Comparison of Outcomes of Leadless Versus Transvenous Pacemakers Following Tricuspid Valve Surgery

Transvenous pacemaker implantation after tricuspid valve surgery may cause adverse outcomes due to lead-valve interactions. Although leadless pacemakers may mitigate these risks, empirical data remain limited.

We compared outcomes of leadless versus transvenous pacemakers following tricuspid surgery using a target trial emulation framework. We analyzed Medicare beneficiaries aged ≥65 years who underwent tricuspid valve surgery and received a pacemaker during the index admission between 2017 and 2021, using propensity score matching weight analysis to control for confounders. Primary outcomes were in-hospital death and 2-year heart failure hospitalization. Secondary outcomes included 2-year death.

We included 185 and 1336 patients in the leadless and transvenous groups, respectively. Use of leadless pacemakers increased from 6.3% in 2017 to 17.5% in 2021. Leadless pacemaker recipients more often underwent tricuspid valve replacement (29.2% versus 8.5%) while concomitant mitral surgery was less common (69.2% versus 86.8%). After adjustment, we found no evidence that in-hospital death (adjusted odds ratio, 1.82 [95% CI, 0.65-5.13] for leadless) and 2-year heart failure hospitalizations (subdistribution hazard ratio [HR], 0.88 [95% CI, 0.60-1.30] for leadless) differed between the 2 groups. We also found no evidence that 2-year death (adjusted HR, 1.04 [95% CI, 0.69-1.57] for leadless) differed between groups.

No statistically significant differences were detected between leadless versus transvenous pacemaker implantations after tricuspid valve surgery. However, CIs were wide, and a clinically meaningful difference in either direction cannot be excluded. The study may therefore be underpowered, and the absence of echocardiographic data limits assessment of tricuspid regurgitation, warranting prospective studies.