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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 e440

CLINICAL STATEMENTS AND GUIDELINES on the individual clinical situation but 3 to 5 days after surgery is probably reasonable. 3.	 Surgical left ventricular lead placement is performed as a stand-alone procedure when placement via coronary sinus is unsuccessful.S8.1.2.3.1-10 If a patient has an indication for cardiac resynchronization before cardiac surgery, an 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.S8.1.2.3.1-11–S8.1.2.3.1-13 At the time of a future CRT procedure, the operator can implant a coronary sinus lead or use the capped epicardial lead if necessary.

8.1.2.3.2 Mitral Valve Surgery

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

COR LOE Recommendations

I B-NR 1.  In patients who have new postoperative SND or atrioventricular block associated with persistent symptoms or hemodynamic instability that does not resolve after mitral valve repair or replacement surgery, permanent pacing is recommended before discharge.S8.1.2.3.2-1,S8.1.2.3.2-2

IIa C-LD 2.  In patients undergoing mitral valve surgery, routine placement of temporary epicardial pacing wires is reasonable.S8.1.2.3.2-1–S8.1.2.3.2-3

IIb C-EO 3.  In patients undergoing surgical mitral valve repair or replacement who will likely require future CRT or ventricular pacing, intraoperative placement of a permanent epicardial left ventricular lead may be considered.

Synopsis

Incidence of new atrioventricular block has been reported in as high as 23.5% of patients undergoing mitral valve replacement or ring repair.S8.1.2.3.2-1 In 1 pathologic study, 55 hearts from patients who had not undergone surgery were examined to evaluate the relationship between the atrioventricular node, atrioventricular nodal artery and mitral annulus.S8.1.2.3.2-1 In the dissected hearts, 23% had an atrioventricular nodal artery that ran close to the mitral valve, suggesting that damage to the artery may play a role in the development of atrioventricular block after mitral valve surgery. The need for a PPM after mitral surgery ranges from 1% to 9%.S8.1.2.3.2-1,S8.1.2.3.2-2,S8.1.2.3.2-4 The cause may be influenced by type surgery and may be lower in the repair population in whom an incomplete annuloplasty band could avoid injury to the atrioventricular nodal artery.S8.1.2.3.2-2,S8.1.2.3.2-4

Recommendation-Specific Supportive Text

1.	 The need for PPM placement is common after mitral valve surgery.S8.1.2.3.2-1,S8.1.2.3.2-2,S8.1.2.3.2-5 In part to facilitate postsurgical recovery (such as moving out of the intensive care setting, ambulation and the initiation of anticoagulation), patients in whom new onset atrioventricular block or SND develops and does not improve should undergo permanent pacer placement before discharge for persistent symptomatic or hemodynamically significant bradycardia. Because mitral valve surgery involves injury of the atrioventricular node region rather than the His bundle injury associated with aortic valve surgery, the threshold for pacemaker implant is higher. 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 mitral valve surgery is probably reasonable. 2.	 Placement of temporary epicardial pacing wires at the time of mitral valve surgery is routine practice. The risk of postsurgical bradycardia is relatively frequent, and no study has advocated a selective approach to temporary pacing wire placement.S8.1.2.3.2-1,S8.1.2.3.2-2 However, alternative pacing strategies using pacing pulmonary artery catheters have been described for patients undergoing minimally invasive mitral valve surgery.S8.1.2.3.2-3 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.S8.1.2.3.2-6–S8.1.2.3.2-8 3.	 Surgical left ventricular lead placement is performed as a stand-alone procedure when placement via coronary sinus is unsuccessful.S8.1.2.3.2-9 If a patient has an indication for cardiac resynchronization before cardiac surgery, an 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.S8.1.2.3.2-10–S8.1.2.3.2-12 At the time of a future CRT procedure, the operator can implant a coronary sinus lead or use the capped epicardial lead if necessary.

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