Long-term requirement for pacemaker implantation after cardiac valve replacement surgery

Background: The risk of permanent pacemaker implantation (PPI) after cardiac valve replacement surgery is thought to be highest in the postoperative period. Long-term risks are uncertain. Objective: The purpose of this study was to determine rates and timing of PPI after cardiac valve replacement surgery. Methods: We compared PPI rates of patients undergoing aortic valve replacement (AVR; n = 111,674), mitral valve replacement (MVR; n = 18,402), AVR + MVR (n = 5166), AVR + MVR + tricuspid valve replacement (TVR; n = 114), or coronary artery bypass surgery (CABG) without valve replacement (n = 249,742). Results: Over a period of 14 years (median 3.9 years; interquartile range 1.1-7.4 years), cumulative PPI rates were 3.07-7.6 times higher (P < .001 for all) than after CABG, depending on the number of valves replaced. PPI risks after AVR were higher that those after MVR (hazard ratio [HR] 1.22; 95% confidence interval [CI] 1.16-1.28), AVR + MVR (HR 1.52; 95% CI 1.40-1.65), and AVR + MVR + TVR (HR 2.22; 95% CI 1.40-3.53), independent of known confounders. Cumulative PPI hazard rates from the postoperative period to 10 years after surgery increased after AVR (4.22%-14.4%), MVR (4.38%-15.6%), AVR + MVR (5.59%-18.3%), and AVR + MVR + TVR (7.89%-25.9%) (P < .001 for all). Age, male sex, emergency admission, and preexisting diabetes mellitus, renal impairment, and heart failure were independent predictors of PPI (P < .001 for all). Conclusion: Valve replacement surgery was associated with a long-term risk of PPI. This was particularly high after dual and triple valve replacements. Age, male sex, emergency admission, and preexisting diabetes mellitus, heart failure, and renal impairment were independent predictors of PPI.