian). [Столбиков Ю.Ю., Матюшин Г.В., Протопопов А.В., Самохвалов Е.В., Ищенко О.П., Кобаненко В.О. Частота развития нарушений атриовентрикулярной проводимости и потребности в имплантации электрокардиостимулятора у пациентов после эндоваскулярного протезирования аортального клапана. Сибирский научный медицинский журнал. 2024;44(x):xxx–xxx]. DOI:

23. Hwang YM, Kim J, Nam GB, Choi KJ, Park DW, Kang DY, Park SJ, Park SY. Pacemaker dependency after transcatheter aortic valve replacement compared to surgical aortic valve replacement. Medicine (Baltimore). 2021 Jun 4;100(22):e26123. DOI: 10.1097/MD.0000000000026123. PMID: 34087862; PMCID: PMC8183801.

24. Ravaux JM, Van Kuijk SM, Di Mauro M, Vernooy K, Bidar E, Mariani S, Dato GA, Van T Hof AW, Veenstra L, Kats S, Houterman S, Maessen JG, Lorusso R; Cardiothoracic Surgery Registration Committee of the Netherlands Heart Registration. Incidence and predictors of permanent pacemaker implantation after surgical aortic v alve replacement: Data of the Netherlands Heart Registration (NHR). J Card Surg. 2021 Oct;36(10):3519-3527. DOI: 10.1111/jocs.15803. Epub 2021 Jul 11. PMID: 34250647; PMCID: PMC8518121.

25. ESC/EACTS Scientific Document Group. 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol (Engl Ed). 2022 Jun;75(6):524. English, Spanish. DOI: 10.1016/j.rec.2022.05.006. PMID: 35636831.