Mitigating conduction disturbances in sutureless aortic valve surgery: A standardized anti-oversizing strategy in a large single-center program.

OBJECTIVES

The study objectives were to characterize conduction outcomes and perioperative results in a large, consecutive, single-center program of sutureless self-expanding aortic bioprosthesis implantation and to assess the temporal impact of a standardized, nonoversizing, higher-release implant strategy on permanent pacemaker implantation.

METHODS

We conducted a retrospective cohort study including all sutureless aortic valve procedures performed between October 2013 and March 2025 (n = 1742). Outcomes assessed were permanent pacemaker implantation for complete atrioventricular block, stroke, reexploration for bleeding, renal replacement therapy, infection, and in-hospital mortality. Prespecified subgroup analyses were performed for isolated aortic valve surgery and by surgical approach (full sternotomy vs ministernotomy). Temporal trends were examined across the program's learning curve, with 2017 marking the adoption of a standardized conservative depth, no oversizing implantation strategy. Body size index-prosthesis size interactions were explored using heat-map analyses.

RESULTS

Overall permanent pacemaker implantation occurred in 96 of 1742 patients (5.5%). Rates of stroke, reexploration for bleeding, renal replacement therapy, and in-hospital mortality were 1.7%, 4.7%, 1.8%, and 3.4%, respectively. In isolated surgery (n = 1281), ministernotomy was associated with lower stroke (0.95% vs 3.30%; P = .003), lower renal replacement therapy (0.63% vs 3.00%; P = .001), and lower in-hospital mortality (1.69% vs 6.31%; P < .001) compared with full sternotomy, and permanent pacemaker implantation rates were similar (5.27% vs 5.11%; P = .908). Cumulative permanent pacemaker implantation incidence decreased from early values of approximately 12 to 14% to 5 to 6% after 2017, paralleling adoption of the standardized implantation strategy. Heat-map analyses demonstrated pre-2017 oversizing "hot spots" that largely resolved after standardization.

CONCLUSIONS

In a large real-world sutureless aortic valve program, standardization of sizing and implant depth was associated with sustained reduction in permanent pacemaker implantation without compromising clinical outcomes. Avoidance of oversizing appears central to optimizing conduction results.