Permanent pacemaker implantation following mitral valve surgery. State-of-the-art scoping review

Abstract

Objectives: This scoping review investigates the prevalence, indications, risk factors, timing and outcomes related to permanent pacemaker implantation following mitral valve surgery.

Methods: A comprehensive search of PubMed, Embase and Cochrane databases was conducted to identify studies on permanent pacemaker implantation after mitral valve surgery. Relevant articles discussing prevalence, indications, risk factors, optimal timing, device choice and long-term dependency were included, prioritizing clinical studies and reviews published in the last 2 decades.

Results: The incidence of permanent pacemaker implantation after isolated mitral valve surgeries varies from 1% to 10%, with observation periods ranging from 2 to 12 days across centres. Atrioventricular block is the most common indication. Risk factors include older age, atrial fibrillation, reduced left ventricular function and prior cardiac surgery. Patients undergoing mitral valve replacement face a higher risk compared to those having mitral valve repair, while minimally invasive surgery and left atriotomy approach are linked to a lower permanent pacemaker rate. Long-term pacemaker dependency ranges between 20% and 60%, with increased rates observed in patients with atrioventricular block or those operated in the setting of infective endocarditis.

Conclusions: This review highlights the complex interplay of factors influencing permanent pacemaker implantation after mitral valve surgery. Future research should focus on strategies to reduce postoperative conduction abnormalities and better identify patients who may require permanent pacemaker during long-term follow-up.

Keywords: Dependency; Mitral valve surgery; Mortality; Permanent pacemaker implantation; Risk factors; Timing.

Graphical abstract

Figure 1:

Preoperative characteristics predisposing to permanent pacemaker implantation after mitral valve surgery. Size of each bubble is an approximation the HR of each risk factor. AF: atrial fibrillation; DM: diabetes mellitus; LBBB: left bundle branch block; LVEF: left ventricular ejection fraction; MI: myocardial infarction; NYHA: New York Heart Association; RBBB: right bundle branch block.

Figure 2:

Surgical approach to mitral valve. Operative field view for mitral valve surgery (A). Incision line through the right atrium (red dashed line), together with the position of the conduction system elements: sinus node and accessory pathways. View after opening of the right atrium (B), with the incision line through the interatrial septum. Triangle of Koch is to be seen at the floor of right atrium together with atrioventricular node position against the preferred incision line (black dashed line). Operative view of the mitral valve after opening of the left atrium and stay sutures placement (C); posteromedial commissure of the mitral valve remains within close proximity to the bundle of His. Left vent positioned at the floor of left atrium. Detailed anatomical relationship of mitral valve annulus with surrounding critical structures (D): circumflex artery and its branches, bundle of His, left bundle branch and coronary sinus.

Figure 3:

Summary of the evidence on permanent pacemaker implantation following mitral valve surgery. The intensity of the background’s colour reflects the increasing risk of complications as the colour intensifies. Bolded pacemaker types as in recommendations. AVB: atrioventricular block; BMI: body mass index; COPD: chronic obstructive pulmonary disease; DM: diabetes mellitus; LAD: left anterior descending; LBBB: left bundle branch block; LVEF: left ventricle ejection fraction; MV: mitral valve; PM: pacemaker; RBBB: right bundle branch block.