Intraoperative Leadless Pacemaker Implant During Valve Surgery
Quick Takes
- Intraoperative leadless cardiac pacemaker (LCP) implantation under direct visualization is a safe strategy to provide permanent pacing in patients undergoing valve surgery, with a postoperative electrical performance comparable to percutaneously placed LCPs.
- The approach of intraoperative implantation of an LCP in carefully selected patients may reduce complications attendant to a second procedure and shorten hospitalization.
Study Questions:
What is the long-term safety and efficacy of intraoperative leadless cardiac pacemaker (LCP) implantation?
Methods:
This was a retrospective single-center cohort study of consecutive patients (n = 100) who underwent intraoperative LCP implantation during valve surgery. Safety and efficacy were assessed at implantation and follow-up visits.
Results:
A total of 100 patients underwent intraoperative LCP implantation. The surgery involved the tricuspid valve in 99 patients (99%), including tricuspid valve repair in 59 (59%) and tricuspid valve replacement in 40 (40%). Most of the patients (78%) underwent multivalve surgery. The indication for LCP implantation was elevated risk of postoperative atrioventricular block in 54% and pre-existing bradyarrhythmias in 46%. LCP implantation was successful in all patients. During a median of 11 months of follow-up, no device-related complications occurred. At 12-month follow-up, the pacing thresholds were acceptable (≤2.0 V at 0.24 milliseconds) in 95% of patients.
Conclusions:
Intraoperative LCP implantation under direct visualization is a safe strategy to provide permanent pacing in patients undergoing valve surgery, with a postoperative electrical performance comparable to percutaneously placed LCPs.
Perspective:
Postoperative heart block is not uncommon following valve surgery, and it leads to permanent pacemaker implantation. Preoperative right bundle branch and multivalve surgery, especially one that includes the tricuspid valve, may be some of the strongest predictors of needing a device postoperatively. The prevailing standard is to place an epicardial lead in patients with the highest risk of needing the pacemaker postoperatively or implant a transvenous pacemaker at a separate time after surgery.
The current study challenges this paradigm by implanting a leadless device (Medtronic’s Micra VR or Micra AV) intraoperatively, under direct visualization, in patients who will either definitely or very likely need bradycardia therapy after their cardiac surgery. This strategy could reduce complications compared with patients undergoing valve surgery who require an intraoperative epicardial pacemaker lead, a traditional transvenous pacemaker, or transfemoral LCP. This approach may also reduce duration of intensive care unit stay and hospitalization. One must weigh these potential benefits against the possibility that some or many patients who receive a prophylactic pacemaker may rarely use it or may not need it at all. Further studies are needed to evaluate the cost and effectiveness of this treatment approach. This strategy could be aided by future, more predictive risk stratification tools for postoperative need for pacing in the modern era.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Arrhythmias and Clinical EP, Cardiac Surgery and VHD
Keywords: Cardiac Surgical Procedures, Pacemaker, Artificial
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