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Criteria for Early Pacemaker Implantation in Patients With Postoperative Heart Block After Congenital Heart Surgery
Son Q Duong1, Yuan Shi2, Heather Giacone1
1Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA (S.Q.D., H.G., B.M.N., D.B.G., B.H., D.S., C.D.R., A.Y.S., D.M.K., A.M.D, C.A.A.).
Insights
This study identifies risk factors for permanent pacemaker placement (PPM) in children after heart surgery, enabling earlier decisions. Developing criteria for early PPM can improve care efficiency and reduce risks associated with temporary pacing.
Area of Science:
- Pediatric Cardiac Surgery
- Electrophysiology
- Congenital Heart Disease Management
Background:
- Current guidelines suggest observing patients for atrioventricular node recovery until postoperative days 7-10 before considering permanent pacemaker placement (PPM) after congenital cardiac surgery.
- This study aimed to establish criteria for identifying patients at high risk of requiring PPM, aiding in surgical decision-making for early intervention.
Approach:
- A decision tree model was developed and validated to predict the need for PPM in patients with heart block after congenital cardiac surgery.
- The model analyzed cases of second-degree and complete heart block (CHB) on postoperative day 0, with separate models for persistent CHB and those without recovery by postoperative day 4.
Key Points:
- Persistent complete heart block on postoperative day 0 and older age were associated with a higher likelihood of requiring PPM.
- Four key risk factors for PPM in persistent CHB were identified: aortic valve replacement/subaortic stenosis repair/Konno procedure, ventricular L-looping, atrioventricular valve replacement, and absence of preoperative antiarrhythmic agents.
- The postoperative day 4 model demonstrated high specificity (0.89) and positive predictive value (0.94) for PPM need, which was maintained in prospective validation.
Conclusions:
- A data-driven approach yielded actionable criteria for identifying patients who require PPM.
- Consideration for early PPM on postoperative day 4 may be appropriate for patients with specific risk factors, potentially reducing temporary pacing risks and enhancing care efficiency.
Background:
Guidelines recommend observation for atrioventricular node recovery until postoperative days (POD) 7 to 10 before permanent pacemaker placement (PPM) in patients with heart block after congenital cardiac surgery. To aid in surgical decision-making for early PPM, we established criteria to identify patients at high risk of requiring PPM.
Methods:
We reviewed all cases of second degree and complete heart block (CHB) on POD 0 from August 2009 through December 2018. A decision tree model was trained to predict the need for PPM amongst patients with persistent CHB and prospectively validated from January 2019 through March 2021. Separate models were developed for all patients on POD 0 and those without recovery by POD 4.
Results:
Of the 139 patients with postoperative heart block, 68 required PPM. PPM was associated with older age (3.2 versus 1.0 years; P=0.018) and persistent CHB on POD 0 (versus intermittent CHB or second degree heart block; 87% versus 58%; P=0.001). Median days [IQR] to atrioventricular node recovery was 2 [0-5] and PPM was 9 [6-11]. Of the 100 cases of persistent CHB (21 in the validation cohort), 59 (59%) required PPM. A decision tree model identified 4 risk factors for PPM in patients with persistent CHB: (1) aortic valve replacement, subaortic stenosis repair, or Konno procedure; (2) ventricular L-looping; (3) atrioventricular valve replacement; (4) and absence of preoperative antiarrhythmic agent (in POD 0 model only). The POD 4 model specificity was 0.89 [0.67-0.99] and positive predictive value was 0.94 [95% CI 0.81-0.98], which was stable in prospective validation (positive predictive value 1.0).
Conclusions:
A data-driven analysis led to actionable criteria to identify patients requiring PPM. Patients with left ventricular outflow tract surgery, atrioventricular valve replacement, or ventricular L-Looping could be considered for PPM on POD 4 to reduce risks of temporary pacing and improve care efficiency.
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