Magnetic resonance imaging in patients with cardiac implantable electronic devices: the RESONANCE Spanish registry.

BACKGROUND AND AIMS: Despite increasing evidence demonstrating the safety of magnetic resonance imaging (MRI) in patients with cardiac implantable electronic devices (CIEDs), this procedure is often neglected in this population. This Spanish registry aimed to determine the proportion of MRI referrals and performance among patients with pacemakers (PMs) or implantable cardioverter-defibrillators (ICDs). METHODS: This prospective, multicenter, open-label registry involved 21 Spanish centers. Data were collected upon implant of PMs or ICDs from BIOTRONIK and one year after, and included the number of MRIs and computed tomography scans prescribed, performed and denied, and reasons for denial. RESULTS: Data from 1105 patients (mean age: 74.2 years) were analyzed and 982 completed the follow-up. Of them, 82.2% had a PM and 17.8% an ICD. A total of 351 imaging tests were prescribed in 220 patients (19.9%), including 52 MRIs in 39 patients (3.5%) and 299 computed tomography scans in 196 patients (17.8%). Among the MRIs, 44 (84.6%) were performed, five (9.6%) were not performed, and three (5.8%) were replaced by an alternative test. Most of the indicated computed tomography scans were performed (97.7%). The proportion of patients with an MRI scan referral was 4.6% during the pre-COVID-19 period and 2.6% during the COVID-19 period. No MRI-related arrhythmic ventricular event was reported. CONCLUSION: This registry revealed that only 3.5% of patients with CIEDs had an MRI referral over the study, with rates decreasing to 2.6% during the COVID-19 period. These rates contrast with the 85 MRIs conducted per 1000 inhabitants in Spain in 2020.

Case report: Successful implantation of atrial lead in Marshall vein in a patient with sinus node dysfunction.

This case demonstrates that utilizing the vein of Marshall as an alternative option for atrial lead implantation is both safe and effective when encountering challenges during atrial lead implantation.

Pacemaker lead extraction saved a severe lead-induced tricuspid regurgitation: a case report.

Background: Pacemaker lead-induced tricuspid regurgitation is a common complication after cardiac implantable electronic device (CIED) implantation. Cardiac implantable electronic device lead removal is a challenge procedure. Case summary: A 72-year-old lady was admitted due to worsening heart failure. She had a history of permanent atrial fibrillation and had a permanent single-chamber pacemaker implanted 8 years ago due to complete heart block. Transthoracic echocardiography identified severe lead-related tricuspid regurgitation. The patient underwent successful lead extraction and received a new implantation of left bunch bundle area pacing. Transthoracic echocardiographic examination 2 days after the procedure showed a significant decrease of the tricuspid regurgitation. The patient also reported an improvement in heart failure symptoms. Discussion: Pacemaker lead-related tricuspid regurgitation introduces negative haemodynamic overload, carrying high risk for the development of heart failure and worse outcome. The present case shows a rapid relief of symptom and improvement of echocardiography findings, indicating the significance of mechanistic approach in the treatment of lead-related tricuspid mechanical interference.

Risk factors and incidence of new-onset heart failure with conventional pacemaker implant: A nationwide study.

Background: Studies have shown that the risk of new-onset heart failure (HF) is higher postimplantation for patients receiving right ventricular pacing. Objective: This study aimed to investigate incidence, risk factors, and implications for long-term prognosis of new-onset HF in patients after pacemaker implantation. Methods: Patients without pre-existing HF who received a pacemaker in Sweden during the period of 2005 to 2020 were identified via the nationwide Pacemaker Registry. Data were crossmatched with the population registry and national disease registries. The primary outcome was new-onset HF within 5 years, and a risk score for this was developed and validated. Results: In all, 65,579 patients met the inclusion criteria (10,351 single-chamber ventricular and 55,228 dual-chamber pacemakers). A total of 13,792 (21.0%) patients were diagnosed with HF within 5 years postimplantation. Of these, 6244 (45.3%) were hospitalized for HF. Patients with new-onset HF were more likely to die within 5 years (41.2% vs 19.7%, P < .0001). Risk factors for new-onset HF included increasing age, male sex, hypertension, diabetes, atrial fibrillation, chronic lung and kidney disease, ischemic heart disease, and atrioventricular block. In a combined score using these variables, patients in the highest risk-score quartile had a hazard ratio of 5.36 (95% CI 4.91-5.86, P < .001) and an absolute risk of 32% for developing HF. Conclusion: Pacemaker therapy is associated with >20% risk of new-onset HF within 5 years, and we identified 9 risk factors associated with the diagnosis of new-onset HF. The proposed score based on these variables can be used to identify patients at high risk for new-onset HF.

Comparison of Postoperative Outcomes between Leadless and Conventional Transvenous Pacemakers Implantation: An Up-to-Date Meta-analysis.

Background: Leadless cardiac pacemakers (LCPs) are emerging as viable alternatives to conventional transvenous pacemakers (TVPs). This study aimed to systematically compare the postoperative outcomes of LCPs and TVPs based on available published studies. Methods: We conducted a systematic review and meta-analysis of literature comparing outcomes from LCP and TVP implantations. Data analysis was performed using Stata/MP 17.0. The evaluated endpoints included pericardial effusion or perforation, puncture site events, infective endocarditis, lead or device dislodgement, pocket-related complications, tricuspid regurgitation or dysfunction, any infection, increased right ventricle (RV) pacing threshold, embolism, and thrombosis. Aggregated odds ratios (OR) and 95% confidence intervals (CI) were determined. Sensitivity analyses were conducted for heterogeneity if I2 was >50% or p < 0.01, otherwise, the random-effects model was chosen. Publication bias was analyzed if the number studies exceeded ten. Results: The meta-analysis included 24 observational studies with 78,938 patients, comprising 24,191 with LCP implantation and 54,747 with TVP implantation. The results indicated a significantly lower incidence of lead or device dislodgment (OR = 3.32, 95% CI: 1.91-5.77, p < 0.01), infective endocarditis (OR = 3.62, 95% CI: 3.10-4.24, p < 0.01), and infection (OR = 3.93, 95% CI: 1.67-9.24, p < 0.01) in the LCP group compared to the TVP group. In contrast, incidences of puncture site complications (OR = 0.24, 95% CI: 0.19-0.32, p < 0.01) and pericardial effusion or perforation (OR = 0.33, 95% CI: 0.28-0.39, p < 0.01) were significantly higher in the LCP group. Conclusions: Compared with TVP, LCP implantation is associated with a lower risk of infective endocarditis, lead or device dislodgment, infections, and pocket-related complications. However, LCP implantation carries a higher risk of puncture site complications and pericardial effusion or perforation. These findings underscore the need for careful consideration of patient-specific factors when choosing between LCP and TVP implantation. The PROSPERO Registration: https://www.crd.york.ac.uk/prospero/ (CRD42023453145).

Fungal Leadless Pacemaker Endocarditis Managed by Percutaneous Vacuum-Assisted Evacuation of Vegetation, Pacemaker Extraction, and Replacement.

Leadless cardiac pacemakers (LCPs) mitigate the risks of traditional transvenous devices such as lead fracture and infection. Two LCPs are clinically available, using either a helix or tined active fixation approach. There are rare reports of LCP infection-all involving the tined device. We report the first pathologically confirmed fungal endocarditis involving a helix-based LCP. This was successfully managed by catheter-based mechanical vacuum evacuation of the vegetation, followed by device extraction and replacement.

Safety of Magnetic Resonance Imaging in Patients with Cardiac Implantable Electronic Devices.

BACKGROUND: MRI (magnetic resonance imaging) represents the diagnostic image modality of choice in several conditions. With an increasing number of patients requiring MRI for diagnostic purposes, the issue of safety in patients with cardiac implantable electronic devices (CIED) undergoing this imaging modality will play an ever more important role. The purpose of this study was to assess the safety and device function following MRI in an unrestricted real-world cohort of patients with a wide array of cardiac devices. METHODS: We conducted a retrospective single-center study including 1010 MRI studies conducted in adult patients (≥18 years) with an implanted CIED treated in the University Hospital of Munich (LMU) between July 2012 and March 2024. Patients with non-MR conditionally labeled leads, abandoned or epicardial leads, as well as lead fragments, were included for analysis. RESULTS: Across a total of 1010 MRIs (920 total MR-conditional device generators) performed in patients with an implanted CIED, there were no deaths, reports of discomfort, palpitations, heating, or ventricular arrythmias in the 24 h following MRI. Only 2/1010 MRIs were followed by a reported atrial arrhythmia within 24 h, both in patients with an MR-conditional pacemaker (PM) device without an abandoned lead. No significant changes in device function following MRI from baseline were observed across all included CIEDs. Lastly, no instances of severe malfunction, such as generator failure, loss of capture, electrical reset, or inappropriate inhibition of pacing, were found in post-MRI interrogation reports across all MRI studies. CONCLUSIONS: Based on the analysis of 1010 MRIs undergone by patients with CIEDs, following standardized device interrogation, manufacturer-advised device programming, monitoring of vital function, and manufacturer-advised reprogramming, MRI can be performed safely and without adverse events or changes in device function.

Recurrence rate and predictors in non-ischemic reversible bradyarrhythmias.

Objective: Non-ischemic symptomatic reversible bradyarrhythmia is a poorly characterized yet common clinical challenge. This study aimed to assess the incidence and predictors of recurrence and the need for permanent cardiac pacing in patients with non-ischemic symptomatic reversible bradyarrhythmia. Methods: This prospective single-center study enrolled 124 consecutive adult patients with non-ischemic symptomatic reversible bradyarrhythmia who were followed up for up to 24 months after conservative management during index hospitalization. The primary endpoint was a recurrence of bradyarrhythmia requiring permanent cardiac pacing. The secondary endpoint was a composite of recurrence requiring permanent pacing, readmission, or death. Univariate and multivariate analyses were conducted to determine the predictors of the endpoints. Results: Sinus node and atrioventricular node diseases were seen in 66.1% and 33.9% of patients, respectively. The most common causes of bradyarrhythmia were negative chronotropic drugs (58.1%) and hyperkalemia (55.6%). Permanent pacing was required in 21.8% of patients after a recurrence. Advanced atrioventricular block at presentation (HR: 6.10, 95% CI: 2.45-15.20, p < 0.001) and bifascicular block at discharge (HR: 3.63, 95% CI: 1.58-8.33, p = 0.002) during index hospitalization were significant independent predictors of recurrence requiring cardiac pacing. Conclusion: Non-ischemic symptomatic reversible bradyarrhythmia is associated with a high risk of recurrence. Permanent cardiac pacing should be considered during index hospitalization in patients with advanced atrioventricular block and/or bifascicular block.

Feasibility, safety and clinical impact of a less-invasive totally-endovascular (LITE) technique for transfemoral TAVI: A 1000 patients single-centre experience.

Background: Trans-femoral (TF) represents the main access for TAVI. Although there are various technical strategies to conduct TF-TAVI (pacing modality, secondary arterial access, primary access puncture etc.), the optimal technique is not recognized. Aims: In the present study, we assessed the impact of systematic use of LITE-TAVI in terms of feasibility, safety, and main access complication management using VARC-3 outcomes definitions. Methods: At our institution, a less-invasive totally-endovascular (LITE) technique for TF-TAVI has been developed since 2017. Key aspects are: precise TAVI access puncture using angiographic-guidewire ultrasound guidance; radial/ulnar approach as the default "secondary access"; non-invasive pacing (by guidewire stimulation or definitive pacemaker external programmer). Results: 1022 consecutive TF-TAVI patients (55 % women, mean age: 80 years, mean EuroSCORE II 6.1 %, mean STS-PROM 4.3 %, mean STS/ACC TVT TAVR mortality score 3.4 %) were approached using the LITE technique. Technical success was achieved in 993 (97.2 %) patients. Access-related major vascular complications occurred in 12 (1.2 %) and VARC-3 ≥ type 2 bleedings in 12 (1.2 %) patients. At 30-day, all-cause death occurred in 17 (1.7 %) patients. This figure resulted significantly lower than expected on the bases of the mortality predicted not only by EuroSCORE II (6.1 %, p < 0.001) and STS-PROM score (4.3 %; p < 0.001), but also by STS/ACC TVT TAVR mortality score (3.4 %; p = 0.01). Conclusions: Systematic use of LITE-TAVI is feasible and is associated with an extremely low rate of access-related bleeding and vascular complications which may drive to outcome improvement.

Machine learning for pacemaker implantation prediction after TAVI using multimodal imaging data.

Pacemaker implantation (PMI) after transcatheter aortic valve implantation (TAVI) is a common complication. While computed tomography (CT) scan data are known predictors of PMI, no machine learning (ML) model integrating CT with clinical, ECG, and transthoracic echocardiography (TTE) data has been proposed. This study investigates the contribution of ML methods to predict PMI after TAVI, with a focus on the role of CT imaging data. A retrospective analysis was conducted on a cohort of 520 patients who underwent TAVI. Recursive feature elimination with SHAP values was used to select key variables from clinical, ECG, TTE, and CT data. Six ML models, including Support Vector Machines (SVM), were trained using these selected variables. The model's performance was evaluated using AUC-ROC, F1 score, and accuracy metrics. The PMI rate was 18.8%. The best-performing model achieved an AUC-ROC of 92.1% ± 4.7, an F1 score of 71.8% ± 9.9, and an accuracy of 87.9% ± 4.7 using 22 variables, 9 of which were CT-based. Membranous septum measurements and their dynamic variations were critical predictors. Our ML model provides robust PMI predictions, enabling personalized risk assessments. The model is implemented online for broad clinical use.

Pacemaker Implantation for Low-Grade Conduction Abnormalities After Balloon-Expandable Transcatheter Aortic Valve Implantation.

INTRODUCTION: A frequent complication after TAVI are postinterventional conduction abnormalities requiring permanent pacemaker implantation. In this study, we analyzed the characteristics of borderline conduction abnormalities leading to pacemaker implantation and the resulting ventricular pacing amounts. METHODS AND RESULTS: All patients who underwent balloon-expandable TAVI between 2014 and 2019 in our tertiary center were analyzed in a retrospective manner. One hundred and sixty-five patients of 1083 TAVI-patients developed postinterventional conduction abnormalities leading to pacemaker implantation. Of these 19 (11.5%) did not represent a clear indication for cardiac pacing according to current European guidelines. Patient characteristics, underlying conduction abnormalities, and the temporal change of ventricular pacing percentages at 24 h and 6 weeks after pacemaker implantation were analyzed. The dominating borderline conduction abnormalities leading to pacemaker implantation were new-onset persisting bundle-branch-blocks and new first-degree AV-blocks with progression of AV-delay. While pacemaker implantation was safe and without severe complications in all cases, only 6 of 19 patients had high pacing amounts (95%-100%) after 24 h while 11 patients had low to no pacing amounts (0%-5%). After 6 weeks, 8 patients showed decreasing pacing amounts, no patient had an increasing amount of ventricular pacing and all patients had an intrinsic ventricular rhythm > 30/min. CONCLUSION: In our cohort of 1038 TAVI patients, 19 patients underwent PMI for borderline CAs (11.5% of all PMI). Of these, only 2 patients had high pacing amounts after 6 weeks. The risk of complete persisting heart block in these patients is very low. Furthermore, algorithms to reduce ventricular pacing are highly effective to avoid ventricular pacing whenever reasonable.

Development of Pericarditis Following Implantation of Micra Leadless Pacemaker.

Pacemakers are frequently essential in managing conduction disorders. Recently, the advancement of leadless pacemakers (LPs) has emerged, offering an alternative without the need for an upper shoulder incision or pacing leads. Despite the advantages, including reduced infection risk and improved durability, the novel nature of LPs means that some complications are still being identified. This report presents a unique case of pericarditis occurring after the implantation of a Micra leadless pacemaker (MLP) (Medtronic, Minneapolis, MN). It demonstrates the critical need for careful post-procedural monitoring to promptly detect and address potential complications associated with this emerging technology.

Failure of pacemaker therapy in a pediatric patient with neurally mediated complete heart block and syncope: A case report.

Neurally mediated syncope (NMS) is a well-known condition that can be subdivided into three subgroups: vasopressor type, cardioinhibitory type, and mixed type. While different degrees of sinus bradycardia occur at the time of syncope in all types, complete heart block is a rare event that can lead to pulselessness during syncope. We present a case of a 14-year-old girl with documented NMS before and after temporary pacemaker implantation, who had complete heart block during syncope. The patient's temporary pacemaker placement was ineffective in preventing syncope during a repeat head-up tilt test, indicating that permanent pacing may not be effective in this patient. Midodrine, an alpha-adrenergic agonist, was started, and the patient experienced complete control of syncope episodes without recurrence during a 2-month follow-up.

Physiologic pacing in congenitally corrected transposition of the great arteries with electroanatomic mapping guidance: a case report.

Background: This case report details the application of left bundle branch pacing in a patient with congenitally corrected transposition of the great arteries (cc-TGA), a rare congenital heart defect characterized by anatomical complexities that pose unique challenges in the management of device-related complications and heart failure. The patient's history is notable for complex anatomical considerations, cardiovascular implantable electronic device (CIED) infection, and heart failure. Case summary: The patient underwent a series of interventions, including treatment for pocket-site infections, abandonment of epicardial leads, and an unsuccessful attempt at trans-catheter leadless pacemaker implantation. Given the patient's complex anatomy and prior CIED infection, traditional pacing methods were deemed unsuitable, leading to the selection of left bundle branch pacing. The lead implantation was guided using 3D electro-anatomical mapping to ensure synchronous physiologic pacing in a patient with heart failure. Discussion: The case underscores the heightened risks faced by cc-TGA patients, with a focus on systemic right ventricular dysfunction and pacing-induced ventricular dysfunction. In these patients, ventricular synchrony is critical and can be achieved with biventricular pacing. Physiologic pacing emerges as a promising alternative to cardiac resynchronization therapy (CRT), especially in cases where endovascular CRT is unfeasible. This case demonstrates the utilization of 3D electro-anatomical mapping for achieving successful physiologic pacing in complex congenital heart lesions. At the 12-month follow-up, the patient presented with stable clinical status and a narrow QRS complex. Echocardiography indicated improvement in the right systemic ventricular function.

Transcatheter non-acute retrieval of the tine-based leadless ventricular pacemaker.

AIMS: We report our single-centre experience of mid-term to long-term retrieval and reimplantation of a tine-based leadless pacemaker [Micra transcatheter pacing system (TPS)]. The TPS is a clinically effective alternative to transvenous single-chamber ventricular pacemakers. Whereas it is currently recommended to abandon the TPS at the end of device life, catheter-based retrieval may be favourable in specific scenarios. METHODS AND RESULTS: We report on nine consecutive patients with the implanted TPS who subsequently underwent transcatheter retrieval attempts. The retrieval system consists of the original TPS delivery catheter and an off-the-shelf single-loop 7 mm snare. The procedure was guided by fluoroscopy and intracardiac echocardiography. After an implantation duration of 3.1 ± 2.8 years (range 0.4-9.0), the overall retrieval success rate was 88.9% (8 of 9 patients). The mean procedure time was 89 ± 16 min, and the fluoroscopy time was 18.0 ± 6.6 min. No procedure-related adverse device events occurred. In the one unsuccessful retrieval, intracardiac echocardiography revealed that the TPS was partially embedded in the ventricular tissue surrounding the leadless pacemaker body in the right ventricle. After retrieval, three patients were reimplanted with a new TPS device. All implantations were successful without complications. CONCLUSION: A series of transvenous late retrievals of implanted TPS devices demonstrated safety and feasibility, followed by elective replacement with a new leadless pacing device or conventional transvenous pacing system. This provides a viable end-of-life management alternative to simple abandonment of this leadless pacemaker.

Endocardial ablation of ganglionated plexus for the treatment of carotid sinus syndrome.

INTRODUCTION: Carotid sinus syndrome (CSS), characterized by exaggerated vagal responses leading to asystolic pauses with carotid sinus massage (CSM), often necessitates pacemaker implantation. This study investigates cardioneuroablation (CNA) as an alternative strategy for CSS. METHODS: Prospective study of consecutive patients referred for CNA due to CSS. All patients underwent CSM, atropine test and 24-h Holter monitoring before the procedure and at 6 months. The primary objective was the absence of any cardioinhibitory response to CSM following CNA. Secondary objectives included the combined endpoint of syncope and presyncope-free survival, pacemaker-free survival, differences in heart rate variation (HRV), as well as differences in the pre- and postprocedure atropine tests and in the SF-36 quality-of-life questionnaire. RESULTS: A total of 13 consecutive patients (84.6% male, mean age 63.8 ± 12.3 years) were included. CSM revealed a symptomatic asystolic pause in all patients before CNA (7.3 [5.6-10.5] s). After the procedure, all the patients had a negative CSM, and only one patient (7.7%) had a positive CSM at 6 months. After a median follow-up of 11.2 (10.6-16.3) months, syncope or presyncope-free survival was 84.6%, and none required pacemaker implantation. There was an improvement in the energy and health change items in the SF-36 questionnaire. There was a reduction in HR increase in the atropine test at 6 months (pre-CNA: 66% [52-84] vs. post-CNA 26.0% (19.8-29.3]; p = .008) and in HRV parameters. CONCLUSIONS: In this proof-of-efficacy study, performed in patients affected by asystolic CSS, CNA was effective in reducing the rate of cardioinhibitory responses, suggesting a potential efficacy in also reducing syncopal recurrences. Controlled trials are warranted to corroborate clinical findings.

Impact of burden and distribution of aortic valve calcification on the hemodynamic performance and procedural outcomes of a self-expanding, intra-annular transcatheter aortic valve system.

Aortic valve calcification (AVC) has been explored as a powerful predictor of procedural complications in patients undergoing transcatheter aortic valve implantation (TAVI). However, little evidence exists on its impact on intra-annular devices' performance. We aimed to investigate the impact of AVC burden and distribution pattern on the occurrence of paravalvular leak (PVL), conduction disturbances requiring permanent pacemaker implantation (PPI) and 30-day clinical outcomes in patients undergoing TAVI with a self-expanding, intra-annular device. According to AVC, 103 patients enrolled in a single medical centre from November 2019 to December 2022 were divided into tertiles. Valve Academic Research Consortium (VARC)-3 definitions were used to classify procedural complications and outcomes. Patients in the highest AVC tertile showed an increased occurrence of mild or more PVL and conduction disorders (p < 0.001 and p = 0.006). AVC tertiles (highest tertile) emerged as an independent predictor of PVL (OR 7.32, 95%CI 3.10-17.28, p < 0.001) and post-TAVI conduction disturbances (OR 3.73, 95%CI 1.31-10.60, p = 0.013) but not of PPI (OR 1.44, 95%CI 0.39-5.35, p = 0.579). Considering calcium distribution, ROC analyses revealed that annular AVC but not left ventricle outflow tract (LVOT) calcium burden significantly indicated the development of PVL (AUC 0.863, 0.77-0.93, p < 0.001) and conduction disorders/PPI (AUC 0.797, 0.70-0.89, p < 0.001 and 0.723, 0.58-0.86, p = 0.018, respectively). After adjustment for age and sex, the highest tertile remained an independent predictor of the 30-day composite outcome (death, myocardial infarction, stroke, major vascular complications, type 3/4 bleedings, acute kidney injury, PPI and ≥ moderate PVL) (OR 3.26; 95%CI 1.26-8.40, p = 0.014). A higher AVC is associated with an increased risk of PVL and conduction disturbances after TAVI with a self-expanding, intra-annular device. However, our findings suggest a minor role for LVOT calcification compared with annular AVC in the performance of this specific prosthesis.

Outcomes of leadless pacemaker implantation in the United States based on sex.

BACKGROUND: To determine differences in baseline characteristics and outcomes of leadless pacemaker implantation based on sex. METHODS: For the purpose of this study, data were extracted from the National Inpatient Sample database for years 2016-2020. The study group was then stratified based on sex. Baseline characteristics and in-hospital outcomes including complications were then analyzed in each group. Multivariable logistic regression models were created to analyze the association of sex with important outcomes of mortality, major complications (defined as pericardial effusion requiring intervention and any vascular complication), prolonged length of stay (defined as > 6 days), and increased cost of hospitalization (defined as median cost > 34,098$) after leadless pacemaker implantation. RESULTS: A total of 29,000 leadless pacemakers (n in women = 12,960, 44.7%) were implanted during our study period. Women were found to have an increased burden of co-morbidities as compared to men. In the adjusted analysis, the likelihood of mortality (aOR 1.27, 95% CI 1.14-1.43), major complications (aOR 1.07, 95% CI 0.98-1.18), prolonged length of stay (aOR 1.09, 95% CI 1.04-1.15), and increased hospitalization cost (aOR 1.14, 95% CI 1.08-1.20) were higher in women as compared to men after leadless pacemaker implantation. CONCLUSION: Important and significant differences exist in leadless pacemaker implantation in women as compared to men. These findings highlight the need for evaluating etiologies behind such differences with a goal of improving outcomes in all patients after leadless pacemaker implantation.

Factors Associated with Permanent Pacemaker Placement After Tricuspid Valve Operations.

BACKGROUND: Conduction abnormalities requiring permanent pacemaker (PPM) implantation are common after tricuspid valve operations, though incidence is variable. This study aims to investigate contemporary rates of and risk factors for PPM after tricuspid operations. METHODS: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to identify patients with tricuspid repair or replacement from 2011 to 2020. Factors independently associated with risk of postoperative PPM during index hospital admission were examined using multivariable logistic regression with a complete case approach. Annualized hospital and surgeon volumes were calculated. RESULTS: We identified 71,937 patients undergoing tricuspid operations. Median patient age was 66 (53-74) years, 56% were female (n=40,590), and median ejection fraction was 56% (48%-60%). Tricuspid operations were concomitant in 87% (n=62,457), elective in 62% (n=44,393), and included repair in 86% (n=61,720). Overall postoperative incidence of PPM was 15% (n=10,857); 13% (n=8,304) after repair and 25% (n=2,553) after replacement; 4% (n=174) for isolated tricuspid repair and 24% (n=1,248) for isolated tricuspid replacement. Multivariable analysis showed baseline characteristics, endocarditis, concomitant operations, longer CPB time, tricuspid replacement, and lower hospital and surgeon tricuspid operative volumes were independently associated with greater risk for PPM. After adjustment, tricuspid replacement had 3.2 times greater PPM risk compared to tricuspid repair. CONCLUSIONS: Nationally, 15% of patients undergoing tricuspid operations required postoperative PPM implantation. PPM risk was increased with concomitant valve operations, tricuspid replacement, longer CPB time, and operations performed by less experienced surgeons and centers. Innovation is needed to decrease this significant morbidity.