How To Reduce Postoperative Pacemaker Implantation After Sutureless Valve Implantation? A Single Center Experience.
Antonio Lio, Antonio Miceli, Matteo Ferrarini, Mattia Glauber.
Cardiothoracic Center, Istituto Clinico Sant'Ambrogio, Milan, Italy.
Objective. Sutureless technology for aortic valve replacement (AVR) has been recently adopted due to its potential advantages related to shortended cross-clamp and cardiopulmonary bypass (CPB) times. However, sutureless valve implantation is associated with an increased risk of postoperative pacemaker (PMK) implantation. We report our single center experience with a low rate of PMK implantation.
Methods. A retrospective study was undertaken on 78 patients that underwent sutureless AVR from January 2015 to September 2016. 6 patients with a previous implanted PMK were excluded.
Results. 48 patients underwent isolated sutureless AVR, 24 patients had associated surgery and 10 patients underwent redo operations. Mean age was 74 ± 7 years and mean logistic EuroSCORE II was 3.7 ± 1.9%. Surgery was performed through a standard sternotomy in 14 patients and with a minimally invasive approach in 58. Mean CPB and cross-clamp times were 107 ± 41 and 70 ± 32 minutes, respectively. Postoperatively, 1 patient died (1.4%). No patient required new PMK implantation during in-hospital stay. At follow-up only 1 PMK was implanted.
Conclusion. Several explanations may be considered for our low rate of PMK implantation. First, proper position of the valve: to have a perfect sealing is necessary that the prosthetic annular gown covers thoroughly the native annulus; if sutureless valve is positioned some millimiters lower, the nitinol stent may compress the conduction bundles and causes heart block. Mild decalcification of aortic annulus may also be the mechanism behind the occurrence of conduction disorders because of the high pressure at the level of the membranous septum. The sizing is another crucial aspect to avoid PMK insertion: in case of uncorrect sizing, the risk may be higher if a larger valve is chosen. Finally, we strongly believe that baloon dilatation is not required as it might create an injury of the conduction system.
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