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Thorac Cardiovasc Surg
DOI: 10.1055/a-2052-8848
Original Cardiovascular

Baseline CT-Based Risk Factors for Atrioventricular Block after Surgical AVR

Marie Claes‡   *
1   Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
,
Francesco Pollari‡   *
1   Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
,
Hazem Mamdooh
1   Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
,
Theodor Fischlein
1   Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
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Abstract

Background We aimed to evaluate the impact of membranous interventricular septum (MIS) length and calcifications of the native aortic valve (AV), via preoperative multidetector computed tomography (MDCT) scan, on postoperative atrioventricular block III (AVB/AVB III) and permanent pacemaker implantation in surgical aortic valve replacement (SAVR).

Methods We retrospectively analyzed preoperative contrast-enhanced MDCT scans and procedural outcomes of patients affected by AV stenosis who underwent SAVR at our center (June 2016–December 2019). The study population was divided into two groups (AVB and non-AVB), and variables were compared with a Mann–Whitney's U-test or chi-square test. Data were further analyzed using point biserial correlation and logistic regression.

Results A total of 155 (38% female) patients (mean age of 71.2 ± 6 years) were enrolled in our study: conventional stented bioprosthesis (N = 99) and sutureless prosthesis (N = 56) were implanted. A postoperative AVB III was observed in 11 patients (7.1%). AVB patients had significant greater calcifications in left coronary cusp (LCC) -AV (non-AVB = 181.0 mm3 [82.7–316.9] vs. AVB = 424.8 mm3 [115.9–563.2], p = 0.044), LCC left ventricular outflow tract (LVOT) (non-AVB = 2.1 mm3 [0–20.1] vs. AVB = 26.0 mm3 [0.1–138.0], p = 0.048), right coronary cusp (RCC) -LVOT (non-AVB = 0 mm3 [0–3.5] vs. AVB = 2.8 mm3 [0–29.0], p = 0.039), and consequently in total LVOT (non-AVB = 2.1 mm3 [0–20.1] vs. AVB = 26.0 mm3 [0.1–138.0], p = 0.02), while their MIS was significantly shorter than in non-AVB patients (non-AVB = 11.3 mm [9.9–13.4] vs. AVB = 9.44 mm [6.98–10.5]; p=0.014)). Partially, these group differences correlated positively (LCC -AV, r = 0.201, p = 0.012; RCC -LVOT, r = 0.283, p ≤ 0.001) or negatively (MIS length, r = −0.202, p = 0.008) with new-onset AVB III.

Conclusion We recommend including an MDCT in preoperative diagnostic testing for all patients undergoing surgical AVR for further risk stratification.

Keywords

aortic valve - preoperative multidetector computed tomography - MDCT scan - surgery - complications

Authors' Contribution

All authors have read and approved the final version of the manuscript. M.C. and F.P. contributed equally to the article. M.C. provided the data analysis and interpretation as well as the drafting of the article. F.P. designed the study and critically revised the article.


Note

A part of the work presented in the current study was achieved in the framework of the following diploma thesis: M. Claes (2022). Hidden pitfalls? Risk of atrioventricular block following surgical aortic valve replacement: A computed tomographic analysis of baseline characteristics. (Unpublished diploma thesis). Paracelsus Medizinische Privatuniversität, Nürnberg.


* Both authors contributed equally to this work and should be considered both as shared first authors.




Publication History

Received: 30 August 2022

Accepted: 09 March 2023

Accepted Manuscript online:
13 March 2023

Article published online:
26 April 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Misumida N, Pagath M, Ogunbayo GO. et al. Characteristics of and current practice patterns of pacing for high-degree atrioventricular block after transcatheter aortic valve implantation in comparison to surgical aortic valve replacement. Catheter Cardiovasc Interv 2019; 93 (07) E385-E390
    CrossrefPubMedGoogle Scholar
  • 2 Mazine A, Teoh K, Bouhout I. et al. Sutureless aortic valve replacement: a Canadian multicentre study. Can J Cardiol 2015; 31 (01) 63-68
    CrossrefPubMedGoogle Scholar
  • 3 Bouhout I, Mazine A, Rivard L. et al. Conduction disorders after sutureless aortic valve replacement. Ann Thorac Surg 2017; 103 (04) 1254-1260
    CrossrefPubMedGoogle Scholar
  • 4 Vogt F, Moscarelli M, Nicoletti A. et al. Sutureless aortic valve and pacemaker rate: from surgical tricks to clinical outcomes. Ann Thorac Surg 2019; 108 (01) 99-105
    CrossrefPubMedGoogle Scholar
  • 5 Wald DS, Bestwick JP. Association between serum calcium, serum phosphate and aortic stenosis with implications for prevention. Eur J Prev Cardiol 2018; 25 (05) 551-556
    CrossrefPubMedGoogle Scholar
  • 6 Xia C, Lei W, Hu Y, Yang H, Zeng X, Chen M. Association of serum levels of calcium phosphate and vitamin D with risk of developing aortic stenosis: the UK Biobank cohort. Eur J Prev Cardiol 2022; 29 (11) 1520-1528
    CrossrefPubMedGoogle Scholar
  • 7 Otto CM, Kuusisto J, Reichenbach DD, Gown AM, O'Brien KD. Characterization of the early lesion of ‘degenerative’ valvular aortic stenosis. Histological and immunohistochemical studies. Circulation 1994; 90 (02) 844-853
    CrossrefPubMedGoogle Scholar
  • 8 Otto CM, Nishimura RA, Bonow RO. et al. 2020 ACC/AHA Guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143 (05) e72-e227
    PubMedGoogle Scholar
  • 9 Fujita B, Schmidt T, Bleiziffer S. et al; GARY Executive Board. Impact of new pacemaker implantation following surgical and transcatheter aortic valve replacement on 1-year outcome. Eur J Cardiothorac Surg 2020; 57 (01) 151-159
    CrossrefPubMedGoogle Scholar
  • 10 Mori S, Tretter JT, Toba T. et al. Relationship between the membranous septum and the virtual basal ring of the aortic root in candidates for transcatheter implantation of the aortic valve. Clin Anat 2018; 31 (04) 525-534
    CrossrefPubMedGoogle Scholar
  • 11 Hamdan A, Guetta V, Klempfner R. et al. Inverse relationship between membranous septal length and the risk of atrioventricular block in patients undergoing transcatheter aortic valve implantation. JACC Cardiovasc Interv 2015; 8 (09) 1218-1228
    CrossrefPubMedGoogle Scholar
  • 12 Hokken TW, van Wiechen MP, Ooms JF. et al. Impact of interventricular membranous septum length on pacemaker need with different transcatheter aortic valve implantation systems. Int J Cardiol 2021; 333: 152-158
    CrossrefPubMedGoogle Scholar
  • 13 Villa E, Clerici A, Messina A. et al. Risk factors for permanent pacemaker after implantation of surgical or percutaneous self-expanding aortic prostheses. J Heart Valve Dis 2016; 25 (06) 663-671
    PubMedGoogle Scholar
  • 14 Roberts WC, Ko JM. Frequency by decades of unicuspid, bicuspid, and tricuspid aortic valves in adults having isolated aortic valve replacement for aortic stenosis, with or without associated aortic regurgitation. Circulation 2005; 111 (07) 920-925
    CrossrefPubMedGoogle Scholar
  • 15 Michelena HI, Suri RM, Katan O. et al. Sex differences and survival in adults with bicuspid aortic valves: verification in 3 contemporary echocardiographic cohorts. J Am Heart Assoc 2016; 5 (10) e004211
    CrossrefPubMedGoogle Scholar
  • 16 Carabello BA, Paulus WJ. et al. Aortic stenosis. Lancet 2009; 373 (9667): 956-966
    CrossrefPubMedGoogle Scholar
  • 17 Morimoto S, Kato S, Hiramitsu S. et al. Role of myocardial interstitial edema in conduction disturbances in acute myocarditis. Heart Vessels 2006; 21 (06) 356-360
    CrossrefPubMedGoogle Scholar
  • 18 Kopp AF, Küttner A, Trabold T, Heuschmid M, Schröder S, Claussen CD. Multislice CT in cardiac and coronary angiography. Br J Radiol 2004; 77 (Spec No 1): S87-S97
    CrossrefPubMedGoogle Scholar
  • 19 Jilaihawi H, Makkar RR, Kashif M. et al. A revised methodology for aortic-valvar complex calcium quantification for transcatheter aortic valve implantation. Eur Heart J Cardiovasc Imaging 2014; 15 (12) 1324-1332
    CrossrefPubMedGoogle Scholar
  • 20 Pollari F, Großmann I, Vogt F. et al. Risk factors for atrioventricular block after transcatheter aortic valve implantation: a single-centre analysis including assessment of aortic calcifications and follow-up. Europace 2019; 21 (05) 787-795
    CrossrefPubMedGoogle Scholar
  • 21 Surawicz B, Childers R, Deal BJ. et al; American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology, American College of Cardiology Foundation, Heart Rhythm Society, Endorsed by the International Society for Computerized Electrocardiology. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. J Am Coll Cardiol 2009; 53 (11) 976-981
    CrossrefPubMedGoogle Scholar
  • 22 Fujita B, Kütting M, Seiffert M. et al. Calcium distribution patterns of the aortic valve as a risk factor for the need of permanent pacemaker implantation after transcatheter aortic valve implantation. Eur Heart J Cardiovasc Imaging 2016; 17 (12) 1385-1393
    CrossrefPubMedGoogle Scholar
  • 23 Mauri V, Reimann A, Stern D. et al. Predictors of permanent pacemaker implantation after transcatheter aortic valve replacement with the SAPIEN 3. JACC Cardiovasc Interv 2016; 9 (21) 2200-2209
    CrossrefPubMedGoogle Scholar
  • 24 Pollari F, Vogt F, Großmann I. et al. Risk of conduction disturbances following different transcatheter aortic valve prostheses: the role of aortic valve calcifications. J Geriatr Cardiol 2022; 19 (03) 167-176
    PubMedGoogle Scholar
  • 25 Maeno Y, Abramowitz Y, Kawamori H. et al. A highly predictive risk model for pacemaker implantation after TAVR. JACC Cardiovasc Imaging 2017; 10 (10 Pt A): 1139-1147
    CrossrefPubMedGoogle Scholar
  • 26 Sharma E, McCauley B, Ghosalkar DS. et al. Aortic valve calcification as a predictor of post-transcatheter aortic valve replacement pacemaker dependence. Cardiol Res 2020; 11 (03) 155-167
    CrossrefPubMedGoogle Scholar
  • 27 Dweck MR, Boon NA, Newby DE. Calcific aortic stenosis: a disease of the valve and the myocardium. J Am Coll Cardiol 2012; 60 (19) 1854-1863
    CrossrefPubMedGoogle Scholar
  • 28 Pollari F, Berretta P, Albertini A. et al. Pacemaker after sutureless and rapid-deployment prostheses: a progress report from the SURD-IR. Thorac Cardiovasc Surg 2022 Oct 18. Doi: 10.1055/s-0042-1757778. Epub ahead of print
    PubMedGoogle Scholar
  • 29 Yanagisawa H, Tabata M. Modified annular suturing technique for minimizing postoperative pacemaker use after surgical aortic valve replacement. Gen Thorac Cardiovasc Surg 2021; 69 (02) 254-259
    CrossrefPubMedGoogle Scholar
  • 30 Ben-Dor I, Pichard AD, Gonzalez MA. et al. Correlates and causes of death in patients with severe symptomatic aortic stenosis who are not eligible to participate in a clinical trial of transcatheter aortic valve implantation. Circulation 2010; 122 (11, Suppl): S37-S42
    CrossrefPubMedGoogle Scholar