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Original Articles: Adult Cardiac

Invited Commentary

Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, Desk J-4–133, Cleveland, OH 44122

(Email: mangia{at}ccf.org).

Recent reports have suggested that tricuspid valve repair performed at the time of mitral valve operation results in a lower incidence of advanced heart failure, defined as New York Heart Association (NHYA) functional class III or IV, and improves survival [1]. The operation is not without risk. One of those risks, as demonstrated by Jokinen and colleagues [2], is that almost one-quarter of patients undergoing a tricuspid valve operation (whether isolated or as part of a multiple valve operation) require permanent pacemaker therapy.

It is difficult to explain why patients who required permanent pacemaker therapy experienced a higher incidence of transient ischemic attacks and cerebrovascular accidents. It is indisputable, however, that when placed in the context of heart block, atrial fibrillation, or sick sinus syndrome, permanent pacemaker therapy conferred a survival advantage on this cohort, likely by protecting them against lethal bradyarrhythmias. These patients also likely complained of diminished quality of life (specifically, lack of mobility and energy) because of nonphysiologic pacing of the right ventricle.

Several groups have demonstrated that patients with preoperative left or right bundle branch block, with a preoperative PR interval exceeding 200 milliseconds, undergoing multiple valve operations, with prior valve operations, aged older than 70 years, or of female gender are at higher risk for requiring postoperative implantation of a permanent pacemaker [3]. Accordingly in patients such as these coming to operation, one may want to consider placing permanent epicardial leads at the time of operation instead of waiting for the patient to "declare himself" postoperatively. Furthermore, in patients with advanced symptomatic heart failure (NYHA functional class III or IV), left ventricular ejection fraction of less than 0.20, a left ventricular end-diastolic dimension of 75 mm or more, or a peak oxygen consumption of less than 10 mL/kg/min, strong consideration should be given to placement of biventricular epicardial leads at the time of operation. Institution of biventricular pacing in patients with heart failure has been shown to improve symptomatic heart failure, increase peak oxygen consumption, increase walk distance, and decrease left ventricular chamber dimension [4].

Although all analogies eventually break down, it is not unreasonable to extrapolate that aggressive attempts to convert patients to sinus rhythm (such as with the Maze procedure), reduction atrioplasty, and a more liberal application of epicardial biventricular pacing systems in the cohort of patients described in the Jokinen study might have ameliorated some of the subjective feelings of loss of energy and mobility that the patients described in their quality of life assessments.

	References

Top References

 

1. Calafiore AM, Gallina S, Iaco AL, et al. Mitral valve surgery for functional mitral regurgitation: should moderate-or-more tricuspid regurgitation be treated?. A propensity score analysis. Ann Thor Surg 2009;87:698-703.[Abstract/Free Full Text]
2. Jokinen JJ, Turpeinen AK, Pitkänen O, et al. Pacemaker therapy after tricuspid valve operations: implications on mortality, morbidity, and quality of life Ann Thorac Surg 2009;87:1806-1815.[Abstract/Free Full Text]
3. Koplan BA, Stevenson WG, Epstein LM, et al. Development and validation of a simple risk score to predict the need for permanent pacing after cardiac valve surgery J Am Coll Cardiol 2003;41:795-801.[Abstract/Free Full Text]
4. Hansky BA, Vogt J, Zittermann A, et al. Cardiac resynchronization therapy: long-term alternative to cardiac transplantation? Ann Thor Surg 2009;87:432-438.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Abeel A. Mangi Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Mangi, A. A. Search for Related Content PubMed PubMed Citation Articles by Mangi, A. A. Related Collections Valve disease Related Article