Long-term conduction outcomes after valve surgery: incidence and predictors of persistent AV block and high ventricular pacing burden

Background

Permanent pacemaker implantation after valvular surgery is commonly required for high-grade atrioventricular block (AVB). However, the long-term persistence of conduction disturbances and ventricular pacing burden may differ depending on the operated valve.

Methods

We retrospectively analyzed patients who underwent valve surgery followed by pacemaker implantation for postoperative complete AV block (AVB III) or severe bradyarrhythmia/asystole between March 2009 and June 2025. Follow-up data included persistence of high-grade AVB and ventricular pacing burden >20%.

Results

A total of 225 patients (127 males and 98 females) were analyzed (137 with isolated valve surgery and 88 with combined procedures). After a median follow-up of 35±41 months, persistent AV block was present in 16 patients (76.2%) after isolated tricuspid surgery, 42 patients (51.9%) after aortic surgery, 27 patients (40.7%) after mitral valve replacement, and in 1 patient after mitral valve repair.

Among combined valve procedures, persistent AV block occurred in 2 patients (66.7%) after aortic–tricuspid surgery, in 13 patients (61.9%) after aortic–mitral surgery, and in 18 patients (40%) after mitral–tricuspid surgery.

Ventricular pacing >20% was observed in 19 patients (90%) after isolated tricuspid procedures and in 52 patients (75%) after combined valve surgery. Aortic–tricuspid and aortic–mitral combinations both showed near 100% VP >20% (23 patients), while mitral–tricuspid combinations reached 64% (29 patients).

Chi-square analysis demonstrated a significant association between valve surgery type and persistent AV block at follow-up (p = 0.044). The association between valve surgery type and VP burden >20% showed a statistical trend but did not reach significance (p = 0.066).

Multivariable logistic regression demonstrated that tricuspid valve surgery was associated with a substantially increased risk of persistent AV block. Three-fold higher odds of persistent AVB compared with isolated aortic valve surgery (OR 2.97, 95% CI 0.99–8.88).

Compared with isolated mitral valve repair, patients undergoing combined mitral–tricuspid repair showed higher rates of persistent AVB (12.5% vs. 39%). Logistic regression indicated a 4.5-fold increased odds, though this did not reach statistical significance (OR 4.53, 95% CI 0.49–42.1, p = 0.18).

The time interval between valve surgery and pacemaker implantation did not show a statistically significant association with persistent AV block.

Conclusion

Persistence of conduction disturbances after valve surgery is strongly influenced by the type of procedure performed. These findings suggest that individualized strategies may help optimize pacemaker implantation. Nevertheless, rates of persistent AV block and high ventricular pacing burden remained high at long-term follow-up in all patients with high-grade AV block after valve surgery.