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Kusumoto et al 2018 Bradycardia Clinical Practice Guidelines

Circulation. 2019;140:e382–e482. DOI: 10.1161/CIR.0000000000000628 August 20, 2019 e439 CLINICAL STATEMENTS AND GUIDELINES

3.	 Surgical left ventricular lead placement is performed as a stand-alone procedure when placement via coronary sinus is unsuccessful.S8.1.2.2-7 If a patient has an indication for cardiac resynchronization before cardiac surgery, an epicardial placement of a left ventricular lead at the time of surgery for AF may offer future benefit without significant risk of harm. In addition, placement of a nonapical, lateral epicardial lead will allow more pacing options if the patient undergoes a future atrioventricular nodal ablation. 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.S8.1.2.2-8–S8.1.2.2-10 At the time of a future CRT procedure the operator can implant a coronary sinus lead or use the capped epicardial lead if necessary. 8.1.2.3. Valvular Surgery There are many types of valve surgeries. In adult cardiac surgery, the most commonly affected valves are the aortic, the mitral and the tricuspid. The pulmonary valve is rarely a target of intervention and when it is, does not usually disturb cardiac conduction. Approximately 5% of the roughly 100 000 patients annually undergoing valve surgery in North America have required pacemaker implantation before hospital discharge.S8.1.2.3-1 Several papers have identified a myriad of risk factors associated with PPM implant after valve surgery that include: preoperative RBBB, multivalve surgery particularly those that included the tricuspid valve, preoperative LBBB, preoperative PR interval >200 ms, prior valve surgery, age >70 years, reoperations, longer cumulative cross-clamp times, and absence of preoperative sinus rhythm.S8.1.2.3-2,S8.1.2.3-3 The rates of PPM implant after valve surgery vary widely and depend on the operation. Pacemaker implantation rates for single and multiple valves were as follows: mitral alone 3.5%, aortic alone 5.1%, tricuspid alone 12%, aortic plus mitral 10%, mitral plus tricuspid 16%, and combined aortic, mitral, and tricuspid 25%.S8.1.2.3-2,S8.1.2.3-4

8.1.2.3.1 Surgical Aortic Valve Replacement or Repair

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

COR LOE Recommendations

I C-LD 1.  In patients undergoing surgical aortic valve replacement or repair, routine placement of temporary epicardial pacing wires is recommended.S8.1.2.3.1-1–S8.1.2.3.1-3

I B-NR 2.  In patients who have new postoperative SND or atrioventricular block associated with persistent symptoms or hemodynamic instability that does not resolve after aortic valve replacement, permanent pacing is recommended before discharge.S8.1.2.3.1-1–S8.1.2.3.1-5 IIb C-EO 3.  In patients undergoing aortic valve surgery who will likely require future CRT or ventricular pacing, intraoperative placement of a permanent epicardial left ventricular lead may be considered.

Synopsis

The most common injury to the conduction system after surgical aortic valve replacement is injury to the common bundle from edema, removal of calcium, or deeply placed sutures. The requirement for pacemaker after aortic valve replacement is common, ranging between 3% and 8.5%: the highest risk is likely in patients with preoperative conduction disturbance.S8.1.2.3.1-1–S8.1.2.3.1-3 Available data suggest that most patients do not recover atrioventricular conduction.S8.1.2.3.1-4,S8.1.2.3.1-6 One study found that patients who received a pacemaker within 30 days after aortic valve replacement had a higher, long-term risk of death.S8.1.2.3.1-5

Recommendation-Specific Supportive Text

1.	 Placement of temporary epicardial pacing wires at the time of aortic valve surgery is routine practice. The risk of postsurgical bradycardia is high, and no study has advocated a selective approach to temporary pacing wire placement.S8.1.2.3.1-1–S8.1.2.3.1-3 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.S8.1.2.3.1-4–S8.1.2.3.1-9 2.	 The need for PPM placement is frequent after aortic valve replacement.S8.1.2.3.1-1–S8.1.2.3.1-3 Because the aortic valve is anatomically located near the bundle of His, while the mitral valve is close to the atrioventricular node, atrioventricular block after aortic valve surgery has a lower threshold for recommending pacing compared with the mitral valve, and conduction is less likely to resume.S8.1.2.3.1-4,S8.1.2.3.1-6 This suggests that patients who have new atrioventricular block which does not resolve or SND should undergo PPM implantation before discharge for persistent symptomatic or hemodynamically significant bradycardia. Specific timing of pacemaker implant has not been formally studied and will always depend

Recommendations for Pacing After Aortic Valve Surgery (Continued)

COR LOE Recommendations

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