Need For Pacemaker Insertion Research Articles

Sex-based outcomes of surgical myectomy for hypertrophic cardiomyopathy: An analysis from the National Readmission Database

BackgroundThere is a paucity of data on sex differences in outcomes after surgical myectomy (SM) for hypertrophic cardiomyopathy (HCM). MethodsPatients who received SM for HCM during October 1, 2015, through December 31, 2018, were identified from the US National Readmission Database. The primary end point of this study was in-hospital mortality. The secondary end points were major bleeding, acute kidney injury, new pacemaker implantation, severe disability surrogates (non-home discharge and need for mechanical ventilation), resources utilization surrogates (length of stay and cost of hospitalization), and 30-day outcomes (readmission rate, mortality, and new pacemaker insertion). ResultsA total of 3031 patients were included in the current analysis. Using propensity score matching, 2 well matched cohorts were compared (women = 1170 and men = 1127). Women had a higher requirement for new pacemaker insertion compared with men (10.9% vs 6.8%; P = .029), higher number of non-home discharges (13.8% vs 7.9%; P < .01), and longer length of hospital stay (median = 7 [interquartile range, 5-9] days) versus (median = 6 [interquartile range, 5-8] days). There was no difference in in-hospital mortality, major bleeding, blood transfusion, acute kidney injury, or hospitalization costs for women versus men. At 30 days, women continued to show a higher need for pacemaker insertion (11.3% vs 7.1%; P = .03) and had a higher readmission rate than men (10.9% vs 7.1%; P = .02). There was no difference in 30-day mortality between women and men (3% vs 2.4%; P = .54). ConclusionsAmong the HCM cohort who received SM, significant sex-based differences in the outcomes were observed. Women had higher new pacemaker insertion rate, higher non-home discharge rate, and higher rate of 30-day readmission compared with men.

Totally endoscopic aortic valve replacement with stented biological and mechanical aortic prostheses

Abstract Background Endoscopic mitral valve surgery has become the gold standard of care in many expert centres around the globe. The aortic valve has not met the same popularity mainly due to the very confined space in the aortic root, and to the close proximity with the sternum which restricts the movement of the endoscopic instruments. When endoscopic aortic valve replacement is practiced in expert centres, is usually performed with the use of sutureless bioprostheses. We hereby present our experience of totally endoscopic aortic valve replacement (TEAVR) with conventional mechanical and biological prostheses. Methods Since January 2019, fifty-two consecutive patients with significant aortic stenosis and/or aortic regurgitation, who were operated with TEAVR with conventional prostheses were studied. 7,69% of the cases were REDOs. The prostheses used were either stented bovine pericardial in 84,6% of the patients and bileaflet mechanical in 15,4%. The operations were performed through a 3 to 4 cm working incision in the 3rd intercostal space (ICS) right parasternally (where an extra small soft tissue protector was deployed), a 10 mm port for the 3D, 30°, endoscope, and a 5 mm port for the left atrial vent. On full cardiopulmonary bypass, the heart was arrested with cardioplegia which was administered either in the aortic root or directly in the coronary ostia. A transverse aortotomy was performed 3 cm above the right coronary ostium. The native valve (tricuspid or bicuspid) was excised, the annulus was sized and the prostheses were inserted using twelve to fifteen annular sutures who were secured using an automated suture-fastening device. In order to facilitate exposure in the aortic root, a metal self-expandable net was used. Results The average age of the patients treated was 68,3 years (range 36–81, median 72). The mean EuroSCORE2 was 3,22 (0,9–12,01, SEM:0,71). The mean size of the prostheses inserted was 23,72 mm (21–27, median 23) and the mean postoperative peak gradient was 12,15 (5–19, SEM: 1,00). Mean cross clamp and CPB times were 75,38 min (SEM:5,87) and 116,30 (SEM:8,63). There was no case of paravalvular leak or pacemaker insertion. There was no mortality in this cohort of patients. There was one case of cerebrovascular accident. Conclusions TEAVR can be performed safely with conventional aortic prostheses. There are several advantages of the technique over the other aortic valve replacing approaches. Over the other surgical techniques has the advantage of not fracturing the sternum or spreading or dislodging the ribs and increased patient satisfaction. Over the TAVI has the advantages of fully removing the diseased native valve, securing the prosthesis at the exact annular level without any paravalvular leaks or need for pacemaker insertion and the ability of using mechanical prostheses. The main disadvantages of the technique are the relatively prolonged cross clamp and CPB times and the steep learning curve. TEAVR Funding Acknowledgement Type of funding source: None

Outcomes of Transcatheter Aortic Valve Replacement With Percutaneous Coronary Intervention versus Surgical Aortic Valve Replacement With Coronary Artery Bypass Grafting

We aimed to compare the outcomes of combined surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG) to concurrent transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) in a large U.S. population sample. The National Inpatient Sample was queried for all patients diagnosed with aortic valve stenosis who underwent SAVR with CABG or TAVR with PCI during the years 2016 to 2017. Study outcomes included all-cause in-hospital mortality, acute stroke, pacemaker insertion, vascular complications, major bleeding, acute kidney injury, sepsis, non-home discharge, length of stay and cost. Outcomes of hospitalization were modeled using logistic regression for binary outcomes and generalized linear models for continuous outcomes. Overall, 31,205 patients were included (TAVR + PCI = 2,185, SAVR + CABG = 29,020). In reference to SAVR + CABG, recipients of TAVR + PCI were older with mean age 82 versus 73 years, effect size (d) = 0.9, had higher proportions of females 47.6% versus 26.6%, d = 0.4 and higher prevalence of congestive heart failure and chronic renal failure. On multivariable analysis, TAVR + PCI was associated with lowers odds for mortality adjusted OR: 0.32 (95% CI: 0.17 to 0.62) p = 0.001, lower odds for acute kidney injury, sepsis, non-home discharge, shorter length of stay and higher odds for vascular complications, need for pacemaker insertion and higher cost. The occurrence of stroke was similar between both groups. In conclusion, results from real-world observational data shows less rates of mortality and periprocedural complications in TAVR + PCI compared to SAVR + CABG.

Etiology of syncope in patients with preexisting atrioventricular conduction disorders.

The discussion about the feasibility of empiric pacemaker implantation in patients with preexisting atrioventricular (AV) conduction disorders continues. The aim of the study was to determine the etiology of syncope and the need for pacemaker insertion in patients with AV conduction impairment using implantable loop recorder (ILR). ILR was implanted after negative diagnostic workup in 37 patients with syncope (24 men, 13 women, age 72±10 years) and preexisting impairment of AV conduction. First-degree AV block (AVB I) was present in 26 patients, and bundle branch block (BBB) in 17 patients. ILR-based diagnosis was made in 28 patients (75%)-sinus arrest in 13 patients, complete AVB in 10 patients, and vasodepressor syncope in five patients. In patients with preexisting BBB, sinus arrest occurred during ILR monitoring significantly more frequently than in patients without BBB (53%vs 20%, P = .03). Complete AVB was significantly less common in patients with preexisting BBB than in patients without BBB (12%vs 40%, P=.04). On multivariate regression analysis, the only independent predictor of AVB occurrence during ILR monitoring was preexisting AVB I (P=.03). The only independent predictor of sinus arrest during ILR monitoring was preexisting BBB (P=.03). In patients with preexisting AV conduction disorders, prevailing syncopal mechanism during ILR monitoring was asystole. However, sinus arrest occurred more often than complete AVB and was predicted by preexisting BBB. Preexisting AVB wasa predictor of complete AVB during ILR monitoring.

National Trends of Outcomes in Transcatheter Aortic Valve Replacement (TAVR) Through Transapical Versus Endovascular Approach: From the National Inpatient Sample (NIS)

BackgroundTo evaluate the trends in complication rates following transcatheter aortic valve replacement (TAVR) procedures according to the type of vascular approach (endovascular vs. transapical) in a large US population sample. MethodsThe National Inpatient Sample (NIS) was queried for all patients diagnosed with aortic stenosis who underwent a TAVR procedure in the United States during the years 2012–2016. Outcomes assessed were peri-procedural mortality, cardiac, and non-cardiac complications. Hospitalization outcomes were modeled using logistic regression for binary outcomes and generalized linear models for continuous outcomes. ResultsThere were 97,320 endovascular-TAVR patients and 11,140 transapical-TAVR patients. The mean age was 80.8 years (standard error of the mean: ± 0.1). Most patients were males (53.7%) and Caucasian (87.1%). On multivariate analysis, after adjusting for age, gender, comorbidities, as well as hospital factors, patients with the transapical approach had a higher risk for mortality and adverse outcomes. Among the endovascular-TAVR group, national trends showed a diminishing incidence of procedural mortality (incidence rate ratio [IRR] 0.77; 95% CI: 0.72–0.84, p < 0.001), stroke (IRR 0.80; 95% CI: 0.73–0.87, p < 0.001), and all secondary outcomes, but no significant change in myocardial infarction. In contrast, most transapical-TAVR related procedural complications remained unchanged over time, except for a significant decrease in stroke, acute respiratory failure and need for pacemaker insertion. ConclusionNational trends show a steady increase in the number of endovascular-TAVR procedures with a concurrent decrease in procedural complications.

Investigating the Manifestation of Coronary Artery Disease and Determining the Role of Effective Factors in the Need for Pacemaker Insertion in These Patients.

BACKGROUND:Many patients who are candidates for a pacemaker are also at the same time risk factors for coronary artery disease such as high blood pressure, hypertension, diabetes, and hyperlipidemia, and therefore the probability of having coronary artery disease is significant. Effective diagnostic measures can be taken to prove the factors affecting the incidence of CAD in patients undergoing pacemakers at high-risk, including angiography. Therefore, it can prevent complications during and after pacemaker implantation, which leads to an increase in the quality of treatment in patients requiring pacemaker implantation.AIM:Therefore, the purpose of this study was to determine the predictive factors of significant coronary artery disease in patients with pacemaker implantation to identify patients in need of coronary angiography at the time of pacemaker implantation.METHODS:This retrospective study was carried out to examine the patients’ files that were placed at the heart of Imam Reza Hospital during the period between March 2017 and September 2017. Demographic data, risk factors, echocardiography findings, and angiography, were collected and then recorded using a checklist. Statistical analysis was performed using SPSS software version 22 and Chi-square, and Mann-Whitney tests were used for determining significates variables.RESULTS:A group of 102 patients who had undergone a permanent cardiac pacemaker insertion due to an atrioventricular (AV) Block were included in the study, and also coronary anatomy was determined coronary angiography. Based on the results, 13.7% of patients with cardiac pacemaker had obstructive coronary artery disease (stenosis > 70%). Factors affecting coronary artery stenosis on angiography include gender, chest pain, history of myocardial infarction, angioplasty, diabetes, smoking, history of aspirin intake, calcium blocker and Plavix, high hematocrit, ST elevation and ST depression in the ECG, and severe mitral regurgitation.CONCLUSION:It seems that in most patients requiring permanent pacemaker insertion because of the atrioventricular (AV) Block, angiography does not change the patient’s fate, and so can be ignored. However, in patients who have several risk factors from the listed above, coronary angiography is recommended during admission.

First‐in‐man transfemoral transcatheter aortic valve replacement with the 29 mm Edwards SAPIEN XT Valve

To demonstrate the feasibility of transfemoral transcatheter aortic valve replacement (TAVR) with the 29 mm Edwards SAPIEN XT valve and Novaflex™ + delivery system through a 20F expandable sheath (eSheath™, Edwards Lifesciences, USA). In addition, to describe the use of the Novaflex + delivery system and expandable sheath. TAVR has undergone significant advances in device technology resulting in smaller profile sheaths and delivery systems, allowing transfemoral delivery of a 29 mm valve. Twelve patients underwent transfemoral TAVR with the 29 mm Edwards SAPIEN XT valve and Novaflex + delivery system through a 20F expandable sheath. Baseline clinical and procedural characteristics are evaluated. In-hospital and 30-day outcomes are reported according to Valve Academic Research Consortium criteria. All patients were male with a mean aortic annulus diameter of 25.0 ± 1.1 mm and 25.9 ± 1.2 mm, on transesophageal echocardiography and multidetector computerized tomography, respectively. Mean iliofemoral minimal luminal diameter (MLD) was 8.0 ± 0.8 mm. Successful deployment of the valve occurred in 11 out of 12 patients. Valve embolization occurred in one patient. Aortic valve area increased from 0.7 ± 0.2 to 2.0 ± 0.5 cm(2) (P < 0.001). There were two major vascular complications; however, there were no in-hospital or 30-day neurological events, need for pacemaker insertion, or mortality. Transfemoral TAVR with the 29 mm Edwards SAPIEN XT valve and Novaflex + delivery system through a 20F expandable sheath was feasible with acceptable short-term outcomes.

Meta‐analysis of complications in aortic valve replacement: Comparison of Medtronic‐Corevalve, Edwards‐Sapien and surgical aortic valve replacement in 8,536 patients

We sought to establish the complication rates following transcatheter aortic valve replacement (TAVR) in the context of high risk and octogenarian surgical aortic valve replacement (SAVR) in the contemporary literature, and to critically analyze population characteristics and outcomes. TAVR studies were selected from nonoverlapping series and SAVR studies for comparison if they met similar entry criteria. Bayesian meta-analytic methods were employed. For the 5024 TAVR and 3512 SAVR patients included in the study, TAVR subjects had greater baseline renal impairment (P < 0.001), a higher incidence of prior myocardial infarction (P = 0.032) and respiratory disease (P = 0.005) and a higher logistic EuroSCORE (P = 0.039). There were no significant differences observed in complications studied in SAVR and TAVR: 30 day mortality (9% vs 8.5%, P = 0.31), 1 year mortality (18.4% vs 22.8%, P = 0.65), 30 day stroke (2.4% vs 2.6%, P = 0.72), new permanent pacemaker (5.9% vs 12.1%, P = 0.055) and dialysis inception (2.4% vs 4.1%, P = 0.70). We also compared demographics and outcomes between the two types of transcatheter valves. Apart from some variation in functional status, there were no significant differences at baseline with different TAVR designs. The only difference in complications was the need for pacemaker insertion, higher with the Medtronic-Corevalve than with the Edwards-Sapien design (24.5% vs 5.9% P < 0.0001). Complications for elderly and high risk aortic stenosis patients being treated by TAVR appear comparable to those selected for SAVR in the real-world.

Sex Differences in the Relationship Between Amiodarone Use and the Need for Permanent Pacing in Patients With Atrial Fibrillation

Amiodarone use was associated with an increased need for pacemaker insertion in a retrospective study of patients with atrial fibrillation (AF) and prior myocardial infarction. The aims of this study were to determine prospectively whether amiodarone increases the need for pacemakers in a general population of patients with AF and whether this effect is modified by sex. The study included 1005 patients with new-onset AF who were enrolled in the Fibrillation Registry Assessing Costs, Therapies, Adverse events, and Lifestyle (FRACTAL). Multivariable Cox regression models, including time-dependent covariates accounting for medication exposure, were used to evaluate the risk of pacemaker insertion associated with amiodarone use. Amiodarone use was associated with an increased risk of pacemaker insertion (hazard ratio [HR], 2.01; 95% confidence interval [CI], 1.08-3.76) after adjustment for age, sex, atrial flutter, coronary artery disease, heart failure, and hypertension. The effect of amiodarone use was modified by sex, with a significant risk in women but not in men (HR, 4.69; 95% CI, 1.99-11.05 vs HR, 1.05; 95% CI, 0.42-2.58 [P = .02]). This interaction remained significant after adjustment for weight, body mass index, weight-adjusted amiodarone dose, and use of other antiarrhythmic or rate control drugs. The risk of bradyarrhythmia requiring pacemaker insertion associated with amiodarone use for AF is significantly greater in women than in men, independent of weight or body mass index.

Clinical experience with one hundred consecutive patients undergoing orthotopic heart transplantation with bicaval and pulmonary venous anastomoses

Objective: Our objective was to assess survival, need for pacemaker insertion, and rejection frequency with a new surgical technique of orthotopic heart transplantation using bicaval and pulmonary venous anastomoses. Methods: We retrospectively reviewed 100 consecutive patients who had orthotopic heart transplantation with this technique between July 1991 and September 1995. Results: The mean age was 57.0 ± 11.1 years, with 51 patients being 60 years or older. The mean donor/recipient weight ratio was 0.92, and in 28 patients the ratio was less than 0.8. The early (30-day) survival was 100% and the 1- and 2-year survivals were 98% ± 2% and 96% ± 2%, respectively. Survival was not affected by age or by the duration of the OKT3 therapy ( p > 0.2 for each of these parameters). The seven late deaths were due to infection ( n = 2), graft atherosclerosis ( n = 3), acute rejection ( n = 1), and nonspecific graft failure ( n = 1). No permanent pacemaker was required in the first 6 months after the operation, and all the patients were discharged in normal sinus rhythm. Freedom from treated rejection was significantly greater in patients with 7 days of OKT3 therapy than in patients with 14 days of therapy ( p < 0.0001). Conclusions: Orthotopic heart transplantation with bicaval and pulmonary venous anastomoses offers an improved alternative to the standard biatrial technique, with a 30-day mortality of 0% in 100 consecutive patients, excellent intermediate-term survival, and elimination of the need for pacemaker insertion. More normal anatomic configuration and synchronous function of the atria may have contributed to these results. (J T horac C ardiovasc S urg 1996;112:1496-503)

Congenital complete atrioventricular block: Clinical and electrophysiologic predictors of need for pacemaker insertion

Because an initial Adams-Stokes attack in the patient with congenital complete atrioventricular (A-V) block may sometimes prove fatal, there is a need to be able to identify the patient at great risk of having such attacks. Twenty-four children with congenital complete A-V block were followed up for 1 to 19 years to determine the efficacy of current methods of predicting risk for Adams-Stokes syncope and the usefulness of pacemaker therapy in relieving symptoms. The heart rate at rest, configuration of surface electrocardiographic complexes, data obtained during intracardiac electrophysiologic study and response to graded treadmill exercise testing were compared in children with and without syncope. One or more Adams-Stokes episodes were experienced by eight children, one of whom died. Only a persistent heart rate at rest of 50 beats/min or less demonstrated any significant (probability [p] < 0.01) correlation with the incidence of syncope. Intracardiac electrophysiologic study was of little benefit because the site of block did not correlate with syncope. Although the increase in heart rate during treadmill exercise testing showed no correlation with prevalence of syncope or location of block, exercise-induced ventricular ectopic beats may have predictive value in older children and young adults. Ventricular pacemakers were implanted in 10 children. Each child was asymptomatic over a 1 to 10 year follow-up period. Because extreme bradycardia may contribute to the prevalence of Adams-Stokes attacks in children with congenital complete A-V block, careful evaluation of heart rate at rest may be an effective means of differentiating patients at risk of syncope. Pacemaker therapy is a feasible and effective method of treatment in young children and relieves symptoms.

Clinical and electrophysiologic prediction of need for pacemaker insertion in children with congenital complete atrioventricular block

Clinical and electrophysiologic prediction of need for pacemaker insertion in children with congenital complete atrioventricular block