title: Risk Factors and Outcomes of Patients Requiring a Permanent Pacemaker After Aortic Valve Replacement in the United States.
abstract: BACKGROUND
  The need for permanent pacemaker implantation (PCM) following surgical aortic valve replacement (SAVR) is uncommon but can lead to increased hospital resource utilization. Using nationwide data, we sought to (1) identify hospital, patient, and procedure-level risk factors for PCM after SAVR and (2) determine incremental resource utilization.
  
  
  METHODS
  We identified 659,692 patients from the Nationwide Inpatient Sample database who underwent SAVR with or without coronary artery bypass grafting (CABG), mitral valvuloplasty (MVr), or mitral valve replacement (MVR) between 1998 and 2009. Patients with pre-existing pacemakers, a concomitant Maze procedure, or endocarditis were excluded. Multivariable regression analysis and propensity matching were used for comparisons of outcomes and costs.
  
  
  RESULTS
  Overall prevalence of PCM was 5.1% (n = 34,020; SAVR alone, 4.8%; SAVR + CABG, 4.6%; SAVR + MVr, 7.7%; SAVR + MVR, 10%). Important risk factors for PCM after SAVR were coexisting comorbidities, older age, and addition of mitral valve surgery. Hospital volume and teaching status, location, race, and sex were not associated with PCM. Among matched pairs, patients requiring PCM had lower in-hospital mortality (3.1% vs. 6.4%, p < 0.001) but longer median length of stay (12 vs. 9 days, p < 0.001) and higher hospital costs ($50,000 vs. $37,000, p < 0.001), and they were less likely to be discharged home (33% vs. 36%, p < 0.001). Factors associated with later PCM (postoperative day ≥6) included SAVR + MVR, female sex, fewer comorbidities, northeastern region, and higher hospital volume. Median hospital costs were greater ($57,000 vs. $48,000, p < 0.001) among patients whose pacemakers were implanted later.
  
  
  CONCLUSIONS
  PCM following SAVR is associated with lower hospital mortality, but increased cost and length of stay. doi: 10.1111/jocs.12769 (J Card Surg 2016;31:476-485).
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Robich
authors.affiliation: Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio.
authors.forename: Nicholas K
authors.initials: NK
authors.lastname: Schiltz
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Douglas R
authors.initials: DR
authors.lastname: Johnston
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Mick
authors.affiliation: Department of Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Amar
authors.initials: A
authors.lastname: Krishnaswamy
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Rodrigo A
authors.initials: RA
authors.lastname: Iglesias
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Dustin
authors.initials: D
authors.lastname: Hang
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Roselli
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Edward G
authors.initials: EG
authors.lastname: Soltesz
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000601:surgery*; D001145:Arrhythmias, Cardiac / Q000453:epidemiology* / Q000209:etiology / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial; D011183:Postoperative Complications; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects*; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology