Prophylactic epicardial pacemaker implantation in tricuspid valve replacement surgery: a commentary

Bazire et al. [1] report their single-centre experience of prophylactic epicardial pacemaker implantation in patients undergoing tricuspid valve replacement; both isolated and concomitant. The group addresses an important challenge facing cardiac surgeons. Specifically, it is difficult to predict those patients who will require pacing following tricuspid valve replacement and the rate is high. For those requiring postoperative pacing, transvenous systems are contraindicated in those with mechanical valves and discouraged in those with bioprostheses [2]. It is therefore reasonable to consider the utility of a prophylactic epicardial strategy to avoid subjecting patients to a further surgical intervention and separate placement of an epicardial system. From a cohort of 59 patients available for analysis, the authors determined that cardiac pacing was required in almost half (46%) of patients undergoing the procedure [1]. This rate seems high relative to data from Alkhouli et al. [3] who reported a pacemaker rate of 33.7% in the replacement group, but may be partially explained by the fact that only patients undergoing isolated tricuspid valve replacement were examined while the present study included concomitant procedures also. From an original cohort of 80 patients, 20 died either in the postoperative period or following discharge, reflective of the high-risk nature of this mixed patient group [1]. The mortality rate (13.75%, n = 11) in the postoperative period mirrors that of a meta-analytical study by Sarris-Michopolous et al. [4] who reported a mortality rate of 12.6%, although these patients underwent isolated tricuspid replacement.