Abstract
Permanent pacemaker implantation (PPI) represents a rare complication after cardiac surgery, with no uniform agreement on timing and no information on follow-up. A multicenter retrospective study was designed to assess pacemaker dependency (PMD) and long-term mortality after cardiac surgery procedures. Between 2004 and 2016, PPI-patients from 18 centers were followed. Time-to-event data were evaluated with semiparametric regression Cox models and semiparametric Fine and Gray model for competing risk framework. Of 859 (0.90%) PPI-patients, 30% were pacemaker independent (PMI) at 6 months. PMD showed higher mortality compared with PMI (10-year survival 80.1% ± 2.6% and 92.2% +2.4%, respectively, log-rank p-value < 0.001) with an unadjusted hazard ratio for death of 0.36 (95% CI 0.20 to 0.65, p< 0.001 favoring PMI) and an adjusted hazard ratio of 0.19 (95% CI 0.08 to 0.45, p< 0.001 with PMD as reference). Crude cumulative incidence function of restored PMI rhythm at follow-up at 6 months, 1 year and 12 years were 30.5% (95% CI 27.3% to 33.7%), 33.7% (95% CI 30.4% to 36.9%) and 37.2% (95% CI 33.8% to 40.6%) respectively. PMI was favored by preoperative sinus rhythm with normal conduction (SR) (HR 2.37, 95% CI 1.65 to 3.40, p< 0.001), whereas coronary artery bypass grafting and aortic valve replacement were independently associated with PMD (HR 0.63, 95% CI 0.45 to 0.88, p = 0.006 and HR 0.807, 95% CI 0.65 to 0.99, p = 0.047 respectively). Time-to-implantation was not associated with increased rate of PMI. Although 30% of PPI-patients are PMI after 6 months, PMD is associated with higher mortality at long term.
Highlights
Permanent pacemaker implantation (PPI) represents a rare complication after cardiac surgery, with no uniform agreement on timing and no information on follow-up
The unadjusted hazard ratio for overall mortality was 0.39, in favor of pacemaker independent (PMI)
The adjusted hazard ratio was 0.22 with pacemaker dependency (PMD) as reference group, thereby confirming association of PMD with increased long-term mortality (Table 2)
Summary
Permanent pacemaker implantation (PPI) represents a rare complication after cardiac surgery, with no uniform agreement on timing and no information on follow-up. Brady-arrhythmia’s requiring pacemaker implant include sick sinus syndrome, atrial fibrillation with slow ventricular response, and several degrees of A/V block.[3] pacemaker dependency decays with time, depending on the type of indication, new or recurrent conduction disturbances may develop at variable time points after hospital discharge.[2,4,5] data addressing this topic are heterogeneous, dependent on local protocols, and, poorly informative.[3] Current guidelines consider advanced second or third degree A/V block lasting at least 7 days after cardiac surgery as a class I indication for PPI, but the evidence is based on relatively small studies ranging between 150 and 250 patients, with short-term follow up.[6,7] the impact of a PPI after cardiac surgery on survival is not known Based on these premises we developed a multicenter working group to thoroughly investigate the actual incidence of PPI after cardiac surgery procedures in a large population. The purposes of this study were to evaluate the pacemaker dependency after PPI, to describe the influence of pre-operative sinus rhythm with normal conduction (SR) on pacemaker dependency and to assess the long-term mortality after PPI
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