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High incidence of permanent pacemaker after Cox-maze IV and mitral valve surgery: a nationwide registry-based study

Torbjörn Ivert1, Gabriella Boano2,3, Farkas Vanky2,3

  • 1Department of Cardiothoracic Surgery, Karolinska University Hospital and Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.

Interdisciplinary Cardiovascular and Thoracic Surgery
|April 4, 2025
PubMed

Insights

Patients undergoing Cox-maze IV (CMIV) and mitral valve surgery face a higher long-term risk of permanent pacemaker implantation. Sinus node dysfunction is a key reason for late pacemaker needs in CMIV patients.

Area of Science:

  • Cardiology
  • Cardiac Surgery
  • Electrophysiology

Background:

  • Atrial fibrillation is a common arrhythmia often treated with surgical ablation.
  • Mitral valve surgery is frequently performed for valvular heart disease.
  • The Cox-maze IV procedure is an advanced surgical ablation technique.

Purpose of the Study:

  • To evaluate the long-term risk of permanent pacemaker implantation after Cox-maze IV (CMIV) procedure combined with mitral valve surgery.
  • To compare pacemaker implantation rates between CMIV and mitral valve surgery alone in patients with atrial fibrillation.

Main Methods:

  • Retrospective, nationwide, registry-based analysis of 397 patients undergoing CMIV and mitral valve surgery (2009-2017).
  • Comparison with 346 patients undergoing mitral valve surgery without ablation (2014-2017).
  • Follow-up extended to September 30, 2022.

Main Results:

  • CMIV patients had a doubled adjusted risk of pacemaker implantation after 8 years (HR 1.96).
  • Pacemaker implantation rates at 8 years were 27% in CMIV patients vs. 13% in the control group.
  • Atrioventricular block was the primary cause for early pacemaker implantation, while sinus node dysfunction led to late implantation in CMIV patients.

Conclusions:

  • Concomitant CMIV and mitral valve surgery is associated with a higher rate of postoperative pacemaker implantation.
  • Sinus node dysfunction is the predominant indication for late pacemaker implantation in patients who underwent CMIV.
  • Careful consideration of pacemaker dependency is warranted for patients undergoing CMIV with mitral valve surgery.
Abstract

Keywords:
Cox-mazemitral valve surgerypacemaker

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