Long-Term Pacemaker Dependency after Permanent Pacemaker Implantation Secondary to Heart Valve Surgery

Objectives: Conduction disturbances with need for pacemaker (PM) implantation are common after valve surgery. However, they may resolve and patients may regain their own rhythm without need for permanent pacing. Little evidence is available on the actual rate of long-term PM dependency and its predictors.

Methods: We analyzed 142 patients undergoing PM implantation after valve surgery/intervention between 2011 and 2016. Follow-up was longitudinal. At the time of analysis, 33.1% (n = 47) had died and 33.1% (n = 47) were lost to follow-up. PM interrogation was performed in 37.3% (n = 53) at a median of 52 months (8–87 m). The primary endpoint was PM dependency at follow-up. A multivariate logistic regression analysis was performed to identify predictors of long-term PM dependency.

Results: Mean age was 70.3 years (SD: 10.7), 37.7% were female (n = 20), and logistic Euroscore I was 8.9% (SD: 15.1%). Types of procedures performed were: conventional aortic valve replacement (AVR) 47.2% (n = 25), transcatheter aortic valve implantation (TAVI) 20.8% (n = 11), mitral valve replacement (MVR) 15.1% (n = 8) and repair 18.9% (n = 10), and tricuspid valve replacement (TVR) 1.9% (n = 1) and repair 15.1% (n = 8). Valve surgery was combined in 5.7% (n = 3), additional coronary artery bypass grafting (CABG) was performed in 28.3% (n = 15), and ablation was performed in 26.4% (n = 14). Time to PM implantation after surgery was 6.2 days (SD 3.9). Indications were: sick-sinus syndrome (7.5%, n = 4), bradyarrhythmia (13.2%, n = 7), asystole without escape rhythm (3.8%, n = 2), intermittent atrioventricular block (AVB; 5.7%, n = 3), second-degree AVB (7.5%, n = 4), and total AVB (67.9%, n = 36). At follow-up, 47.2% of patients (n = 25) were not PM dependent. There was no difference in time interval from surgery to PM implantation between PM-dependent (6.2 days; SD: 4.6 days) and -independent (6.1 days; SD: 3.1 days) patients (p = 0.42). Between TAVI and AVR, there was no difference in long-term PM dependency (TAVI: 63.6%, n = 7; AVR: 64.0%, n = 16; p = 1.00). Independent predictors of PM dependency were AVR (OR: 3.8, p = 0.043) and PM implantation for total AVB (OR: 4.6, p = 0.03). In the initial cohort of 142 patients, lead endocarditis occurred in 3.8% (n = 2) and lead perforation in 1.9% (n = 1).

Conclusion: Nearly half of patients followed up after valve surgery were no longer PM dependent. The timing of PM implantation was not associated with long-term PM dependency. Total AVB and conventional AVR were associated with long-term PM dependency.