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Permanent pacemaker rate following Commando and Hemi-Commando procedures: a systematic review and meta-analysis
Yang Zhang1, Ren Zhu1, Guanshui Yu1
1Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Maoming, China.
Insights
The Commando procedure often requires a permanent pacemaker, with a pooled rate of 22.3%. The Chimney Commando modification shows a significantly lower rate (6.3%), suggesting a potentially safer alternative.
Area of Science:
- Cardiovascular Surgery
- Medical Device Implantation
Background:
- The Commando procedure, involving double-valve replacement and intervalvular fibrous body reconstruction, carries a significant risk of atrioventricular block.
- This necessitates permanent pacemaker implantation in a substantial number of patients, with existing estimates showing wide variability.
Purpose of the Study:
- To systematically review and meta-analyze existing literature to determine the pooled permanent pacemaker rate following Commando and Hemi-Commando procedures.
- To compare the permanent pacemaker rates between different modifications of the Commando procedure.
Main Methods:
- A comprehensive search of major databases (PubMed, Embase, Web of Science, Cochrane CENTRAL) was conducted up to April 2, 2026.
- Twelve studies comprising 797 patients were included, with data pooled using a random-effects model and logit transformation.
- Subgroup, sensitivity, and publication bias analyses were performed to assess the robustness and potential biases of the findings.
Main Results:
- The overall pooled permanent pacemaker rate after Commando and Hemi-Commando procedures was 22.3% (95% CI: 16.1%-30.0%), with significant heterogeneity observed (I² = 73.7%).
- The Chimney Commando modification demonstrated a significantly lower permanent pacemaker rate (6.3%) compared to the traditional Commando procedure (28.3%) (p < 0.001).
- Sensitivity analyses supported the findings, though Egger's test suggested potential small-study effects (p = 0.0041).
Conclusions:
- Approximately one in five patients undergoing Commando surgery requires a permanent pacemaker.
- The Chimney Commando modification appears to be associated with a substantially lower risk of permanent pacemaker implantation.
- While promising, these findings are preliminary and hypothesis-generating; further prospective studies are needed to validate the benefits of the Chimney technique, particularly in high-risk patient groups.
Objective:
The Commando procedure (double-valve replacement with intervalvular fibrous body reconstruction) is associated with a high risk of postoperative atrioventricular block requiring permanent pacemaker implantation. However, precise estimates vary widely. This systematic review and meta-analysis aimed to determine the pooled permanent pacemaker rate after Commando and Hemi-Commando procedures.
Methods:
PubMed, Embase, Web of Science, and Cochrane CENTRAL were searched from inception to April 2, 2026. Studies reporting permanent pacemaker rates after Commando or Hemi-Commando surgery (sample size ≥ 5) were included. A random-effects model was used to pool proportions, with logit transformation. Subgroup analyses were performed by procedure type. Sensitivity analyses and publication bias assessment (Egger's test) were conducted.
Results:
Twelve studies with 13 data points (797 patients) were included. The pooled permanent pacemaker rate was 22.3% (95% confidence interval: 16.1%-30.0%), with substantial heterogeneity (I² = 73.7%). Subgroup analysis showed that the Chimney Commando modification had a significantly lower rate (6.3%, 95% CI: 3.2%-12.1%) compared with the traditional Commando procedure (28.3%, 95% CI: 21.2%-36.7%; p for subgroup difference < 0.001). Sensitivity analyses confirmed the robustness of the findings. Egger's test indicated potential small-study effects (p = 0.0041).
Conclusions:
One in five patients undergoing Commando surgery requires a permanent pacemaker. Preliminary evidence suggests that the Chimney Commando modification may be associated with a substantially lower risk (6.3% vs. 28.3%). Based on these preliminary findings, the Chimney technique might be a reasonable option in carefully selected patients with small annuli or those undergoing redo surgery, where conduction injury risk is inherently high. However, given the limited evidence, this recommendation should be considered hypothesis-generating. Future prospective comparative studies are needed to validate these hypothesis-generating findings.
Systematic Review Registration:
https://osf.io/sgd2e/.
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