Permanent Pacemaker Dependency Research Articles

Abstract 10311: Atrioventricular Junctional Ablation in Patients With Atrial Fibrillation With and Without Heart Failure: A Meta-Analysis

Introduction: Rapid atrial fibrillation (AF) leads to heart failure (HF), but can also result from cardiac remodelling during HF. Atrioventricular junctional ablation (AVJA) cures rapid AF at the cost of permanent pacemaker dependency. We compared mortality in AF patients treated with AVJA to pharmacological therapy. Methods: We performed data searches in the PubMed, Central, and Embase till Marts 31, 2022. Inclusion criteria were observational and randomised controlled trials evaluating mortality and left ventricular ejection fraction (LVEF) in patients with AF. An exclusion criterion was lack of a parallel study design.Our primary endpoint was all-cause mortality. A secondary endpoint was the mean difference (MD) in LVEF during the follow-up. Endpoints were assessed through meta-analyses computing hazard ratios (HRs) and MDs. Mantel-Haenszel and DerSimonian random effect models were applied, respectively. LVEF<41% was used as a surrogate for HF in a sensitivity analysis. Results: Overall,1738 studies were found from the data searches. Of these, 24 fulfilled the inclusion criteria (HF, N=15). The range of age was 60-75 years and 14 to 74% were women. The follow-up time varied between 3 to 96 months. AVJA as compared with pharmacological therapy reduced all-cause mortality by 27% in patients with AF (Fig. 1), whereas the LVEF MD between groups was not significantly different (Fig. 2). In HF patients, mortality was significantly favouring AVJA as compared with pharmacological therapy (HR, 0.68; 95% confidence interval [CI], 0.51 to 0.91; P=0.009) but not for the LVEF (MD, 1.12; 95% CI, -2.90 to 5.14; P=0.54). In patients without HF, neither mortality nor the LVEF MD were significantly different between AJVA and pharmacological therapy (results not reported). Conclusion: Mortality was significantly reduced in the AVJA group as compared with the pharmacological therapy group. This benefit was only persistent in HF patients in a sensitivity analysis.

Risk of Permanent Pacemaker Implantation Following Bentall Operation

Conduction disorders following cardiac surgery are common complications with incidences of permanent pacemaker dependency up to 5%. However, data on pacemaker implantation rates in the long-term follow-up after Bentall operations are scarce. In a retrospective study, a mixed cohort of 260 patients including endocarditis and aortic dissection undergoing Bentall operation between March 1996 and December 2015 was analyzed. Median follow-up time was 60 (12-107) months. Early and late rates of permanent pacemaker implantation and associated risk factors were investigated. In the postoperative course 31 (11.9%) permanent pacemakers were implanted. The 30-day incidence of pacemaker implantations was 7.7% with operations performed after a median of 6 (3-12) days after the Bentall operation. After ten years, 21% of the Bentall patients were permanent pacemaker dependent. The risk factors for permanent pacemaker dependency included age above 75 years (16.1% vs 5.7%; P < 0.001), preoperative cardiac conduction disturbance (32.3% vs 22.7%, P = 0.018), aortic valve stenosis (38.7% vs 23.1, P = 0.008), infective endocarditis (19.4% vs 7.4%, P = 0.004), tricuspid valve reconstruction (6.5% vs 0.9%, P = 0.033), sepsis (12.9% vs 4.4%, P < 0.001) and non-cardiac reoperation (19.4% vs 8.7%, P = 0.004). Pacemaker implantation significantly increased the length of initial hospitalization (13 [8-26] days vs 8 [7-13] days; P = 0.003). In the long-term follow-up, mortality was not different between the groups. Permanent pacemaker dependency is a frequent complication in the short- and long-term follow-up after Bentall operations. Screening for cardiac conduction disturbances in the short- and long-term follow-up is recommended.

Permanent pacemaker dependency in patients with new left bundle branch block and new first degree atrioventricular block after transcatheter aortic valve implantation

Conduction disorders with need for permanent pacemaker (PPM) implantation remain frequent complications after transcatheter aortic valve implantation (TAVI). Up to 22% of PPM after TAVI are implanted for new onset left bundle branch block (LBBB) and atrioventricular block (AVB) I. However, clinical benefit and predictors of ventricular pacing in TAVI patients receiving PPM for this indication remain unclear. We retrospectively evaluated pacemaker interrogation data of patients who received a PPM post TAVI for new LBBB and new AVB I. The primary endpoint of this study was relevant ventricular pacing (ventricular pacing rate: Vp ≥ 1%) at the first outpatient pacemaker interrogation. Secondary endpoints were predictors for relevant ventricular pacing. At the first pacemaker interrogation (median follow up at 6.23 [2.8–14.8] months), median ventricular pacing frequency was 1.0% [0.1–17.8]. Out of 61 patients, 36 (59%) had Vp rates ≥ 1%. Patients with frequent ventricular pacing showed longer QRS duration (155 ms ± 17 ms vs. 144 ms ± 18 ms, p = 0.018) at the time of PPM implantation and were less likely treated with a balloon-expandable Edwards Sapiens Valve (39% vs. 12%, p = 0.040). Our findings suggest that the majority of patients with new LBBB and new AVB I after TAVI show relevant ventricular pacing rates at follow up. Further prospective studies are necessary to identify patients at higher risk of pacemaker dependency.

Long-term Outcomes Associated With Permanent Pacemaker Implantation After Surgical Aortic Valve Replacement

Prior studies investigating the long-term clinical outcomes of patients who have undergone permanent pacemaker implantation after aortic valve replacement reported conflicting results. To investigate long-term outcomes after primary surgical aortic valve replacement among patients who underwent postoperative permanent pacemaker implantation. This cohort study included all patients who underwent surgical aortic valve replacement in Sweden from 1997 to 2018. All patients who underwent primary surgical aortic valve replacement in Sweden and survived the first 30 days after surgical treatment were included. Patients who underwent preoperative permanent pacemaker implantation, concomitant surgical treatment for another valve, or emergency surgical treatment were excluded. Patients who underwent concomitant coronary artery bypass grafting or surgical treatment of the ascending aorta were included. Follow-up data were complete for all patients. Data were analyzed from October through December 2020. Patients underwent implantation of a permanent pacemaker or implantable cardioverter defibrillator within 30 days after aortic valve replacement. The primary outcome was all-cause mortality. Among 24 983 patients who underwent surgical aortic valve replacement, 849 patients (3.4%) underwent permanent pacemaker implantation within 30 days after surgical treatment and 24 134 patients (96.6%) did not receive pacemakers in that time. The mean (SD) age of the total study population was 69.7 (10.8) years, and 9209 patients were women (36.9%). The mean (SD) and maximum follow-up periods were 7.3 (5.0) years and 22.0 years, respectively. At 10 years and 20 years after surgical treatment, the Kaplan-Meier estimated survival rates were 52.8% and 18.0% in the pacemaker group, respectively, and 57.5% and 19.6% in the nonpacemaker group, respectively. All-cause mortality was statistically significantly increased in the pacemaker group compared with the nonpacemaker group (hazard ratio [HR], 1.14; 95% CI, 1.01-1.29; P = .03), and so was risk of heart failure hospitalization (HR, 1.58; 95% CI, 1.31-1.89; P < .001). No statistically significant increase was found in the risk of endocarditis in the pacemaker group. This study found that there were increased risks of all-cause mortality and heart failure hospitalization among patients who underwent permanent pacemaker implantation after surgical aortic valve replacement, suggesting that these risks are important considerations, especially in an era when transcatheter aortic valve replacement is used in younger patients at lower risk of adverse surgical outcomes. These findings further suggest that future research should investigate how to avoid permanent pacemaker dependency after surgical and transcatheter aortic valve replacement.

Effect of donor selection on the early outcome of heart transplant recipients

Recipients receiving heart transplants from 83 donors from 1995 to 2002 were analyzed to evaluate the effect of various donor factors on recipient outcomes. The 83 donors (13 women and 70 men; 2-51 years old) had cold ischemic times ranging between 55 and 287 minutes. Donor age, cause of death, inotropic support, and cold ischemic times of the hearts were compared to 1-year left ventricular ejection fraction, permanent pacemaker dependency, 30-day mortality, and 1-year survival in the recipients. Donors receiving low-dose inotropic support resulted in recipients with permanent pacemaker dependency in 14.8%, and 30-day mortality and 1-year survival rates of 7.4% and 70.3%, respectively. Donors not receiving inotropic support resulted in recipients with permanent pacemaker dependency in 3.5%, and 30-day mortality and 1-year survival of 3.5% and 83.9%, respectively. Cold ischemic times less than or equal to 120 minutes showed 30-day mortality and 1-year survival rates of 0% and 90.9%, respectively. Cold ischemic times equal to or more than 121 minutes showed 30-day mortality and 1-year survival rates of 8% and 76%, respectively. Increased donor age (P=.22) and cold ischemic time showed an increase in mortality without affecting mean ejection fraction in survivors. Use of inotropic support in donors (P=.95) showed an increase in mortality without affecting mean ejection fraction in survivors.

Effect of Donor Selection on the Early Outcome of Heart Transplant Recipients

Recipients receiving heart transplants from 83 donors from 1995 to 2002 were analyzed to evaluate the effect of various donor factors on recipient outcomes. The 83 donors (13 women and 70 men; 2-51 years old) had cold ischemic times ranging between 55 and 287 minutes. Donor age, cause of death, inotropic support, and cold ischemic times of the hearts were compared to 1-year left ventricular ejection fraction, permanent pacemaker dependency, 30-day mortality, and 1-year survival in the recipients. Donors receiving low-dose inotropic support resulted in recipients with permanent pacemaker dependency in 14.8%, and 30-day mortality and 1-year survival rates of 7.4% and 70.3%, respectively. Donors not receiving inotropic support resulted in recipients with permanent pacemaker dependency in 3.5%, and 30-day mortality and 1-year survival of 3.5% and 83.9%, respectively. Cold ischemic times less than or equal to 120 minutes showed 30-day mortality and 1-year survival rates of 0% and 90.9%, respectively. Cold ischemic times equal to or more than 121 minutes showed 30-day mortality and 1-year survival rates of 8% and 76%, respectively. Increased donor age (P=.22) and cold ischemic time showed an increase in mortality without affecting mean ejection fraction in survivors. Use of inotropic support in donors (P=.95) showed an increase in mortality without affecting mean ejection fraction in survivors.