National Heart and Lung Institute, Imperial College London, London W12 0HS, UK.
Department of Cardiology, Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, Hill End Road, London UB9 6JH, UK.
Europace. 2023 Aug 2;25(9). doi: 10.1093/europace/euad238.
For bradycardic patients after cardiac surgery, it is unknown how long to wait before implanting a permanent pacemaker (PPM). Current recommendations vary and are based on observational studies. This study aims to examine why this variation may exist.
We conducted first a study of patients in our institution and second a systematic review of studies examining conduction disturbance and pacing after cardiac surgery. Of 5849 operations over a 6-year period, 103 (1.8%) patients required PPM implantation. Only pacing dependence at implant and time from surgery to implant were associated with 30-day pacing dependence. The only predictor of regression of pacing dependence was time from surgery to implant. We then applied the conventional procedure of receiver operating characteristic (ROC) analysis, seeking an optimal time point for decision-making. This suggested the optimal waiting time was 12.5 days for predicting pacing dependence at 30 days for all patients (area under the ROC curve (AUC) 0.620, P = 0.031) and for predicting regression of pacing dependence in patients who were pacing-dependent at implant (AUC 0.769, P < 0.001). However, our systematic review showed that recommended optimal decision-making time points were strongly correlated with the average implant time point of those individual studies (R = 0.96, P < 0.001). We further conducted modelling which revealed that in any such study, the ROC method is strongly biased to indicate a value near to the median time to implant as optimal.
When commonly used automated statistical methods are applied to observational data with the aim of defining the optimal time to pacing after cardiac surgery, the suggested answer is likely to be similar to the average time to pacing in that cohort.
对于心脏手术后出现心动过缓的患者，尚不清楚植入永久性起搏器 (PPM) 前需要等待多长时间。目前的建议存在差异，且基于观察性研究。本研究旨在探讨这种差异存在的原因。
我们首先对本院患者进行了研究，其次对研究心脏手术后传导障碍和起搏的系统综述进行了研究。在 6 年期间的 5849 例手术中，有 103 例（1.8%）患者需要植入 PPM。只有植入时的起搏依赖和从手术到植入的时间与 30 天的起搏依赖相关。起搏依赖消退的唯一预测因素是从手术到植入的时间。然后，我们应用了常规的接收器工作特征 (ROC) 分析程序，寻求决策的最佳时间点。这表明，对于所有患者，预测 30 天起搏依赖的最佳等待时间为 12.5 天（ROC 曲线下面积 (AUC) 为 0.620，P = 0.031），对于预测植入时起搏依赖的患者的起搏依赖消退（AUC 为 0.769，P < 0.001）。然而，我们的系统综述表明，推荐的最佳决策时间点与这些个别研究的平均植入时间点密切相关（R = 0.96，P < 0.001）。我们进一步进行了建模，结果表明，在任何此类研究中，ROC 方法都强烈偏向于将接近植入中位数的时间作为最佳时间。
当应用常用的自动化统计方法旨在定义心脏手术后起搏的最佳时间时，建议的答案很可能与该队列的平均起搏时间相似。
