Relation of Prolonged Pacemaker Dependency After Cardiac Surgery to Mortality

Abstract

on behalf of the GIROC Investigators 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 longterm 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.

The prevalence of permanent pacemaker implantation after open-heart surgeries; eight years of experience in Tehran heart center

“…Conduction defects are common complications following open-heart surgeries, approximately appearing in 10–15% of patients undergoing open-heart surgeries [ 1 – 3 ]. The lowest incidence of such a complication is seen after CABG, while valvular surgery provides the highest prevalence of permanent pacemaker implantation (PPI) [ 1 , 2 ].…”

Commentary: If you start me up…I may never stop?

“…Furthermore, pacemaker dependency after device implantation may also play an important role in distant survival. 6 The work by Bianco and colleagues 7 from the University of Pittsburgh presented in the current issue of the Journal adds valuable data to this controversy and suggests that when adjusted for patient characteristics, PPM implantation after isolated valve or valve and coronary surgery does not affect distal survival. Although the authors present a large clinical cohort, the results and conclusions of the study need to be evaluated through a prism of several methodologic limitations.…”

Commentary: Take your time!

“…This policy might reduce health costs, patient discomfort, and most of all improve survival, as pacemaker implantation has been considered a potential risk factor for poor survival at follow-up. 4 Second, balloon-expandable valves should be considered over self-expandable valves in those patients with such risk factors as right BBB, small annuli, and calcified aortic valves.…”

“…3 A multicenter retrospective analysis of 859 patients requiring PPI after cardiac surgery found that found that 30% were pacemaker-independent at 6 months. 4 Interestingly, pacemaker dependency was associated with an increased risk of long-term mortality. This information raises some doubts regarding the correct timing for PPI.…”

“…This policy might reduce health costs, patient discomfort, and most of all improve survival, as pacemaker implantation has been considered a potential risk factor for poor survival at follow-up. 4 …”