Epicardial Pacing in Cardiac Arrest Post Open Heart Surgery

Indications and Rationale

Temporary epicardial pacing wires should be routinely placed during all open heart surgeries to manage potential postoperative arrhythmias that could lead to cardiac arrest, as recommended by the American Heart Association and the American College of Cardiology 1, 2
Arrhythmias are extremely common after cardiac surgery, with ventricular arrhythmias occurring frequently in the immediate postoperative period due to hypothermia, ischemia, and electrolyte abnormalities, affecting a significant portion of the patient population 1, 3
The risk of heart block requiring temporary or permanent pacing is highest in the immediate postoperative period, with permanent pacemaker implantation required in approximately 1.5% of all cardiac surgery cases, according to the American College of Cardiology 1

Patients undergoing mitral valve surgery have a 1-9% risk of requiring permanent pacing, and tricuspid valve surgery carries an even higher risk of postoperative conduction disorders, making epicardial pacing particularly important, as stated by the American College of Cardiology 2
Aortic valve procedures frequently affect the His bundle, potentially requiring temporary or permanent pacing, as noted in the Circulation journal 1
Patients undergoing surgery for atrial fibrillation should have routine placement of temporary epicardial pacing wires, and up to 11% of patients undergoing a Cox Maze IV procedure with mitral valve surgery require postoperative permanent pacemaker implantation, according to the American College of Cardiology 4

For patients with new postoperative sinus node dysfunction or atrioventricular block associated with symptoms or hemodynamic instability that does not resolve after surgery, permanent pacing is recommended before discharge, as recommended by the American College of Cardiology 2, 4
The timing of permanent pacemaker implantation has not been formally studied but 5-7 days post-surgery is generally considered reasonable, according to the American College of Cardiology 4

Other risk factors for requiring pacing include preoperative conduction abnormalities, multivalve surgery, prior valve surgery, age >70 years, and reoperations, as identified by the American College of Cardiology and the Circulation journal 1, 2