Pacemaker implantation after cardiac surgery: a contemporary, nationwide perspective

Abstract

ABSTRACTBackgroundCardiac surgery entails an increased risk for brady-arrhythmias. Currently known rates for permanent pacemaker (PPM) implantation after cardiac surgery are derived from non-contemporary studies. This study aimed to explore the incidence and indications for PPM implantation at 30 days and one year after different cardiac surgical procedures in a modern cohort.MethodsAll first-time coronary artery bypass grafting (CABG) and/or valvular surgery patients in Sweden 2006 - 2020 without previous PPM or implantable cardioverter-defibrillator (ICD) (n= 76,447) were included in this nationwide population-based study using data from four national registries. Patients undergoing heart transplantation and those who subsequently received an ICD were excluded.ResultsA PPM was implanted in 8.2% (n= 6,271) of the patients, 35% (n= 2,196) within the first 30 days and 46.3% (n= 2,647) at one year following surgery. The main indication of PPM implantation was atrioventricular block. Tricuspid valve surgery exhibited the highest cumulative incidence for PPM both at 30 days (6.8% (95% confidence interval 4.3 – 10.0)) and one year (8.8% (95% CI 6.0 – 12.0)) surpassing mitral valve surgery (30-day 5.3% (95% CI 4.7-6.0); one-year 6.5% (95% CI 5.8-7.3)), aortic valve surgery (30-day 4.8% (95% CI 4.5-5.1); one-year 6.0% (95% CI 5.6-6.3)) and CABG (30-day 0.74% (95% CI 0.66-0.83); one-year 1.3% (95% CI 1.2-1.35)). The incidence following combined operations (multiple valves and/or coronary surgery) was 6.5% (95% CI 6.0 – 6.9) and 8.1% (95% CI 7.7 – 8.6) at 30 days and one year respectively. Concomitant ablation surgery increased the risk even further (adjusted Hazard Ratio 9.20 (95% CI 7.96-10.64), p<0.001).ConclusionsThe need for PPM after cardiac surgery is common, primarily due to atrioventricular block. Tricuspid valve surgery is associated with the highest risk for PPM implantation amongst isolated procedures. Combined procedures and concomitant surgical ablation further increase that risk.CLINICAL PERSPECTIVEWhat is new?Permanent pacemaker after cardiac surgery is not uncommon with atrioventricular blocking being the main indication.Tricuspid valve surgery had the highest cumulative incidence at 30 days and one year, exceeding other isolated procedures.Combined cardiac surgical procedures and concomitant ablation surgery increased the risk even further.What are the clinical implications?This information is valuable while informing individual patients awaiting cardiac surgery about potential post-operative complications.Recognizing patients at higher risk enables targeted postoperative care, including closer monitoring for signs of conduction disturbances.Studies investigating and identifying predictors of post-cardiac surgery bradyarrhythmias and subsequent need for permanent pacemakers are needed.