Key result
Novel risk criteria predict need for permanent pacemaker placement with ~94% positive predictive value.
Why the study?
Guidelines recommend observation until postoperative days 7 to 10 before permanent pacemaker placement in patients with heart block after congenital cardiac surgery, but criteria to identify patients at high risk for early PPM are needed.
Can a decision tree model identify patients at high risk of requiring permanent pacemaker placement after congenital heart surgery to guide early implantation?
Observational (n=100)
Can a decision tree model identify patients at high risk of requiring permanent pacemaker placement after congenital heart surgery to guide early implantation?
A data-driven decision tree model can accurately identify patients requiring permanent pacemaker placement after congenital heart surgery by postoperative day 4, potentially reducing the risks of prolonged temporary pacing.
Answers are grounded in this paper and cite their sources.
May support early pacemaker decisions after congenital heart surgery; hypothesis-generating and requires prospective validation before practice change.
BACKGROUND: Guidelines recommend observation for atrioventricular node recovery until postoperative days (POD) 7 to 10 before permanent pacemaker placement (PPM) in patients with heart block after congenital cardiac surgery. To aid in surgical decision-making for early PPM, we established criteria to identify patients at high risk of requiring PPM. METHODS: We reviewed all cases of second degree and complete heart block (CHB) on POD 0 from August 2009 through December 2018. A decision tree model was trained to predict the need for PPM amongst patients with persistent CHB and prospectively validated from January 2019 through March 2021. Separate models were developed for all patients on POD 0 and those without recovery by POD 4. Median days [IQR] to atrioventricular node recovery was 2 [0-5] and PPM was 9 [6-11]. Of the 100 cases of persistent CHB (21 in the validation cohort), 59 (59%) required PPM. A decision tree model identified 4 risk factors for PPM in patients with persistent CHB: (1) aortic valve replacement, subaortic stenosis repair, or Konno procedure; (2) ventricular L-looping; (3) atrioventricular valve replacement; (4) and absence of preoperative antiarrhythmic agent (in POD 0 model only). The POD 4 model specificity was 0.89 [0.67-0.99] and positive predictive value was 0.94 [95% CI 0.81-0.98], which was stable in prospective validation (positive predictive value 1.0). CONCLUSIONS: A data-driven analysis led to actionable criteria to identify patients requiring PPM. Patients with left ventricular outflow tract surgery, atrioventricular valve replacement, or ventricular L-Looping could be considered for PPM on POD 4 to reduce risks of temporary pacing and improve care efficiency.
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Duong et al. (2022) conducted an observational in Heart block after congenital cardiac surgery (n=100). High-risk criteria (specific surgeries, ventricular L-looping, absence of preop antiarrhythmics) vs. Absence of high-risk criteria was evaluated on Need for permanent pacemaker placement (PPM) (PPV 0.94, 95% CI 0.81-0.98). High-risk criteria including specific surgeries and ventricular L-looping predicted the need for permanent pacemaker placement with a positive predictive value of 0.94.
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