THE LONG-TERM IMPACT OF PERMANENT CARDIAC PACING AFTER SURGICAL AORTIC VALVE REPLACEMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS

Permanent pacemaker (PPM) implantation after isolated surgical aortic valve is associated with short- and long-term complications. However, the impact of PPM implantation on long-term mortality has not been fully established. While some studies have demonstrated no effect, others have suggested that PPM reduces long-term survival. Therefore, our objective was to determine whether PPM post-SAVR increases the risk of mortality by performing a systematic review and meta-analysis.

We searched MEDLINE and EMBASE from inception to December 2020 for studies comparing mortality between post-SAVR patients who received PPM and those who did not. Studies were excluded, if they enrolled pediatric patients, if patients underwent other concomitant cardiac surgical procedure, and if transcatheter, sutureless, or rapid deployment valvular prosthesis were used. Random effects meta-analysis was performed using the restricted maximum likelihood estimator with Hartung-Knapp adjustment. The effect sizes were reported as relative risk (RR) with 95% confidence intervals. The analyses were performed using the metaprop and metafor packages for R version 3.01. The literature search yielded a total of 1,903 articles – of which 30 underwent full text review. Three articles met the inclusion and exclusion criteria, thus yielding a total of 9,105 patients. Two out of the three articles reported the hazard ratio adjusted for multiple covariates. The articles had at least 5 years of follow-up, and the pooled age was similar between the PPM (72 [95%CI 68-76] years) group and no PPM group (74 [95%CI 68-76] years). There was no difference between the groups in the number of men (PPM: 59% vs no PPM: 63%, p=0.90), patients with diabetes (PPM: 30% vs no PPM: 24%, p=0.31), hypertension (PPM: 72% vs no PPM: 68%, p=0.28), and atrial fibrillation (PPM: 21% vs no PPM: 13%, p=0.06). There was no difference in early mortality between the PPM and no PPM groups (RR 1.19; 95%CI 0.20-7.08; I2=23%). However, PPM implantation was associated with higher late mortality (RR 1.49; 95%CI 1.25-1.77; I2=0%) compared to the no PPM group.

While PPM post-SAVR does not increase early mortality, PPM independently increases the risk of mortality in the long-term. With the widespread adoption of innovative techniques like transcatheter and rapid deployment/sutureless valves that are known to be associated with high PPM rates, it becomes very important to observe for any excess long-term mortality that might be related to PPM implantation after these techniques.