Permanent pacemaker implantation after cardiac surgery and long-term outcome

Background Patients undergoing cardiac surgery are at risk of perioperative conduction system damage leading to permanent placement of a cardiac electronic implantable device (CIED) which is a common complication following cardiac surgery. Studies evaluating the long-term outcomes following permanent pacemaker implantation in cardiac surgery patients are contradictory and inconsistent. The current study aimed to evaluate the long-term outcome across the spectrum of cardiac surgery in a nationwide contemporary setting. Methods All adult patients in Sweden, without previous CIED who had cardiac surgery between 2006 and 2020 were included. Data was obtained from nationwide registries. Cox proportional hazards models were used to account for comorbid conditions and perioperative characteristics and to evaluate the association between permanent pacemaker or implantable cardioverter defibrillator (ICD) implantation and the risk of all-cause mortality, cardiovascular mortality and heart failure hospitalisation. Results Among 76 223 patients (mean age 67.8 years, 25% female), 2150 (2.8%) received a permanent pacemaker and 348 (0.5%) received an ICD within 30 days after surgery. During a mean follow-up of 6.8 years (SD 10.7), pacemaker implantation was associated with a higher risk of all-cause mortality (adjusted HR (aHR) 1.09, 95% CI 1.01 to 1.19) and heart failure hospitalisation (aHR 1.36, 95% CI 1.22 to 1.52). Cardiovascular mortality showed a similar but statistically non-significant trend. ICD implantation was not associated with all-cause mortality but was associated with increased risks of heart failure hospitalisation and cardiovascular mortality. Subgroup analyses did not show any significant interactions between comorbid conditions and outcomes. Conclusion Permanent pacemaker implantation after cardiac surgery was associated with a higher risk of all-cause mortality and heart failure hospitalisation. These findings were consistent across cardiac surgical subtypes and underscore the need for careful long-term surveillance for these patients.