Predictors of permanent pacemaker requirement after cardiac surgery for infective endocarditis

Abstract

Background: Infectious endocarditis is often complicated by conduction abnormalities at the time of presentation. Cardiac surgery is the treatment of choice for many infectious endocarditis patients, but carries an additional risk of persistent postoperative conduction abnormality. We sought to define the incidence and clinical predictors of significant postoperative conduction abnormalities necessitating permanent pacemaker implantation after cardiac surgery for infectious endocarditis. Methods: All consecutive patients with infectious endocarditis who were surgically treated at Cleveland Clinic from 2007 to 2013 were identified using the Cleveland Clinic Infective Endocarditis Registry and the Cardiovascular Information Registry. Patients with a pre-existing cardiac implantable electronic device were excluded. The primary outcome was the need for permanent pacemaker placement postoperatively for atrioventricular block. Regression analysis was performed to identify risk factors for permanent pacemaker requirement. Results: Among 444 infectious endocarditis patients who underwent cardiac surgery for infectious endocarditis, 57 (13%) required postoperative permanent pacemaker for atrioventricular block. Multivariable analysis identified that prolongation in preoperative PR and QRS intervals, Staphylococcus aureus as the infectious endocarditis organism, the presence of intracardiac abscess, tricuspid valve involvement, and prior valvular surgery independently predicted postoperative permanent pacemaker placement. The developed model exhibited excellent predictive ability (c-statistic 0.88) and calibration. Conclusion: Infectious endocarditis cardiac surgery patients often require a postoperative permanent pacemaker. Preoperative conduction abnormality, S. aureus infection, abscess, tricuspid valve involvement, and prior valvular surgery are strong predictors of postoperative permanent pacemaker placement.

Comparative Surgical Outcomes of Prosthetic and Native Valve Endocarditis

“… 24) 25) 26) Previous studies demonstrated that aortic valve (AV) involvement, valvular abscess, prior valvular surgery and Staphylococcus aureus infection were strong predictors of postoperative PPM implantation, and valve replacement compared to valve repair surgery was another risk factor. 24) 25) 27) In the present study, PVE was characterized by more common AV and MAIVF involvement, Staphylococci infection and abscess formation as compared with NVE. In addition, valve repair is not available option in PVE.…”

Incidence and predictors of permanent pacemaker implantation after surgical aortic v alve replacement: Data of the Netherlands Heart Registration (NHR)

“…Van Mieghem et al 21 also demonstrated the negative effect of previous cardiac operation on PPI after SAVR. Multiple surgical valve procedures 9 and prior valve surgery 22 has also been described to be risk factors for postoperative PPI. This relationship highly suggests that direct trauma at the time of surgery or ischemic injury during previous surgery can hugely predispose patients to a PPI in the follow‐up.…”

“… 32 By increasing the automaticity of the sino‐atrial node and slowing down the atrio‐ventricular conduction, vasopressor may potentialize previous or concomitant lesions inducing a deceleration of the atrio‐ventricular conduction, leading to higher subsequent postoperative PPI. 22 , 33 Furthermore, the use of dobutamine has been related to the development of postoperative ventricular arrhythmias, emphasizing the potential impact of vasopressor on the heart conduction system. 34 However, as we had no details about the kind of vasopressor used, we were unable to conclude about a specific molecule causing post‐SAVR PPI.…”

Anesthesia Considerations in Infective Endocarditis

“…Given the increased risk of reinfection in patients with infective endocarditis, the timing of permanent pacemaker placement should be carefully evaluated by an interdisciplinary team. 192 The continuation of antibiotic therapy leading to adequate plasma levels is crucial in order to reduce the risk of prosthetic valve endocarditis. Here, dosing might need to be adjusted according to organ dysfunction and/or mechanical organ supporting therapy.…”

“…Given the increased risk of reinfection in patients with infective endocarditis, the timing of permanent pacemaker placement should be carefully evaluated by an interdisciplinary team. 192…”