Long-term Mortality and Pacing Outcomes of Patients with Permanent Pacemaker Implantation after Cardiac Surgery

Syed S. Raza, M.D.; Jian-Ming Li, M.D., Ph.D.; Ranjit John, M.D.; Lin Y. Chen, M.D.; Venkatakrishna N. Tholakanahalli, M.D.; Mackenzie Mbai, M.D.; A. Selcuk Adabag, M.D.

Disclosures

Pacing Clin Electrophysiol. 2011;34(3):331-338. 

In This Article

Abstract and Introduction

Abstract

Background: Approximately 20,000 permanent pacemakers (PPMs) are implanted annually for bradycardia or atrioventricular (AV) block after cardiac surgery. Little is known about the long-term pacing and mortality outcomes and the temporal trends of these patients.
Methods: We examined 6,268 consecutive patients who underwent cardiac surgery at the Minneapolis Veterans Administration Medical Center between 1987 and 2010. Patients who had a PPM within 30 days of cardiac surgery were identified. Pacemaker interrogation records were retrospectively reviewed and mortality was ascertained.
Results: Overall, 141 (2.2%) patients underwent PPM implantation for high-degree AV block (55%) and bradycardia (45%), 9 ± 6 days after surgery. Age, diuretic use, cardiopulmonary bypass time (CPBT), and valve surgery were independent predictors of PPM requirement. After 5.6 ± 4.2 years of follow-up, 40% of the patients were PPM dependent. Longer CPBT (P = 0.03), PR interval >200 ms (P = 0.03), and QRS interval > 120 ms (P = 0.04) on baseline electrocardiogram predicted PPM dependency. In univariable analysis, PPM patients had a higher long-term mortality than those without PPM (45% vs 36%; P = 0.02). However, after adjusting for age, sex, type of surgery, and CPBT, PPM requirement was not associated with long-term mortality (hazard ratio 1.3; 95% confidence interval 0.9–1.9; P = 0.17). Compared to before, incidence of PPM implantation increased after the year 2000 (1.9% vs 2.6%; P = 0.04).
Conclusion: The majority of patients who require PPM after cardiac surgery are not PPM dependent in the long term. Requiring a PPM after surgery is not associated with long-term mortality after adjustment for patient-related risk factors and cardiac surgical procedure.

Introduction

About 1% of patients who undergo coronary artery bypass graft (CABG) surgery and 6–8% of patients who undergo heart valve surgery require permanent pacemaker (PPM) implantation postoperatively for bradycardia or atrioventricular (AV) block.[1–6] Considering that about 500,000 CABG and 200,000 valve surgeries are performed annually in the United States,[7] approximately 20,000 PPM are implanted each year in this context. Advanced age, preexisting cardiac conduction system disease, prolonged cardiopulmonary bypass time (CPBT), and valve surgery are known risk factors for requiring PPM after cardiac surgery.[6,8–11] A risk score to identify the patients with a higher likelihood of requiring postoperative PPM has also been developed.[12]

Although the risk factors and indications for postcardiac surgery PPM are well described, critical gaps of knowledge remain. Data on long-term outcomes of PPM recipients after cardiac surgery are limited. Although there is evidence to suggest that AV conduction improves over time in some patients,[4,6,13,14] incidence and predictors of this phenomenon have not been established. Further, long-term survival of patients who received PPM in comparison to those who did not is unknown. Also, to what extent improvements in cardiac valve technology and surgical techniques that took place in the last decade have impacted the incidence of postcardiac surgery PPM requirement is also unknown. Thus, the objectives of this retrospective cohort study of more than 6,000 postcardiac surgery patients are two-fold: first, to determine long-term clinical outcomes, specifically, pacemaker dependency and survival in recipients of PPM; and second, to examine the secular trends in the incidence of postcardiac surgery PPM implantation.

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