Risk of Pacemaker Implantation After Aortic Root Replacement With and Without Valve Preservation

Background: We compared the outcomes of aortic root replacement by composite valve grafts (CVG) and valve-sparing root replacement (VSRR) operations, with an emphasis on postoperative conduction block and the need for permanent pacemaker implantation (PPM). Methods: From 1997 to 2023, 1712 consecutive patients underwent ARR by VSRR (501 [29%]) or CVG (1211 [71%]) at a high-volume aortic center. Results: Patients undergoing CVG were older (59 ± 14 vs 49 ± 14 years, P <.001), with more cardiovascular comorbidities. Compared with CVG, there were more women undergoing VSRR (17% vs. 13%, P =.042) and more patients with connective tissue disease (22% vs 7.3%, P <.001). Multivariable analysis found that the risk for PPM was higher after CVG compared with VSRR (6.5% vs 1.2%; odds ratio [OR], 2.83; 95% CI, 1.23-7.69; P =.024). Other variables associated with PPM include older age (OR, 1.03; 95% CI, 1.01-1.05; P =.006) preoperative renal impairment (OR, 2.69; 95% CI, 1.24-5.6; P =.010), previous operation (OR, 2.76; 95% CI, 1.29-5.62; P =.007), and bicuspid aortic valve (OR, 3.63; 95% CI, 2.13-6.33; P <.001). Among the CVG population, patients who are at increased risk are especially those with some degree of aortic stenosis (OR, 2.06; 95% CI, 1.18-3.61; P =.011). Patients who required PPM had no additive risk for long-term mortality (hazard ratio, 1.01; 95% CI, 0.47-2.17; P =.986); however, they were more likely to have reduced ejection fraction (29.3% vs 16%, P =.014). Conclusions: The incidence of PPM after ARR is low, but rates were higher after CVG compared with VSRR.