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Kusumoto et al 2018 Bradycardia Clinical Practice Guidelines

August 20, 2019 Circulation. 2019;140:e382–e482. DOI: 10.1161/CIR.0000000000000628 e438

CLINICAL STATEMENTS AND GUIDELINES 2.	 The routine placement of temporary epicardial pacing wires at the time of isolated coronary artery bypass has been standard surgical practice. There is a very small risk of significant bleeding leading to morbidity and even mortality after their removal, but this risk is offset by the frequent and unpredictable need for the use of temporary pacing.S8.1.2.1-5,S8.1.2.1-10,S8.1.2.1-11 Some patients are at very low risk for needing temporary pacing after isolated coronary artery bypass. In 1 retrospective analysis, patients without diabetes mellitus, preoperative arrhythmia, or the requirement for pacing while coming off cardiopulmonary bypass had only a 2.6% need for postsurgical temporary pacing compared with 8.6% of patients in the entire cohort.S8.1.2.1-10 Patients undergoing off-pump coronary artery bypass grafting may also warrant special consideration for a strategy that does not use temporary pacing wires.S8.1.2.1-13 However, no large study has clearly identified a benefit to this approach. Temporary cardiac resynchronization using right atrial, right ventricular, and left ventricular pacing wires has been proposed for improving cardiac hemodynamic parameters in the immediate postoperative period in patients with severe left ventricular dysfunction with mixed results though may provide benefits in patients with accompanying LBBB.S8.1.2.1-14–S8.1.2.1-16

3.	 Surgical left ventricular lead placement is performed as a stand-alone procedure when placement via coronary sinus is unsuccessful.S8.1.2.1-17 If a patient has an indication for cardiac resynchronization before cardiac surgery, epicardial placement of a nonapical, lateral left ventricular lead at the time of cardiac surgery may offer future benefit without significant risk of harm. Although traditionally considered a contraindication, it may be that MRI can be performed safely in selected patients with abandoned leads under the auspices of specialized protocols.S8.1.2.1-18–S8.1.2.1-20 At the time of a future CRT procedure, the operator can implant a coronary sinus lead or use the capped epicardial lead if necessary.

8.1.2.2 Surgery for Atrial Fibrillation

Recommendations for Pacing After Surgery for Atrial Fibrillation Referenced studies that support recommendations are summarized in Online Data Supplement 48.

COR LOE Recommendations

I B-NR 1.  In patients undergoing surgery for AF, routine placement of temporary epicardial pacing wires is recommended.S8.1.2.2-1–S8.1.2.2-4

I B-NR 2.  In patients who have new postoperative SND or atrioventricular block associated with symptoms or hemodynamic instability that does not resolve after surgery for AF, permanent pacing is recommended before discharge.S8.1.2.2-1–S8.1.2.2-4 IIb C-EO 3.  In patients undergoing surgery for AF who will likely require future CRT or ventricular pacing, intraoperative placement of a permanent epicardial left ventricular lead may be considered.

Synopsis

AF is present in 30% to 50% of patients undergoing valve surgery and is associated with reduced survival and increased risk of stroke.S8.1.2.2-2 Successful surgical correction of AF is associated with improved patient survival compared with patients who have recurrent AF.S8.1.2.2-5 Up to 65% of patients undergoing mitral surgery with AF undergo surgery directed toward management of AF.S8.1.2.2-6 A recent single center study found reported that 11% of patients undergoing a Cox Maze IV procedure in addition to mitral valve surgery required postoperative PPM implantation.S8.1.2.2-4 The data on whether surgery for AF is associated with an increased risk for postoperative bradycardia and PPM implant are mixed, in part caused by the significant evolution in the lesion set and surgical technique.S8.1.2.2-1–S8.1.2.2-4 An analysis of the STS registry and an RCT found that adding ablation for AF was associated with an increased likelihood of PPM implantation.S8.1.2.2-1,S8.1.2.2-2 However, a meta-analysis of 16 RCTs found no difference in need for permanent pacer in patients randomized to additional surgery for AF (OR: 0.88; 95% CI: 0.51–1.51; P=0.64).S8.1.2.2-3

Recommendation-Specific Supportive Text

1.	 Placement of temporary epicardial pacing wires at the time of surgery for AF is routine practice. The risk of postsurgical bradycardia is relatively frequent, and no study has advocated a selective approach to temporary pacing wire placement.S8.1.2.2-1–S8.1.2.2-4 2.	 The need for PPM placement is common after surgery for AF usually for SND because atrioventricular block is uncommon.S8.1.2.2-1–S8.1.2.2-4 In part to facilitate recovery after surgery (eg, moving out of the intensive care setting, ambulation and the initiation of anticoagulation), patients in whom new onset SND (and in rare cases atrioventricular block) develops and does not improve should undergo permanent pacer placement before discharge. Specific timing of pacemaker implant has not been formally studied and will always depend on the individual clinical situation but 5 to 7 days after surgery is probably reasonable.

Recommendations for Pacing After Surgery for Atrial Fibrillation (Continued)

COR LOE Recommendations

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