Permanent pacemaker rate following Commando and Hemi-Commando procedures: a systematic review and meta-analysis

Objective The Commando procedure (double-valve replacement with intervalvular fibrous body reconstruction) is associated with a high risk of postoperative atrioventricular block requiring permanent pacemaker implantation. However, precise estimates vary widely. This systematic review and meta-analysis aimed to determine the pooled permanent pacemaker rate after Commando and Hemi-Commando procedures. Methods PubMed, Embase, Web of Science, and Cochrane CENTRAL were searched from inception to April 2, 2026. Studies reporting permanent pacemaker rates after Commando or Hemi-Commando surgery (sample size ≥ 5) were included. A random-effects model was used to pool proportions, with logit transformation. Subgroup analyses were performed by procedure type. Sensitivity analyses and publication bias assessment (Egger's test) were conducted. Results Twelve studies with 13 data points (797 patients) were included. The pooled permanent pacemaker rate was 22.3% (95% confidence interval: 16.1%–30.0%), with substantial heterogeneity ( I² = 73.7%). Subgroup analysis showed that the Chimney Commando modification had a significantly lower rate (6.3%, 95% CI: 3.2%–12.1%) compared with the traditional Commando procedure (28.3%, 95% CI: 21.2%–36.7%; p for subgroup difference < 0.001). Sensitivity analyses confirmed the robustness of the findings. Egger's test indicated potential small-study effects ( p = 0.0041). Conclusions One in five patients undergoing Commando surgery requires a permanent pacemaker. Preliminary evidence suggests that the Chimney Commando modification may be associated with a substantially lower risk (6.3% vs. 28.3%). Based on these preliminary findings, the Chimney technique might be a reasonable option in carefully selected patients with small annuli or those undergoing redo surgery, where conduction injury risk is inherently high. However, given the limited evidence, this recommendation should be considered hypothesis-generating. Future prospective comparative studies are needed to validate these hypothesis-generating findings. Systematic Review Registration https://osf.io/sgd2e/ .