Postoperative PPM Implantation Does Not Affect Long-Term Survival in Patients With AF

Investigators examined prevalence and long-term survival in patients with permanent pacemaker implantation who had preoperative atrial fibrillation before valve surgery.

Permanent pacemaker (PPM) implantation occurs relatively frequently in patients with atrial fibrillation (AF), and surgical ablation may improve long-term survival, according to a study in Heart Rhythm.

Investigators sought to assess the incidence of PPM implantation after valve surgery, with or without concomitant procedures, and its effect on long-term survival in patients with pre-operative AF and in those undergoing concomitant surgical ablation.

Data were obtained from the HEart surgery In atrial fibrillation and Supraventricular Tachycardia (HEIST) study of patients with AF who had surgery between January 1, 2011, and December 31, 2020. The surgery was conducted at 8 tertiary centers in Poland, the Netherlands, and Italy.

Overall 11,949 patients (median age, 68 years; 55.3% men) with preoperative AF who had a valvular procedure or surgical ablation were identified, of whom 295 (2.5%) had postoperative implantation of a PPM.

The rates of postoperative PPM implantation were significantly different among the types of procedures (P <.001). Isolated mitral valve repair was associated with the lowest rate of PPM implantation (1.1%). Multivalvular procedures with mitral valve replacement and coronary artery bypass grafting (3.2%) or tricuspid valve surgery (3.3%) were associated with higher rates of PPM implantation.

Only cardiopulmonary bypass time (P =.024), endocarditis (P =.014), and concomitant tricuspid intervention (P <.001) were statistically significant for predicting postoperative PPM implantation in the multivariate analysis. Concomitant ablation was not a risk factor for PPM implantation (P =.228).

After a median follow-up of 4.1 years, PPM implantation was not associated with reduced survival (hazard ratio [HR] 0.96; 95% CI, 0.77-1.19; P =.679), compared with no PPM.

In sensitivity analysis involving only hospital survivors, the results were comparable regarding PPM implantation, with an HR of 1.13 (0.90-1.43; P =.679), and its association with surgical ablation for long-term survival (log rank P <.001).

The investigators noted that the database only included data of patients with AF, and so comparison with non-AF patients was not possible. Also, no single protocol for postoperative PPM implantation exists, as each center had different indications and strategies for managing patients with postoperative arrhythmias. In addition, the registry does not collect data on surgical ablation type, and the number of PPMs may be underestimated.

“In patients with pre-operative atrial fibrillation, the need for PPM implantation after valve surgery or surgical ablation is not an infrequent outcome, with surgical ablation not affecting its prevalence but actually improving long-term survival,” the study authors wrote.


Kowalewski M, Pasierski M, Finke J, et al. Permanent pacemaker implantation after valve and arrhythmia surgery in patients with pre-operative atrial fibrillation. Heart Rhythm. Published online April 13, 2022. doi: 10.1016/j.hrthm.2022.04.007