Commentary: How many doctors does it take to change a lightbulb?

Abstract

Central MessageLeadless pacemaker implantation under direct visualization can be done safely during valve surgery. Further study is needed to determine who benefits from the technique.See Article page XXX. Leadless pacemaker implantation under direct visualization can be done safely during valve surgery. Further study is needed to determine who benefits from the technique. See Article page XXX. Readers of the Journal will find interest in this study by Shivamurthy and colleagues.1Shivamurthy P. Miller M.A. El-Eshmawi A. Boateng P. Pandis D. Pawale A. et al.Leadless pacemaker implantation under direct visualization during valve surgery.J Thorac Cardiovasc Surg. 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (2) Google Scholar The study addresses the feasibility of directly inserting a leadless pacemaker during isolated or concomitant tricuspid valve operation. The authors have done a good job describing the technical considerations about device insertion. Using their technique, all leadless pacemakers were successfully inserted in less than 5 minutes. The process seems relatively straightforward. Marai and colleagues2Marai I. Diab S. Ben-Avi R. Kachel E. Intraoperative implantation of Micra leadless pacemaker during valve surgery.Ann Thorac Surg. 2018; 105: e211-e212Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar reported the first case of successful intraoperative implantation of a leadless pacemaker during valve surgery. Shivamurthy and colleagues1Shivamurthy P. Miller M.A. El-Eshmawi A. Boateng P. Pandis D. Pawale A. et al.Leadless pacemaker implantation under direct visualization during valve surgery.J Thorac Cardiovasc Surg. 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (2) Google Scholar have now added 15 more cases to the literature. In all patients, there have been no reported procedural complications, and it seems that pacing impedance, sensing amplitudes, and pacemaker function have been normal during short-term follow-up (151 ± 119 days). The literature corroborates a high rate of success implantation and low rate of acute complications.3Oliveira S.F. Carvalho M.M. Adao L. Nunes J.P. Clinical outcomes of leadless pacemaker: a systemic review.Minerva Cardioangiol. July 10, 2020; ([Epub ahead of print])Google Scholar,4Zucchelli G. Tolve S. Barletta V. Di Cori A. Parollo M. De Lucia R. et al.Comparison between leadless and transvenous single-chamber pacemaker therapy in a referral centre for lead extraction.J Interv Card Electrophysiol. July 25, 2020; ([Epub ahead of print])Crossref Scopus (2) Google Scholar In my opinion, the issue is not if pacemaker insertion can be done. The authors have demonstrated such. The main issue is whether pacemaker insertion should be done? This is where it becomes quite complex, which may explain why this study had 14 authors. I note in this study (see their Figure 5) that 73% of the patients had a postoperative pacing burden of 0% to 10%. This raises the question: did those patients even need a pacemaker? Or was the pacemaker just an expensive contingency? The authors recognize the controversy. In the discussion section, they do not advocate for routine implantation of the leadless pacemaker at the time of cardiac surgery in patients without a pre-existing indication for pacing. I'm supportive of this technique in patients with a clear preoperative indication for pacemaker therapy such as atrial fibrillation with complete heart block. However, this type of patient was a rarity (7%) compared with the larger group of patients who might, but didn't, need pacing after valve surgery. It comes down to risk and benefit. And I would include cost in the risk-side of that analysis. Leadless pacemaker technology is expensive. A superfluous leadless pacemaker doesn't make financial sense, even if it obviates the need for temporary pacemaker wire implantation and early discharge. Yes, you can safely and easily do leadless pacemaker implantation under direct visualization during valve surgery. Moving forward, the question is, should you do it? This explains my use of the light bulb metaphor in the title. Screwing in the light bulb is easy. Correctly deciding to change the lightbulb is where the apparent difficult lies. Further study is warranted. Leadless pacemaker implantation under direct visualization during valve surgeryThe Journal of Thoracic and Cardiovascular SurgeryPreviewThe leadless cardiac pacemaker is typically implanted percutaneously and has been widely used for patients who have already undergone valve surgery. We sought to determine the feasibility and safety of implanting the leadless pacemaker under direct visualization during valve surgery. Full-Text PDF