Ann Thorac Surg 2008;86:1403. doi:10.1016/j.athoracsur.2008.04.068
© 2008 The Society of Thoracic Surgeons
Correspondence
Permanent Pacemaker Implantation After Isolated Aortic Valve Replacement
Sachin Talwar, MCh,
Shiv Kumar Choudhary, MCh,
Arkalgud Sampath Kumar, MCh
Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, 110029 India
(Email: shivchoudhary{at}hotmail.com).
To the Editor:
We read with interest the article by Dawkins and colleagues [1] on the need for permanent pacemaker implantation (PPI) after isolated aortic valve replacement (AVR). The authors conclude that PPI after AVR is required more often in patients with preoperative aortic regurgitation (AR), those with larger aortic prostheses (24.9 ± 2.8 mm) and patients with preoperative conducting system disease. However, we are not aware of the cause of aortic valve disease in their patients, whether rheumatic or degenerative.
We are in disagreement with the authors' observation that the use of a larger prosthesis size may lead to a higher incidence of PPI. We published a series of 748 patients requiring AVR in 2000 [2]. In 238 (31.8%) of these, large aortic valve prostheses (
25 mm) were implanted and 362 (48.6%) of these had severe AR. There were 14 (1.87%) deaths, and none of these patients required PPI. However, the mean age of these patients was only 35.2 ± 2.7 years and there was no evidence of preoperative conduction system abnormalities, which could probably account for no need for PPI.
Our recent experience with AVR for predominant aortic stenosis (AS) was recently published [3]. Of the 94 patients undergoing AVR for predominant AS, 2 required PPI. The mean age of these patients was 43.2 ± 13.2 years, and almost all of them had severe calcific aortic stenosis. Valves of size 23 mm or more were implanted in 75 patients (80%). A valve of 25 mm or larger was implanted in 55 patients (54.3%). Even though the need for PPI was not exceptionally high, we believe that operative trauma during valve excision and debridement of the aortic annulus was an important factor that contributed to the development of complete heart block with the need for PPI in these 2 patients. Based on our experience, we believe that AR and implantation of large aortic prostheses may not predispose the patients to increased risk of PPI. However, in patients with AR due to preoperative endocarditis and root abscesses, the integrity of the conduction system may be compromised and these patients may be at an increased risk of conduction system abnormalities requiring PPI. In most other cases, technical factors during AVR probably play a greater role and are responsible for the majority of PPI after AVR.
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References
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- Dawkins S, Hobson AR, Kalra PR, Tang AT, Monro JL, Dawkins KD. Permanent pacemaker implantation after isolated aortic valve replacement: incidence, indicators and predictors Ann Thorac Surg 2008;85:108-112.[Abstract/Free Full Text]
- Choudhary SK, Mathur A, Venugopal P, et al. Prosthesis size in aortic valve replacement: surgeon-related variable Asian Cardiovasc Thorac Ann 2000;8:333-338.[Abstract/Free Full Text]
- Joshi K, Talwar S, Velayoudham D, Kumar AS. Aortic valve replacement in predominant aortic stenosis: what is an appropriate size valve? Indian J Thorac Cardiovasc Surg 2007;23:141-145.
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