Risk Factors for Permanent Pacemaker Implantation after Concomitant Surgical Ablation in Cardiac Surgery Patients with Atrial Fibrillation: Subanalysis from the Multicenter CASE-AF Registry

All articles of this category (opens in new window) Background: Only 25 to 40% of atrial fibrillation (AF) patients receive surgical ablation (SA) during cardiac surgery. Surgeons often hesitate due to concerns about added risks. This study aimed to identify risk factors for postoperative permanent pacemaker implantation (PPI) in AF patients undergoing concomitant SA, analyzing data from the German Cardiosurgical Atrial Fibrillation (CASE-AF) registry. Methods: Between September 2016 and November 2024, AF patients with underlying cardiac disease scheduled for surgery with SA were enrolled in the CASE-AF registry from 18 centers. Data were collected prospectively and analyzed retrospectively. Our subgroup analysis included 1,615 patients from September 2016 to November 2024, with SA more than 1 year prior. Based on the new postoperative PPI, the cohort was divided into the PPI and NoPPI groups. Results: Preoperatively, half of the patients had (long-standing) persistent AF (PPI 52.6% vs. NoPPI 43.6%, p = 0.062) and were at least moderately affected (modified European Heart Rhythm Association (mEHRA) symptom classification > IIa) by AF (PPI 56.8% vs. NoPPI 58.0%, p = 0.833). The postoperative PPI rate was 6.3%. The postoperative PPI had no impact on in-hospital or 1-year mortality (PPI 1.8% vs. NoPPI 1.7%, p = 0.947; 4.7% vs. 5.1%, p = 0.947). The proportion of patients without AF recurrence (combined endpoint of no AF recurrence at 3 months, no current AF, no re-ablation, no cardioversion, and no rehospitalization for AF) was about 60% (PPI 58.9% vs. NoPPI 66.7%, p = 0.125). Postoperative normal daily activity was unaffected in 90% (mEHRA I + IIa; PPI 89.2% vs. NoPPI 94.2%, p = 0.106). Risk factors for PPI included older age (OR 1.56 (1.17–2.07), p = 0.002), aortic valve surgery (OR 2.44 (1.51–3.94), p < 0.001), tricuspid valve surgery (OR 2.68 (1.47–4.89), p = 0.002), and complete biatrial maze ablation (vs. left atrial ablation only, OR 3.07 (1.79–5.24), p < 0.001). Conclusion: The rate of new postoperative PPIs was reassuringly low compared to the literature, with no effect on mortality or morbidity during the 12-month follow-up. The potential need for postoperative PPI is minimal and should not be a strong reason to avoid SA. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany