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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.
Frontiers in Cardiovascular Medicine
|July 8, 2026
Summary
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.
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