Pacemaker dependency after Cox Maze procedure concomitant with cardiac surgery, The road between Scylla and Charybdis

Abstract

Abstract Background The Cox Maze (CM) procedure is a well-established treatment for atrial fibrillation. However, recent trials report alarming rates of pacemaker implantation (PMI) during hospitalization after CM. As PMI, generator replacement and Lead management are sometimes accompanied by complications, such as infection or bleeding and represent a burden for patients and healthcare systems. We thought to investigate the rates of pacemaker dependency 6 months after pacemaker implantation regarding the applied energy source and the performed lesion set, to determine whether PPM implantation timing and specific conduction disturbances as indications are associated with late pacemaker dependency. Methods We performed a retrospective review of 3695 patients underwent elective cardiac surgery in our institution between the years 2005 and 2022. Patients who use of devices for rhythm control, resynchronisation therapy, implantablecardioverter defibrillator (ICD) or both were excluded from the present study. A total of 283 patients met the inclusion criteria; Various energy sources, including cryoablation (n= 123) and radiofrequency (n= 160) were used. Left atrial (n= 228) and biatrial (n= 55) ablation was performed The distribution of the preoperative and perioperative variables was similar. Results There was no statistical difference in the incidence pacemaker dependency regarding the applied energy source whether radiofrequencyablation or cryoablation (25% vs. 30%; p = 0.2 respectively). On the other hand, biatrial ablation led to a significant pacemaker dependency rate compared with isolated left-sided ablation (78,2% vs 14.9%; P = .001 respectively), moreover Sinus node dysfunction as indication for PPM implantation was predictive of being not PPM dependent (OR 6.59; 95% CI, 1.67-26.06; P = .007). Conclusion Concomitant CM procedure showed a pacemaker implantation rate of 7,4%. Univariate and multivariate analysis showed biatrial lesion set as the only statistically significant predictor for pacemaker dependency after CM procedure. Further large-scale randomized controlled studies are needed to elucidate the Impact of the CM on the late pacemaker dependency.