Abstract
Background: The incidence of permanent pacemaker (PPM)implantation is higher following mitral valve surgery (MVS)with ablation for atrial fibrillation (AF)compared with MVS alone. Objectives: This study identified risk factors and outcomes associated with PPM implantation in a randomized trial that evaluated ablation for AF in patients who underwent MVS. Methods: A total of 243 patients with AF and without previous PPM placement were randomly assigned to MVS alone (n = 117)or MVS + ablation (n = 126). Patients in the ablation group were further randomized to pulmonary vein isolation (PVI)(n = 62)or the biatrial maze procedure (n = 64). Using competing risk models, this study examined the association among PPM and baseline and operative risk factors, and the effect of PPM on time to discharge, readmissions, and 1-year mortality. Results: Thirty-five patients received a PPM within the first year (14.4%), 29 (83%)underwent implantation during the index hospitalization. The frequency of PPM implantation was 7.7% in patients randomized to MVS alone, 16.1% in MVS + PVI, and 25% in MVS + biatrial maze. The indications for PPM were similar among patients who underwent MVS with and without ablation. Ablation, multivalve surgery, and New York Heart Association functional (NYHA)functional class III/IV were independent risk factors for PPM implantation. Length of stay post-surgery was longer in patients who received PPMs, but it was not significant when adjusted for randomization assignment (MVS vs. ablation)and age (hazard ratio [HR]: 0.81; 95% confidence interval [CI]: 0.61 to 1.08; p = 0.14). PPM implantation did not increase 30-day readmission rate (HR: 1.43; 95% CI: 0.50 to 4.05; p = 0.50). The need for PPM was associated with a higher risk of 1-year mortality (HR: 3.21; 95% CI: 1.01 to 10.17; p = 0.05)after adjustment for randomization assignment, age, and NYHA functional class. Conclusions: AF ablation, multivalve surgery, and NYHA functional class III/IV were associated with an increased risk for permanent pacing. PPM implantation following MVS was associated with a significant increase in 1-year mortality.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 2427-2435 |
| Number of pages | 9 |
| Journal | Journal of the American College of Cardiology |
| Volume | 73 |
| Issue number | 19 |
| DOIs | |
| State | Published - May 21 2019 |
Funding
The AF ablation trial was supported by a cooperative agreement (U01 HL088942)funded by the National Heart, Lung, and Blood Institute, the National Institutes of Neurological Disorders and Stroke of the National Institutes of Health (NIH)and the Canadian Institutes for Health Research (CIHR). The views expressed in this paper are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; National Institutes of Health; or the United States Department of Health and Human Services. This trial was designed to evaluate ablation as a therapeutic approach, not to support FDA-approval for any individual device. Dr. Mack has been a principal investigator for Edwards Lifesciences and Abbott Vascular; and has been an Executive Board member for Medtronic. Dr. Gillinov has been a consultant for Edwards Lifesciences, Medtronic, AtriCure, Abbott, CryolLife, and ClearFlow; has received royalties and equity rights from ClearFlow; and has received institutional royalties from AtriCure. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. P.K. Shah, MD, served as Guest Editor-in-Chief for this paper. Fred Morady, MD, served as Guest Associate Editor for this paper.
Keywords
- biatrial maze
- cardiac surgery
- permanent pacemaker
- pulmonary vein isolation
- valvular heart disease
ASJC Scopus subject areas
- Cardiology and Cardiovascular Medicine
