Permanent pacemaker implantation after mitral valve surgery: Exploring the impact on long-term survival
Permanent pacemaker implantation (PPMI) after mitral valve surgery is not associated with an elevated risk of long-term mortality, according to new findings published in The Annals of Thoracic Surgery.[1]
“The long-term consequences of PPMI for postoperative conduction abnormalities following cardiac surgery remains a topic of ongoing research,” wrote first author Jessica K. Millar, MD, a researcher with the department of surgery at the University of Michigan, and colleagues. “While previously viewed as an inconsequential complication, recent studies have suggested that PPMI is associated with worse morbidity, increased resource utilization, and reduced long-term survival. The degree to which PPMI, itself, is responsible for these outcomes has been debated, as patients requiring PPMI often have elevated baseline operative risk. Recent investigations on this subject have largely focused on PPMI following aortic valve surgery with limited data on cohorts undergoing mitral valve surgery.”
Exploring the data to learn more
To learn more, Millar et al. tracked data from more than 4,500 mitral valve surgery patients treated at a single facility from 2000 to 2022. All patients underwent either mitral valve repair or mitral valve replacement. Concomitant procedures included coronary artery bypass grafting (CABG), ablation, tricuspid valve surgery, and pulmonic valve surgery. Patients were excluded from this study if they had already received a pacemaker, underwent a concomitant aortic valve surgery or presented with a history of prior heart transplant.
Overall, 5.2% of patients required PPMI following mitral valve replacement or repair. Patients requiring PPMI were significantly older and had a significantly higher Society of Thoracic Surgeons risk score than patients who did not. PPMI rates were comparable for men and women and for all races/ethnicities, with one exception: it was much more common in Asian patients.
Patients requiring PPMI were significantly more likely to present with a history of diabetes, hypertension, heart failure or a prior cerebrovascular accident. In addition, these patients had higher rates of mitral stenosis, but comparable rates of mitral insufficiency.
Millar and colleagues also noted that permanent pacemakers were less likely when patients underwent an isolated mitral valve surgery. Patients who required PPMI were also associated with much longer cross-clamp times. However, whether or not a sternotomy was required did not appear to make an impact on the overall PPMI risk.
Short- and long-term data on PPMI after mitral valve surgery
30-day readmission and stroke rates were similar for patients who did and did not require PPMI following treatment. On the other hand, patients who required PPMI were associated with spending much more time in the ICU on average (128 hours vs. 52 hours) as well as longer hospital stays (12 days vs. 5 days).
The median follow-up time was 2.7 years for PPMI patients and 2.5 years for all other patients. After performing a series of analyses to account for patient factors such as age and concomitant procedures, the authors determined that PPMI after mitral valve surgery was not independently associated with a heightened risk of long-term mortality.
Patients who went on to require PPMI, however, were consistently associated with worse health and more complex cases.
“These findings demonstrate the importance of identifying patients at greatest risk for postoperative PPMI to facilitate perioperative planning and improve resource utilization,” the authors wrote.
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Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.