A modified cardiac conduction system-sparing aortic valve replacement technique resulted in only 0.5% of patients requiring permanent pacemaker implantation over a minimum 2-year follow-up.
Cohort (n=179)
No
Does a modified bioprosthetic AVR technique with pledgets placed above the annulus reduce the need for permanent pacemaker implantation in patients undergoing AVR?
A modified AVR technique placing pledgets above the annulus at the right/non-coronary commissure is safe and associated with a very low rate (0.5%) of permanent pacemaker implantation.
Abstract Background/Introduction Damage to the conduction system necessitating implantation of a permanent pacemaker is a known complication of aortic valve replacement (AVR). We hypothesized that applying the pledgets of the sutures that are placed at the commissure between the non-coronary and right coronary sinuses above the annulus would lessen the trauma on the conduction system, thereby decreasing the incidence of complete heart block. Purpose We tested the safety and efficacy of the modified AVR technique in reducing the need for permanent pacemaker implantation. Methods Following institutional IRB approval, patients underwent modified bioprosthetic AVR by a single operator University Medical Center in Lebanon from January 1st, 2018 till December 31st, 2023. The cohort consisted of a total of 179 consecutive patients (68.4± 10.4 yrs, 54% male). The initial phase assessing the safety of the modified AVR consisted of the first 53 patients in whom transesophageal echocardiography (TEE) was performed during bypass and immediately after going off bypass. Transthoracic echocardiography was then performed and the patients were followed for two-years to evaluate valve function. Phase II consisted of 126 patients who were followed for a minimum of 2 years for permanent pacemaker implant. Results Among the 53 patients in Phase I, all had normal valve function and none had a perivalvular leak (PVL) in the immediate postoperative course. Over the next 2 years, all patients continued to have normal bioprosthetic valve function. 11 patients (20%) developed trace PVL, one patient (1.8%) had mild to moderate PVL, and 3 (5%) had mild central aortic regurgitation. None of these were clinically significant or required intervention. Among the entire cohort of 179 patients undergoing modified AVR, 18 (10.1%) had preoperative first-degree atrioventricular block, 24 (13.4%) had pre-operative atrial fibrillation or flutter, 22 (12.3%) had pre-existing right bundle branch block, 8(4.5%) had pre-existing left bundle branch block and 9% had ejection fraction 30%. Only one patient (0.5%) developed postoperative complete heart block necessitating implantation of a dual chamber permanent pacemaker. This patient had a preoperative low ejection fraction (30%) and first-degree AV block (PR 250ms). No other patient required pacemaker implantation over the course of a minimum 2-year follow-up. Conclusions The modified AVR is a simple, safe and effective technique that spares the cardiac conduction system thereby significantly reducing the incidence of post-operative heart block and the need for permanent pacemaker implantation.Modified AVR- pledgets above annulus Pledgets at commissure of Right/Non-cusp
Akar et al. (Sat,) conducted a cohort in Aortic valve replacement (n=179). Modified aortic valve replacement technique (pledgets above annulus) was evaluated on Postoperative complete heart block necessitating permanent pacemaker implantation. A modified cardiac conduction system-sparing aortic valve replacement technique resulted in only 0.5% of patients requiring permanent pacemaker implantation over a minimum 2-year follow-up.
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