Permanent Pacemaker Implantation and Long-Term Outcomes of Patients Undergoing Concomitant Mitral and Tricuspid Valve Surgery

Alexander Iribarne, Department of Cardiothoracic Surgery, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA.
Sundos H. Alabbadi, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Alan J. Moskowitz, Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Gorav Ailawadi, Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan Health System, Ann Arbor, Michigan, USA.
Vinay Badhwar, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia, USA.
Marc Gillinov, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA.
Vinod H. Thourani, Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA.
Keith B. Allen, Department of Cardiothoracic and Vascular Surgery, St Luke's Hospital, St Luke's Mid America Heart Institute, Kansas City, Missouri, USA.
Michael E. Halkos, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
Nirav C. Patel, Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, New York, USA.
Robert S. Kramer, Division of Cardiovascular Surgery, Maine Medical Center, Portland, Maine, USA.
David D'Alessandro, Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.
Samantha Raymond, Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Helena L. Chang, Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Lopa Gupta, Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Kathleen N. Fenton, Division of Cardiovascular Sciences, National Heart. Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
Wendy C. Taddei-Peters, Division of Cardiovascular Sciences, National Heart. Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
Michael W. Chu, Division of Cardiac Surgery, Western University, London Health Sciences Centre, London, Ontario, Canada.
Volkmar Falk, Department of Cardiothoracic and Vascular Surgery, Deutsche Herzzentrum Berlin, Berlin, Germany; Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany; German Centre for Cardiovascular Research, DZHK, Partner Site Berlin, Berlin, Germany.
Joanna Chikwe, Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.

Abstract

BACKGROUND: Tricuspid valve annuloplasty (TA) during mitral valve repair (MVr) is associated with increased risk of permanent pacemaker (PPM) implantation, but the magnitude of risk and long-term clinical consequences have not been firmly established. OBJECTIVES: This study assesses the incidence rates of PPM implantation after isolated MVr and following MVr with TA as well as the associated long-term clinical consequences of PPM implantation. METHODS: State-mandated hospital discharge databases of New York and California were queried for patients undergoing MVr (isolated or with concomitant TA) between 2004 and 2019. Patients were stratified by whether or not they received a PPM within 90 days of index surgery. After weighting by propensity score, survival, heart failure hospitalizations (HFHs), endocarditis, stroke, and reoperation were compared between patients with or without PPM. RESULTS: A total of 32,736 patients underwent isolated MVr (n = 28,003) or MVr + TA (n = 4,733). Annual MVr + TA volumes increased throughout the study period (P < 0.001, trend), and PPM rates decreased (P < 0.001, trend). The incidence of PPM implantation <90 days after surgery was 7.7% for MVr and 14.0% for MVr + TA. In 90-day conditional landmark-weighted analyses, PPMs were associated with reduced long-term survival among MVr (HR: 1.96; 95% CI: 1.75-2.19; P < 0.001) and MVr + TA recipients (HR: 1.65; 95% CI: 1.28-2.14; P < 0.001). In both surgical groups, PPMs were also associated with an increased risk of HFH (HR: 1.56; 95% CI: 1.27-1.90; P < 0.001) and endocarditis (HR: 1.95; 95% CI: 1.52-2.51; P < 0.001), but not with stroke or reoperation. CONCLUSIONS: Compared to isolated MVr, adding TA to MVr was associated with a higher risk of 90-day PPM implantation. In both surgical groups, PPM implantation was associated with an increase in mortality, HFH, and endocarditis.