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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 e441 CLINICAL STATEMENTS AND GUIDELINES

8.1.2.3.3 Tricuspid Valve Surgery

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

COR LOE Recommendations

I C-LD 1.  In patients undergoing tricuspid valve surgery, routine placement of temporary epicardial pacing wires is recommended.S8.1.2.3.3-1–S8.1.2.3.3-4

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 tricuspid valve surgery, permanent pacing is recommended before discharge.S8.1.2.3.3-1–S8.1.2.3.3-4

IIa C-LD 3.  In patients who are undergoing tricuspid valve replacement or tricuspid repair with high risk for postoperative atrioventricular block, intraoperative placement of permanent epicardial leads at the time of cardiac surgery is reasonable.S8.1.2.3.3-1–S8.1.2.3.3-5

Synopsis

The atrioventricular node is intimately related to the tricuspid valve, located between its anterior and septal leaflets; this makes the atrioventricular node particularly susceptible to injury with any tricuspid valve intervention. Surgeons have developed numerous repair techniques to avoid nodal injury, including the design of several incomplete tricuspid rings that have gaps between the anterior and septal leaflets. These techniques avoid suture placement in the area of the atrioventricular node, and thus its injury. The need for pacemaker after repair has been reported to be as low as 2.3%.S8.1.2.3.3-1 However, because isolated tricuspid surgery is rare in the adult population, the exact incidence of conduction disorders attributable to isolated tricuspid intervention is difficult to ascertain. Several series report a much higher incidence, up to 22%.S8.1.2.3.3-2,S8.1.2.3.3-4 Managing conduction abnormalities in this population are additionally complicated by an inability to use transvenous pacing leads in mechanical valves and their interference in the closure of bioprosthetic valves or native valves that have been repaired. Even in native valves, nearly one-quarter of patients suffer significant tricuspid regurgitation associated with placement of an endovascular right ventricular lead.S8.1.2.3.3-5 In patients who need a pacemaker after repair, incidence of moderate to severe or severe tricuspid regurgitation is 42%.S8.1.2.3.3-3

Recommendation-Specific Supportive Text

1.	 Placement of temporary epicardial pacing wires at the time of tricuspid 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.S8.1.2.3.3-1–S8.1.2.3.3-4 2.	 The need for PPM placement is frequent after tricuspid valve surgery.S8.1.2.3.3-1–S8.1.2.3.3-4 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 advanced primary atrioventricular block or SND develops and does not improve should undergo permanent pacer placement after open tricuspid valve surgery. Specific timing of pacemaker implant has not been formally studied and will always depend on the individual clinical situation but 3 to 5 days after surgery is probably reasonable. To minimize valve impingement in the setting of a repaired tricuspid valve, a transvalvular endocardial ventricular lead is ideally placed at the commissure between the anterior and septal tricuspid leaflets. 3.	 The need for PPM placement is frequent after tricuspid valve surgery.S8.1.2.3.3-1–S8.1.2.3.3-4 After repair or replacement, transvalvular endocardial ventricular lead placement can be successfully placed after tricuspid valve repair or bioprosthetic valve replacement but may cause severe tricuspid regurgitation.S8.1.2.3.3-3,S8.1.2.3.3-5,S8.1.2.3.3-6 Transvalvular, endocardial ventricular leads cannot be placed across mechanical valves in the tricuspid position. Patients who are undergoing tricuspid valve replacement or tricuspid repair with high risk for postoperative atrioventricular block should be strongly considered for permanent epicardial pacing leads at the time of cardiac surgery.S8.1.2.3.3-7 Because epicardial leads can fail and subsequent placement of a right ventricular endocardial lead may be problematic in patients after tricuspid valve replacement, at the time of initial tricuspid valve surgery, if possible, intraoperative implantation of several leads (nonapical, lateral left ventricular, right ventricular, and atrial leads) should be considered. 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.S8.1.2.3.3-8–S8.1.2.3.3-10 If a PPM is required in the future, the operator can implant a coronary sinus lead or use the capped epicardial lead if necessary.

8.1.2.4 Transcatheter Aortic Valve Replacement

Recommendations for Conduction Disturbances After Transcatheter Aortic Valve Replacement Referenced studies that support recommendations are summarized in Online Data Supplement 49.

COR LOE Recommendations

I B-NR 1.  In patients who have new atrioventricular block after transcatheter aortic valve replacement associated with symptoms or hemodynamic instability that does not resolve, permanent pacing is recommended before discharge.S8.1.2.4-1–S8.1.2.4-4

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