Permanent Pacemaker Implantation After Surgical Aortic Valve Replacement In Patients With Pre-existing Right Bundle Branch Block
Michiel D. Vriesendorp1, Michael J. Reardon2, Francois Dagenais3, Thomas Gleason4, Martin Misfeld5, Rüdiger Lange6, Mubashir A. Mumtaz7, John Heiser8, Elizabeth Gearhart9, Robert A.F. De Lind van Wijngaarden1, Robert J.M. Klautz1.
1Leiden University Medical Center, Leiden, Netherlands, 2Houston Methodist Debakey Heart and Vascular Centerr, Houson, TX, USA, 3Institut universitaire de cardiologie et de pneumologie de Québec, Quebec, QC, Canada, 4University of Pittsburgh School of Medicine Heart and Vascular Institute, Pittsburgh, PA, USA, 5University Clinic of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany, 6German Heart Centre Munich, Munich, Germany, 7Pinnacle Health, Harrisburg, PA, USA, 8Spectrum Health Medical Group, Grand Rapids, MI, USA, 9Coronary and Structural Heart, Medtronic, Minneapollis, MN, USA.
Objectives Pre-existing right bundle branch block (RBBB) has been found to be associated with higher rates of permanent pacemaker implantation (PPI) in patients who undergo aortic valve replacement, which in turn has been associated with reduced long-term survival. We evaluated these associations in a large cohort of patients who underwent surgical AVR (SAVR) with either a sutured, sutureless, or stentless bioprosthesis. Methods Patients receiving SAVR in the PERIcardial SurGical AOrtic Valve ReplacemeNt Pivotal or Japan trials or the Evolut Low Risk trial were combined. Patients were evaluated according to the presence of RBBB on the baseline electrocardiogram. Kaplan-Meier analyses with log-rank tests were performed to assess the rates of PPI and all-cause mortality during follow-up. Patients with implanted cardiac devices at baseline were excluded from the PPI analysis. Results Pre-existing RBBB was present in 182 of 1801 patients (10.1%); 17 of these patients (9.3%) received sutureless valves, and 165 (90.6%) received sutured valves (1 stentless, 164 stented). Of the 1619 patients without pre-existing RBBB, 188 patients (11.6%) received sutureless valves, and 1430 (88.4%) received sutured valves (1420 stented, 10 stentless; data missing, n=1). Pre-existing RBBB was found to be associated with a higher rate of PPI (Figure) but not all-cause mortality. The rate of PPI in subjects with pre-existing RBBB at 1 month post-procedure was 13.9% (95% CI: 9.5-20.0), compared to 3.8% (95% CI: 2.9-4.8) in those without pre-existing RBBB (p<0.001). The rate at 1 month was 3.5% (95% CI: 2.7-4.6) in patients with a sutured valve versus 14.4% (95% CI: 10.2-20.1) in patients with a sutureless valve (p<0.001). The all-cause mortality rate one month post-procedure was 0.5% (95% CI: 0.1-3.8) in those with pre-existing RBBB and 1.1% (95% CI: 0.7-1.7) in those without pre-existing RBBB (p=0.25). Conclusions In this analysis, pre-existing RBBB was associated with a higher rate of PPI but not all-cause mortality. Future, larger studies should focus on the interaction between valve type and pre-existing RBBB on the outcomes of PPI and mortality. <!--EndFragment-->
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