Criteria for Early Pacemaker Implantation in Patients With Postoperative Heart Block After Congenital Heart Surgery

Abstract

BACKGROUND: Guidelines recommend observation for atrioventricular node recovery until postoperative days (POD) 7 to 10 before permanent pacemaker placement (PPM) in patients with heart block after congenital cardiac surgery. To aid in surgical decision-making for early PPM, we established criteria to identify patients at high risk of requiring PPM. METHODS: We reviewed all cases of second degree and complete heart block (CHB) on POD 0 from August 2009 through December 2018. A decision tree model was trained to predict the need for PPM amongst patients with persistent CHB and prospectively validated from January 2019 through March 2021. Separate models were developed for all patients on POD 0 and those without recovery by POD 4. RESULTS: Of the 139 patients with postoperative heart block, 68 required PPM. PPM was associated with older age (3.2 versus 1.0 years; P =0.018) and persistent CHB on POD 0 (versus intermittent CHB or second degree heart block; 87% versus 58%; P =0.001). Median days [IQR] to atrioventricular node recovery was 2 [0–5] and PPM was 9 [6–11]. Of the 100 cases of persistent CHB (21 in the validation cohort), 59 (59%) required PPM. A decision tree model identified 4 risk factors for PPM in patients with persistent CHB: (1) aortic valve replacement, subaortic stenosis repair, or Konno procedure; (2) ventricular L-looping; (3) atrioventricular valve replacement; (4) and absence of preoperative antiarrhythmic agent (in POD 0 model only). The POD 4 model specificity was 0.89 [0.67–0.99] and positive predictive value was 0.94 [95% CI 0.81–0.98], which was stable in prospective validation (positive predictive value 1.0). CONCLUSIONS: A data-driven analysis led to actionable criteria to identify patients requiring PPM. Patients with left ventricular outflow tract surgery, atrioventricular valve replacement, or ventricular L-Looping could be considered for PPM on POD 4 to reduce risks of temporary pacing and improve care efficiency.

Incidence of Coronary Artery Disease After Permanent Pacemaker Implantation: A Hospital-based Study from East India

“…CHB was found to be the most common cause of PPI (55.2%), followed by SSS (22.3%) and other arrhythmias. These findings are consistent with previous research 14 that reported that patients with postoperative CHB can accurately be identified to undergo permanent pacemaker placement, emphasizing the critical significance of conduction system abnormalities in necessitating pacemaker intervention. The incidence of CHB and SSS emphasizes the therapeutic need for early detection and intervention to improve patient outcomes.…”

“…The incidence of CHB and SSS emphasizes the therapeutic need for early detection and intervention to improve patient outcomes. 14 …”

A retrospective audit of young adults who received permanent pacemakers at a teaching hospital in the Western Cape, South Africa

“…These findings support the notion that the underlying causes of conduction system defects differ between these age groups of patients. Post-operative heart block following the surgical correction or repair of congenital heart disease has been well described (19)(20)(21)(22). In our study population, three patients with congenital heart disease had immediate post-operative heart block which did not revert back to their pre-operative rhythm requiring permanent pacemaker implantation during their time of admission.…”

The prevalence of permanent pacemaker implantation after open-heart surgeries; eight years of experience in Tehran heart center

“…Continuing with the 2.5% in the MVR group of our study, 1.8% [ 3 ], 4.5% [ 27 ], 7.6% [ 23 ], and 8.2% were disclosed by other related evidence. PPI prevalence in the congenital heart surgery group was 0.72% compared to a prevalence rate of 1% [ 28 , 29 ] in recent studies. Moreover, the expected time between surgery and PPI was 11 days, which is in line with previous studies [ 1 , 3 , 21 , 23 ].…”