Post-operative epicardial pacing and hemodynamic support among Aortic Valve Patients

Abstract

Background: Burdens of cardiac and extra-cardiac co-morbidity, coupled with complex surgical and anesthesia interventions, require intense intra- and post-operative monitoring and care to optimize outcomes. Despite a need for clinical guidance, a paucity of studies explores post-operative temporary epicardial pacing, vasopressor and inotropic medication use among aortic valve replacement (AVR) patients. Purpose: To better target post-operative interventions for AVR patients, associations between pre and intra-operative risk factors (e.g., chronic conditions, QRS duration and medication use), cardiovascular interventions (pacing and hemodynamic support), and post-operative outcomes (morbidity and resource utilization) were explored. Methods: Medical records of 195 patients having an AVR from 11/2007 to 10/2011 were reviewed from a single academic medical center. Cross-sectional analyses used multivariable analyses to identify factors associated with temporary epicardial pacing, acute kidney injury, and length of stay. Results: Patients were equally represented in gender, nearly all (88%) Caucasian, with a mean age of 67.7 years (SD=12.9). More than a third of patients (36%) were paced at time of bypass separation; 13% of the total continued to be paced after 7 a.m. of post-operative day-1. Females were more likely to be paced in the CSICU (OR = 3.08, 1.30-7.31), while pre-operative co-morbidities, ejection fraction, QRS duration, stain or ACE/ARB uses and CPB time did not have an independent effect. Post-operative pacing and level of hemodynamic support were not associated with day-2 renal function. Prolonged CSICU stays were associated with female gender, age>75 years, and if both epicardial and hemodynamic supports were used as compared to no cardiovascular support. Prolonged hospital stays were associated with prolonged CSICU stay > 4 days and age>75 years. Conclusions: Post-operative management of AVR patients has considerable variability. While it would be useful to pre-operatively identify patients requiring extended post-operative pacing and hemodynamic support, no co-morbidities were associated. Additional studies are needed to better risk stratify AVR patients so interventions can be targeted so the care team can better plan care and monitor progress.