Long-term Outcomes Associated With Permanent Pacemaker Implantation After Surgical Aortic Valve Replacement

This cohort study investigates the association of long-term adverse clinical outcomes, including mortality, with permanent pacemaker implantation after surgical aortic valve replacement.
Key Points Question Is permanent pacemaker implantation after aortic valve replacement associated with long-term adverse clinical outcomes? Findings In this cohort study of 24 983 patients who underwent surgical aortic valve replacement, increased risks of death and heart failure hospitalization were observed among patients who underwent permanent pacemaker implantation after aortic valve replacement compared with those who did not. Meaning The association of mortality with permanent pacemaker implantation after aortic valve replacement should be considered, especially in an era when transcatheter aortic valve replacement is used among patients who are younger and have lower risks of adverse surgical outcomes.
Importance Prior studies investigating the long-term clinical outcomes of patients who have undergone permanent pacemaker implantation after aortic valve replacement reported conflicting results. Objective To investigate long-term outcomes after primary surgical aortic valve replacement among patients who underwent postoperative permanent pacemaker implantation. Design, Setting, and Participants This cohort study included all patients who underwent surgical aortic valve replacement in Sweden from 1997 to 2018. All patients who underwent primary surgical aortic valve replacement in Sweden and survived the first 30 days after surgical treatment were included. Patients who underwent preoperative permanent pacemaker implantation, concomitant surgical treatment for another valve, or emergency surgical treatment were excluded. Patients who underwent concomitant coronary artery bypass grafting or surgical treatment of the ascending aorta were included. Follow-up data were complete for all patients. Data were analyzed from October through December 2020. Exposures Patients underwent implantation of a permanent pacemaker or implantable cardioverter defibrillator within 30 days after aortic valve replacement. Main Outcomes and Measures The primary outcome was all-cause mortality. Results Among 24 983 patients who underwent surgical aortic valve replacement, 849 patients (3.4%) underwent permanent pacemaker implantation within 30 days after surgical treatment and 24 134 patients (96.6%) did not receive pacemakers in that time. The mean (SD) age of the total study population was 69.7 (10.8) years, and 9209 patients were women (36.9%). The mean (SD) and maximum follow-up periods were 7.3 (5.0) years and 22.0 years, respectively. At 10 years and 20 years after surgical treatment, the Kaplan-Meier estimated survival rates were 52.8% and 18.0% in the pacemaker group, respectively, and 57.5% and 19.6% in the nonpacemaker group, respectively. All-cause mortality was statistically significantly increased in the pacemaker group compared with the nonpacemaker group (hazard ratio [HR], 1.14; 95% CI, 1.01-1.29; P = .03), and so was risk of heart failure hospitalization (HR, 1.58; 95% CI, 1.31-1.89; P