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Permanent Pacemaker Implantation After Isolated Aortic Valve Replacement
Ann Thorac Surg 2008;86:1399 – 403
Stephen A. Olenchock, Jr, DO Cardiothoracic Surgery Department Tufts University School of Medicine and Caritas St. Elizabeth’s Medical Center 11 Nevins St, Suite 306 Boston, MA 02135 e-mail: [email protected] C. Michael Gibson, MD Cardiovascular Division Departments of Medicine Beth Israel Deaconess Medical Center and Harvard Medical School Boston, MA
References 1. Cikirikcioglu M, Duran E. New discussion on an old subject: proximal anastomosis markers in coronary bypass surgery (letter). Ann Thorac Surg 2008; 86:1401–2. 2. Olenchock SA Jr, Karmpaliotis D, Gibson WJ, et al. Impact of saphenous vein graft radiographic markers on clinical events and angiographic parameters. Ann Thorac Surg 2008; 85: 520 – 4.
Permanent Pacemaker Implantation After Isolated Aortic Valve Replacement To the Editor: We read with interest the article by Dawkins and colleagues [1] on the need for permanent pacemaker implantation (PPI) after isolated aortic valve replacement (AVR). The authors conclude that PPI after AVR is required more often in patients with preoperative aortic regurgitation (AR), those with larger aortic prostheses (24.9 ⫾ 2.8 mm) and patients with preoperative conducting system disease. However, we are not aware of the cause of aortic valve disease in their patients, whether rheumatic or degenerative. We are in disagreement with the authors’ observation that the use of a larger prosthesis size may lead to a higher incidence of PPI. We published a series of 748 patients requiring AVR in 2000 [2]. In 238 (31.8%) of these, large aortic valve prostheses (ⱖ 25 mm) were implanted and 362 (48.6%) of these had severe AR. There were 14 (1.87%) deaths, and none of these patients required PPI. However, the mean age of these patients was only 35.2 ⫾ 2.7 years and there was no evidence of preoperative conduction system abnormalities, which could probably account for no need for PPI. Our recent experience with AVR for predominant aortic
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
1403
stenosis (AS) was recently published [3]. Of the 94 patients undergoing AVR for predominant AS, 2 required PPI. The mean age of these patients was 43.2 ⫾ 13.2 years, and almost all of them had severe calcific aortic stenosis. Valves of size 23 mm or more were implanted in 75 patients (80%). A valve of 25 mm or larger was implanted in 55 patients (54.3%). Even though the need for PPI was not exceptionally high, we believe that operative trauma during valve excision and debridement of the aortic annulus was an important factor that contributed to the development of complete heart block with the need for PPI in these 2 patients. Based on our experience, we believe that AR and implantation of large aortic prostheses may not predispose the patients to increased risk of PPI. However, in patients with AR due to preoperative endocarditis and root abscesses, the integrity of the conduction system may be compromised and these patients may be at an increased risk of conduction system abnormalities requiring PPI. In most other cases, technical factors during AVR probably play a greater role and are responsible for the majority of PPI after AVR. Sachin Talwar, MCh Shiv Kumar Choudhary, MCh Arkalgud Sampath Kumar, MCh Department of Cardiothoracic and Vascular Surgery All India Institute of Medical Sciences New Delhi, 110029 India e-mail: [email protected]
References 1. Dawkins S, Hobson AR, Kalra PR, Tang AT, Monro JL, Dawkins KD. Permanent pacemaker implantation after isolated aortic valve replacement: incidence, indicators and predictors. Ann Thorac Surg 2008;85:108 –12. 2. Choudhary SK, Mathur A, Venugopal P, et al. Prosthesis size in aortic valve replacement: surgeon-related variable. Asian Cardiovasc Thorac Ann 2000;8:333– 8. 3. Joshi K, Talwar S, Velayoudham D, Kumar AS. Aortic valve replacement in predominant aortic stenosis: what is an appropriate size valve? Indian J Thorac Cardiovasc Surg 2007; 23:141–5.
CORRECTION Wellisz T, Armstrong JK, Cambridge J, An YH, Wen X, Hill CM, and Fisher TC. The effects of a soluble polymer and bone wax on sternal healing in an animal model. Ann Thorac Surg 2008;85:1776 –1780. The authors of the above-referenced article regret that the name of Qian Kang, MD, was inadvertently left out of the author line on the final version of the manuscript. Dr Kang’s name should have been listed as the sixth author on the manuscript, after Xuejun Wen and before Christopher Hill, and her name should have been affiliated with the following institution: Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina.
Ann Thorac Surg 2008;86:1403 • 0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2008.08.021
MISCELLANEOUS
placed, only 7 underwent repeat surgery. We do not have the data that Cikirikcioglu and Duran [1] requested on the reoperative findings (ie, “Did they encounter fibrosis, narrowing or any marker related pathologic changes around the proximal anastomoses?”) in these 7 patients. Nor do we have information on the region of infarction for the perioperative MIs. We agree with the authors that such additional data would be valuable in subsequent studies and would further guide the decision process on the use of SVG markers.
CORRESPONDENCE
Stephen A. Olenchock, Jr, DO Cardiothoracic Surgery Department Tufts University School of Medicine and Caritas St. Elizabeth’s Medical Center 11 Nevins St, Suite 306 Boston, MA 02135 e-mail: [email protected] C. Michael Gibson, MD Cardiovascular Division Departments of Medicine Beth Israel Deaconess Medical Center and Harvard Medical School Boston, MA
References 1. Cikirikcioglu M, Duran E. New discussion on an old subject: proximal anastomosis markers in coronary bypass surgery (letter). Ann Thorac Surg 2008; 86:1401–2. 2. Olenchock SA Jr, Karmpaliotis D, Gibson WJ, et al. Impact of saphenous vein graft radiographic markers on clinical events and angiographic parameters. Ann Thorac Surg 2008; 85: 520 – 4.
Permanent Pacemaker Implantation After Isolated Aortic Valve Replacement To the Editor: We read with interest the article by Dawkins and colleagues [1] on the need for permanent pacemaker implantation (PPI) after isolated aortic valve replacement (AVR). The authors conclude that PPI after AVR is required more often in patients with preoperative aortic regurgitation (AR), those with larger aortic prostheses (24.9 ⫾ 2.8 mm) and patients with preoperative conducting system disease. However, we are not aware of the cause of aortic valve disease in their patients, whether rheumatic or degenerative. We are in disagreement with the authors’ observation that the use of a larger prosthesis size may lead to a higher incidence of PPI. We published a series of 748 patients requiring AVR in 2000 [2]. In 238 (31.8%) of these, large aortic valve prostheses (ⱖ 25 mm) were implanted and 362 (48.6%) of these had severe AR. There were 14 (1.87%) deaths, and none of these patients required PPI. However, the mean age of these patients was only 35.2 ⫾ 2.7 years and there was no evidence of preoperative conduction system abnormalities, which could probably account for no need for PPI. Our recent experience with AVR for predominant aortic
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
1403
stenosis (AS) was recently published [3]. Of the 94 patients undergoing AVR for predominant AS, 2 required PPI. The mean age of these patients was 43.2 ⫾ 13.2 years, and almost all of them had severe calcific aortic stenosis. Valves of size 23 mm or more were implanted in 75 patients (80%). A valve of 25 mm or larger was implanted in 55 patients (54.3%). Even though the need for PPI was not exceptionally high, we believe that operative trauma during valve excision and debridement of the aortic annulus was an important factor that contributed to the development of complete heart block with the need for PPI in these 2 patients. Based on our experience, we believe that AR and implantation of large aortic prostheses may not predispose the patients to increased risk of PPI. However, in patients with AR due to preoperative endocarditis and root abscesses, the integrity of the conduction system may be compromised and these patients may be at an increased risk of conduction system abnormalities requiring PPI. In most other cases, technical factors during AVR probably play a greater role and are responsible for the majority of PPI after AVR. Sachin Talwar, MCh Shiv Kumar Choudhary, MCh Arkalgud Sampath Kumar, MCh Department of Cardiothoracic and Vascular Surgery All India Institute of Medical Sciences New Delhi, 110029 India e-mail: [email protected]
References 1. Dawkins S, Hobson AR, Kalra PR, Tang AT, Monro JL, Dawkins KD. Permanent pacemaker implantation after isolated aortic valve replacement: incidence, indicators and predictors. Ann Thorac Surg 2008;85:108 –12. 2. Choudhary SK, Mathur A, Venugopal P, et al. Prosthesis size in aortic valve replacement: surgeon-related variable. Asian Cardiovasc Thorac Ann 2000;8:333– 8. 3. Joshi K, Talwar S, Velayoudham D, Kumar AS. Aortic valve replacement in predominant aortic stenosis: what is an appropriate size valve? Indian J Thorac Cardiovasc Surg 2007; 23:141–5.
CORRECTION Wellisz T, Armstrong JK, Cambridge J, An YH, Wen X, Hill CM, and Fisher TC. The effects of a soluble polymer and bone wax on sternal healing in an animal model. Ann Thorac Surg 2008;85:1776 –1780. The authors of the above-referenced article regret that the name of Qian Kang, MD, was inadvertently left out of the author line on the final version of the manuscript. Dr Kang’s name should have been listed as the sixth author on the manuscript, after Xuejun Wen and before Christopher Hill, and her name should have been affiliated with the following institution: Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina.
Ann Thorac Surg 2008;86:1403 • 0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2008.08.021
MISCELLANEOUS
placed, only 7 underwent repeat surgery. We do not have the data that Cikirikcioglu and Duran [1] requested on the reoperative findings (ie, “Did they encounter fibrosis, narrowing or any marker related pathologic changes around the proximal anastomoses?”) in these 7 patients. Nor do we have information on the region of infarction for the perioperative MIs. We agree with the authors that such additional data would be valuable in subsequent studies and would further guide the decision process on the use of SVG markers.
CORRESPONDENCE