Sutureless aortic valve and pacemaker rate: from surgical tricks to clinical outcomes

BACKGROUND: Several studies reported high rates of postoperative permanent pacemaker (PPM) implantation, which has been described as the "Achilles' heel" of sutureless aortic valve replacement (AVR). METHODS: From July 2010 to December 2017, 3158 patients with symptomatic, severe aortic valve stenosis were referred to our cardiac surgery center and 512 received a Perceval sutureless bioprosthesis. Thirty-nine patients who had been discharged with concomitant PPM implantation were re-evaluated. RESULTS: After a cumulative follow-up of 1534 months (100% complete, median 50, IQR 30, max 76, min 3 months), a total of 22 patients were still pacemaker-dependent. Kaplan-Meier analysis showed pacemaker-dependent rhythm in 92.0%, 80.0%, 49.4%, and 32.3% of patients at 1, 2, 4, and 5 years, respectively. At Cox regression analysis, pressure during valve deployment [hazard ratio (HR) 79.41; p=0.0003] and "late-onset" atrioventricular block were found to be independent predictors of sinus rhythm restoration (HR 0.16; p=0.0061). Log-rank test showed significantly lower pacemaker dependency rates in patients with "low-pressure" prosthesis implantation (p<0.0001). CONCLUSIONS: Our study shows that several technical measures, including appropriate annulus decalcification, precise positioning of guiding sutures, release of traction sutures applied to the valve commissures and ballooning with reduced pressure, all reduce the rate of PPM implantation after sutureless AVR. Furthermore, a high proportion of patients were found to be no longer pacemaker-dependent at follow-up.