Pacemaker implantation after concomitant tricuspid valve repair in patients undergoing minimally invasive mitral valve surgery: Results from the Mini-Mitral International Registry

Gloria Faerber; Paolo Berretta; Tom C Nguyen; Manuel Wilbring; Joseph Lamelas; Pierluigi Stefano; Jörg Kempfert; Mauro Rinaldi; Davide Pacini; Antonios Pitsis; Marc Gerdisch; Nguyen Hoang Dinh; Frank Van Praet; Loris Salvador; Tristan Yan; Nikolaos Bonaros; Antonio Fiore; Torsten Doenst; Marco Di Eusanio

doi:10.1016/j.xjon.2023.10.036

Pacemaker implantation after concomitant tricuspid valve repair in patients undergoing minimally invasive mitral valve surgery: Results from the Mini-Mitral International Registry

JTCVS Open. 2023 Nov 19:17:64-71. doi: 10.1016/j.xjon.2023.10.036. eCollection 2024 Feb.

Authors

Gloria Faerber¹, Paolo Berretta², Tom C Nguyen³, Manuel Wilbring⁴, Joseph Lamelas⁵, Pierluigi Stefano⁶, Jörg Kempfert⁷, Mauro Rinaldi⁸, Davide Pacini⁹, Antonios Pitsis¹⁰, Marc Gerdisch¹¹, Nguyen Hoang Dinh¹², Frank Van Praet¹³, Loris Salvador¹⁴, Tristan Yan¹⁵, Nikolaos Bonaros¹⁶, Antonio Fiore¹⁷, Torsten Doenst¹, Marco Di Eusanio²

Affiliations

¹ Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany.
² Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy.
³ Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Tex.
⁴ Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Dresden, Germany.
⁵ Division of Cardiothoracic Surgery, University of Miami, Miami, Fla.
⁶ Cardiac Surgery Unit, Careggi University Hospital, Firenze, Italy.
⁷ Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.
⁸ Cardiac Surgery Unit, University of Turin, Turin, Italy.
⁹ Cardiac Surgery Department, Sant'Orsola Malpighi Hospital, University of Bologna, Italy.
¹⁰ Cardiac Surgery Department, European Interbalkan Medical Center, Thessaloniki, Greece.
¹¹ Franciscan Health Indianapolis, Indianapolis, Ind.
¹² University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam.
¹³ Cardiac Surgery Department, Hartcentrum OLV Aalst, Aalst, Belgium.
¹⁴ Division of Cardiac Surgery, S. Bortolo Hospital, Vicenza, Italy.
¹⁵ Department of Cardiothoracic Surgery, The Royal Prince Alfred Hospital, Sydney, Australia.
¹⁶ Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria.
¹⁷ Henri Mondor Hospital, University of Paris, Paris, France.

Abstract

Objective: Randomized evidence suggests a high risk of pacemaker implantation for patients undergoing mitral valve (MV) surgery with concomitant tricuspid valve repair (cTVR). We investigated the impact of cTVR on outcomes in the Mini-Mitral International Registry.

Methods: From 2015 to 2021, 7513 patients underwent minimally invasive MV with or without cTVR in 17 international centers (MV: n = 5609, cTVR: n = 1113). Propensity matching generated 1110 well-balanced pairs. Multivariable analysis was applied.

Results: Patients with cTVR were older and had more comorbidities. Propensity matching eliminated most differences except for more TR in patients who underwent cTVR (77.2% vs 22.1% MV, P < .001). Mean matched age was 71 years, and 45% were male. European System for Cardiac Operative Risk Evaluation II was still 2.68% (interquartile range [IQR], 0.80-2.63) vs 1.9% (IQR, 1.12-3.9) in matched MV (P < .001). MV replacement (30%) and atrial fibrillation surgery (32%) were similar in both groups. Cardiopulmonary bypass (161 minutes [IQR, 133-203] vs MV: 130 minutes [IQR, 103-166]; P < .001) and crossclamp times (93 minutes [IQR, 66-123] vs MV: 83 minutes [IQR, 64-107]; P < .001) were longer with cTVR. Although in-hospital mortality was similar (cTVR: 3.3% vs MV: 2.2%; P = .5), postoperative pacemaker implantations (9% vs MV: 5.8%; P = .02), low cardiac output syndrome (7.7% vs MV: 4.4%; P = .02), and acute kidney injury (13.8% vs MV: 10%; P = .01) were more frequent with cTVR. cTVR eliminated relevant TR in most patients (greater-than-moderate TR: 6.8%). Multivariable analysis identified MV replacement, atrial fibrillation, and cTVR as risk factors of postoperative pacemaker implantation.

Conclusions: cTVR in minimally invasive MV surgery is an independent risk factor for pacemaker implantation in this international registry. It is also associated with more bleeding, low output syndrome, and acute kidney injury. It remains unclear whether technical or patient factors (or both) explain these differences.

Keywords: minimally-invasive valve surgery; mitral valve surgery; pacemaker implantation; tricuspid repair.