Prophylactic epicardial pacing in tricuspid valve replacement

Abstract

Patients undergoing surgical tricuspid valve replacement (TVR) are at high risk of developing atrioventricular (AV) conduction disorders. Because of this high risk and to avoid implanting a lead through the tricuspid bioprosthesis, patients who undergo TVR in our center usually receive a prophylactic epicardial pacemaker. We aimed to assess the efficacy and safety of prophylactic implantation of epicardial pacemaker after TVR. Among patients who underwent TVR and received prophylactic epicardial pacemaker, clinical evaluations, electrocardiograms and pacemaker interrogation reports were collected and analyzed retrospectively. Pacemaker efficacy assessed by characterizing the physiologic atrioventricular conduction and safety was evaluated by listing and adjudicating postoperative events. From 2014 to 2018, 100 patients underwent TVR, 80 out of them received a prophylactic epicardial pacemaker. Mean age was 57 ± 16 years old and 70% were women. Only 35% patients underwent isolated TVR. Following the postoperative period, heart rhythm was analyzed for 59/80 patients during a median follow-up of 35 months. Cardiac stimulation was considered necessary in 46% of patients: 14% had pacing dependency, 17% had a class I/IIa indication for permanent cardiac pacing (second or third-degree AV block), and 15% had a permanent ventricular pacing (> 80%). No preoperative or operative variables could predict cardiac pacing requirement. Postoperatively, a spontaneous heart rate over 70/minutes ( P = 0.02) and the documentation of narrow QRS (< 120 ms) ( P = 0.03) were significantly associated with a lower risk of long-term cardiac pacing requirement. Serious complications related to epicardial pacemaker were observed in 2.5% of cases. After TVR, permanent cardiac stimulation was required in 46% of patients, mostly for high grade conduction disorders. This high incidence legitimates a pacing strategy for patients undergoing TVR.