Atrial Functional Mitral Regurgitation Is a Risk Factor for Permanent Pacemaker Implantation

<b>Background and Objectives:</b> This study aimed to investigate risk factors for permanent pacemaker (PPM) implantation following the Maze procedure in patients with atrial functional mitral regurgitation (AFMR). <b>Methods:</b> A retrospective cohort of 423 patients who underwent the Maze procedure for persistent or paroxysmal atrial fibrillation from 2010 to 2025 was analyzed. Patients were categorized on the basis of the need for PPM postoperatively. Risk factors and rhythm outcomes were compared using multivariable Cox and logistic regression with backward stepwise selection according to the Akaike Information Criterion. <b>Results:</b> Forty-five patients (10.6%) required PPM implantation following the Maze procedure. The PPM group demonstrated a significantly higher AFMR prevalence than the non-PPM group (28.9% vs. 10.4%, <i>p</i> = 0.001). Preoperative fine P waves and older age were additional significant predictors. The PPM group exhibited lower postoperative sinus rhythm rates and higher junctional rhythm rates. AFMR (hazard ratio [HR], 2.10; <i>p</i> = 0.030), fine P wave (HR, 2.03; <i>p</i> = 0.049), and age (HR, 1.04; <i>p</i> = 0.018) independently predicted PPM implantation. AFMR particularly elevated the late PPM implantation risk. <b>Conclusions:</b> AFMR is an independent risk factor for late nodal dysfunction requiring PPM following Maze procedures. To detect delayed pacemaker requirements postoperatively, extended monitoring is recommended for patients with AFMR.