Atrioventricular Block after Tricuspid Valve Surgery.

Tricuspid valve (TV) surgery is associated with a high risk of postoperative pacemaker requirement. We set out to identify the incidence of atrioventricular block (AVB) after TV surgery and determine whether atrioventricular conduction recovers within time.We investigated pre/intra- and postoperative predictors of AVB in patients who underwent tricuspid valve surgery (not only isolated TV surgery) at our institution between 2004 and 2017. Patients who had pacemakers prior to surgery were excluded.One year after surgery, 5.8% of the surviving cohort had received a pacemaker due to AVB. In the complete follow-up time, 33 out of 505 patients required pacemaker implantation because of AVB. Of the 37 patients who presented to the intensive care unit postoperatively with AVB III, 14 (38%) underwent pacemaker implantation for AVB, and 20 (54%) did not require a pacemaker. AVB III at ICU admission was identified as a predictor of pacemaker implantation (OR: 9.7, CI: 3.8-24.5, P < 0.001). TV endocarditis was also identified as a predictor (OR: 12.4, CI: 3.3-46.3, P < 0.001). Eleven out of 32 patients (34%) with tricuspid endocarditis required a pacemaker for AVB. The mean ventricular pacing burden within the first 5 years after pacemaker implantation was 79%.The issue of AVB after TV surgery is significant. Both the initial rhythm after surgery and etiology of the tricuspid disease can help predict pacemaker requirement. Within the first 5 years after surgery, the ventricular pacing burden remains high without relevant rhythm recovery.

Thrombocytopenia and end stage renal disease are key predictors of survival in patients with cardiac implantable electronic device infections.

INTRODUCTION: Cardiac implantable electronic device (CIED) infections are associated with a high mortality. Our aim was to identify key predictors of survival in patients with CIED infections as to be able to detect high-risk patients and possibly affect modifiable factors. METHODS AND RESULTS: In this observational study, we collected data from 277 patients with CIED infections treated in our department between 2001 and 2017; predictors of survival were evaluated. The median time since the last CIED procedure was 0.83 years (interquartile range [IQR]: 0.25-3.01), median time since initial CIED implant was 4.79 years (IQR: 0.90-11.0 years). Survival at 30 days was 94.9% (95% confidence interval [CI]: 92.3-97.5) and survival at 1 year was 80.9% (CI: 76.4-85.7). Age (odds ratio [OR]: 1.05, CI: 1.01-1.09; P = .009), end stage renal disease (ESRD) with dialysis (OR: 5.14, CI: 1.87-14.11; P = .001), positive blood cultures (OR: 2.19, CI: 1.08-4.45; P = .030), and thrombocytopenia (OR: 2.3, CI, 1.03-5.15; P = .042) were identified as predictors of death within 1 year of treatment of CIED infection. CONCLUSION: Patients with CIED infection with prior ESRD with dialysis or preoperative thrombocytopenia are at an increased risk of 1-year mortality. We suggest that these patients be evaluated critically and resources be allocated to these patients more liberally. A greater understanding of the role of platelets in immunity may improve treatment of advanced infection in the future.

Autologous endothelialized vein allografts in coronary artery bypass surgery - Long term results.

BACKGROUND: Lack of autologous graft material restricts the ability to treat patients requiring coronary artery bypass surgery (CABG). An off the shelf tissue engineered small diameter vascular graft is the holy grail of cardiovascular surgery. METHODS: Allograft saphenous veins were harvested from organ donors, cryopreserved, deendothelialized and then seeded with autologous endothelial cells prior to implantation during coronary artery bypass surgery. All patients treated were followed-up until death and angiographic results were collected. Grafts were explanted during autopsy and immunohistochemistry was performed. RESULTS: Twelve patients received 15 engineered grafts. Mean patient survival was 9.1 ±â€¯1.8 years. Six month graft patency was 80 (95% CI: 59-100) and 9 month graft patency was 50 (95% CI: 27-93) - graft patency detected up to 32 months after surgery. Immunohistochemistry in grafts explanted showed a presence of CD31 and CD68 positive cells in the luminal region of the vessel walls and layers of Collagen Type I in the abluminal vessel walls. CONCLUSIONS: Our small diameter tissue engineered vascular graft shows openness up to 32 months after implantation. Immunohistochemistry suggests that monocyte activation may lead to vessel remodeling with thickening of the vessel wall. Research should concentrate on a manipulation of remodeling processes.

Etiology of tricuspid valve disease is a predictor of bradyarrhythmia after tricuspid valve surgery.

AIMS: The tricuspid valve is situated in close proximity to cardiac conduction tissue and damage to this tissue can affect postoperative rhythm. The aim of this study was to quantify the incidence of pacemaker requirement after tricuspid valve surgery and investigate predictors. METHODS: Data were collected via our operative data collection system and patient files. All patients who underwent surgical procedures of the tricuspid valve from 2004 until 2017 and lacked a pacemaker preoperatively were included in the study. RESULTS: In our cohort of 505 patients 54 required a pacemaker in the first 50 days after surgery. We calculated a 17.5% (95% confidence interval [CI], 13.5-21.3) risk of pacemaker implantation at 4 years postoperatively. Multivariate analysis identified preoperative active endocarditis (odds ratio 3.17; CI, 1.32-7.65; P = 0.010) and "inadequate pacemaker dependent rhythm" (defined as any intrinsic heart rate below 45 per minute requiring pacing) upon admission to the intensive care unit after surgery (odds ratio 5.924; CI, 2.82-12.44; P = 0.001) as predictors for pacemaker requirement in the first 50 days after surgery. Twenty-six pacemakers (48%) were implanted for atrioventricular block, 16 (30%) for sinus node dysfunction and 12 (22%) for atrial fibrillation. Kaplan-Meier analysis showed no difference in survival between the pacemaker and no pacemaker group. CONCLUSION: Surgery of the tricuspid valve has a high burden of postoperative pacemaker requirement. Preoperative active endocarditis and the initial postoperative rhythm are predictors. Understanding this allows for better decision-making regarding further medical/device therapy.

Pediatric heart transplantation-What are the risk factors for pacemaker implantation and how much pacing is required?

BACKGROUND: In an attempt to improve pacemaker therapy after pediatric transplantation, we investigated risk factors, indication for pacing, and pacing burden after pediatric heart transplantation. METHODS AND RESULTS: In this retrospective study, 139 pediatric heart transplant recipients, of whom 122 did not and 17 did require pacemakers, were investigated. Eleven of the 17 patients requiring a permanent pacemaker (PPM) received their heart from a female donor (68.8%); this compares to 48 of 122 patients (43.2%, P  =  0.082) in the group not requiring a pacemaker (No PPM). The donor age and height were significantly greater in the PPM group at a median of 25.26 years (16.29-48.00) and 160 cm (153-170) compared with 11.96 years (1.73-19.95) and 141 cm (89-165) in the No PPM group (P  =  0.003 and 0.015, respectively). Of the 17 patients requiring pacemakers, 13 presented with sinus node dysfunction (SND) and four with atrioventricular block. The atrial pacing burden in patients with SND remained above 60% within the 5 years of follow-up investigated. There was no significant difference in mortality between those patients requiring a PPM and those not (Log-Rank test: P  =  0.672). CONCLUSION: We found that in our cohort donor characteristics were key risk factors for pacemaker implantation in transplanted children. The data suggest that when patients require a pacemaker in posttransplant SND, they will require a relevant amount of pacing for at least 5 years. The pacing burden after this point remains to be investigated. Mortality does not differ between pediatric heart transplant patients with and without pacemakers.

Sinus node dysfunction after heart transplantation-An analysis of risk factors and atrial pacing burden.

INTRODUCTION: We investigated the development of sinus node dysfunction (SND) requiring pacemaker implantation after heart transplant (HTx) especially regarding pacing burden in these patients. PATIENTS AND METHODS: Patients requiring a pacemaker for SND were compared to all other patients in an HTx cohort including transplant patients from 1981 to 2016. RESULTS: Sinus node dysfunction requiring pacemaker implantation developed in 118 patients (10%). These patients had received a biatrial anastomosis more frequently than those in the No SND group 95.8% vs 90.0% (P = .042). The ratio of reperfusion time to aortic cross-clamp time was significantly smaller in the SND group compared to the No SND group 71.7% vs 80.3% (P = .033). This also holds for the ratio of reperfusion time to ischemia time, which was 23.2% and 28.6%, respectively (P = .032). Pacing burden decreased from 90.5% to 66.3% after 2 years and remained around this value in the remaining 4 years of follow-up. CONCLUSION: We identified the biatrial anastomosis and a low ratio of reperfusion time to aortic cross-clamp time as well as to ischemia time as risk factors for SND requiring pacing. After implantation pacemakers continue to pace for over 60% of the time after 6 years.

A Single Center Study of 1,179 Heart Transplant Patients-Factors Affecting Pacemaker Implantation.

BACKGROUND: After around 10% of heart transplant patients require pacemaker implantation. The bradyarrhythmias causing pacemaker requirement include sinus node dysfunction (SND) and atrioventricular block (AVB). This study sought to define clinical predictors for pacemaker requirement as well as identify differences in the patient groups developing SND and AVB. METHODS: Our operative database was used to collect retrospective recipient, donor, and operative data of all patients receiving orthotopic heart transplants between 1981 and 2016. RESULTS: In the 35-year period 1,179 transplants were performed (mean recipient age 45.5 ± 0.5 years, 20.4% female, 90.6% biatrial technique) with bradyarrhythmias requiring pacemaker implantation developing in 135 patients (11.5%). Independent risk factors were prolonged operative time 340 minutes versus 313 minutes (P = 0.027) and a biatrial anastomosis (P = 0.036). Ischemia time, cardiopulmonary bypass time, aortic cross clamp time, and reperfusion time all had no significant effect on pacemaker implantation rates. Similarly, whether the transplant was a reoperation, a retransplant, or performed after primary assist implantation had no effects on pacemaker implantation rates. There was no survival difference between the paced and nonpaced groups. The donor age was higher in the patients who developed AVB as the indication for pacemaker implantation (43 vs 34 years, P = 0.031). Patients with AVB had longer aortic cross clamp times and developed the arrhythmia later than those who developed SND. CONCLUSIONS: Use of the bicaval instead of the biatrial technique and shortened operative times should reduce pacemaker requirement after heart transplantation. Survival is not affected by this complication.

Rescue TAVI for Aortic Regurgitation after Left Ventricular Assist Device Implantation Following Preoperative Impella® Support.

A patient presented with a decompensated cardiomyopathy requiring invasive hemodynamic support with an Impella® heart pump. Extracorporeal life support (ECLS) became necessary during the further course and the patient was bridged to left ventricular assist device (LVAD) implantation. Postoperatively, the patient did not improve as expected due to new aortic regurgitation (AR) that was most likely caused by the previously placed Impella. A SAPIEN 3 transcatheter aortic valve was implanted as a bail-out strategy; an additional valve-in-valve rescue was required due to paravalvular regurgitation. This resulted in a restitution of valvular function and hemodynamic improvement. TAVI appears to be a valuable bail-out option for postoperative AR following LVAD implantation.