# Implications of pacemaker implantation after aortic valve surgery for endocarditis: a nationwide study

## TL;DR

This study finds that needing a pacemaker after heart valve surgery for a rare heart infection does not increase the risk of death or other serious outcomes.

## Contribution

The study provides new evidence on the long-term clinical impact of pacemaker implantation after aortic valve surgery for infective endocarditis.

## Key findings

- Pacemaker implantation was not associated with increased mortality in patients after aortic valve surgery for endocarditis.
- There was no significant link between pacemaker use and reinfection or heart failure in the long term.
- Despite suggesting more severe disease, pacemaker implantation did not jeopardize the benefits of lifesaving surgery.

## Abstract

Infective endocarditis (IE) is associated with a high risk of atrioventricular block and surgery adds to the risk of receiving a permanent pacemaker. The clinical impact of pacemaker implantation in IE patients is insufficiently studied. Our objective was to analyse long-term clinical outcomes in patients who receive a permanent pacemaker after IE surgery.

We conducted a nationwide observational cohort study, including all patients undergoing surgery for aortic valve IE in Sweden 1997–2022. The exposure group was patients who received a permanent pacemaker within 30 days of surgery. We used inverse probability of treatment weighting to account for inter-group differences and flexible parametric models to estimate hazards and cumulative incidences. Outcomes were all-cause mortality, heart failure and reinfection in the prosthetic valve.

Among 2175 patients who underwent surgery for aortic valve endocarditis, 168 (8%) received a permanent pacemaker. The mean age was 59 years; 18% were female. During a mean follow-up of 8.0 years (maximum 26 years), 822 patients (38%) died. At 15 years, the cumulative incidence of all-cause mortality was 60% versus 50% in the pacemaker versus the no pacemaker group; for heart failure, it was 21% versus 16%. We found no association of pacemaker implantation with mortality [hazard ratio (HR) 1.17; 95% confidence interval (CI) 0.86–1.58], heart failure (HR 1.42; 95% CI 0.89–2.29) or reinfection (HR 0.85; 95% CI 0.50–1.45).

Pacemaker implantation after surgery for aortic valve IE is common but was not associated with an increased risk of death, heart failure or reinfection. Although pacemaker need suggests more advanced disease, these results show that lifesaving surgery is not importantly jeopardised by the need for a pacemaker.

Infective endocarditis (IE) is a rare, but often deadly disease, which causes structural damage to the heart valves.