Perspective:

Postoperative heart block is not uncommon following valve surgery, and it leads to permanent pacemaker implantation. Preoperative right bundle branch and multivalve surgery, especially one that includes the tricuspid valve, may be some of the strongest predictors of needing a device postoperatively. The prevailing standard is to place an epicardial lead in patients with the highest risk of needing the pacemaker postoperatively or implant a transvenous pacemaker at a separate time after surgery.

The current study challenges this paradigm by implanting a leadless device (Medtronic’s Micra VR or Micra AV) intraoperatively, under direct visualization, in patients who will either definitely or very likely need bradycardia therapy after their cardiac surgery. This strategy could reduce complications compared with patients undergoing valve surgery who require an intraoperative epicardial pacemaker lead, a traditional transvenous pacemaker, or transfemoral LCP. This approach may also reduce duration of intensive care unit stay and hospitalization. One must weigh these potential benefits against the possibility that some or many patients who receive a prophylactic pacemaker may rarely use it or may not need it at all. Further studies are needed to evaluate the cost and effectiveness of this treatment approach. This strategy could be aided by future, more predictive risk stratification tools for postoperative need for pacing in the modern era.