Conduction abnormalities requiring permanent pacemaker (PPM) implantation remain a recognized complication after heart transplantation (HT). However, contemporary data on PPM utilization, associated outcomes, and adoption of leadless pacing technologies remain limited. A single-center analysis published in Circulation: Arrhythmia and Electrophysiology evaluated PPM implantation among bicaval HT recipients treated between 2010 and 2025. 

Outcomes among patients receiving a pacemaker were compared with matched transplant recipients without PPM implantation. The study included 1,225 bicaval heart transplant recipients, including 28% women, with a median transplantation age of 58 years. 

Findings

• Sixty-six patients (5%) underwent permanent pacemaker implantation after transplantation, with implantation rates remaining stable throughout the study period.
• The main indications for pacing were sinus node dysfunction (62%) and atrioventricular block (29%), with 44% of devices implanted within 1 month after transplantation.
• Median post-transplant survival did not differ significantly between pacemaker recipients and matched patients without pacemakers (12.8 vs 11.5 years; P=0.14).
• Older donor age independently predicted pacemaker implantation after transplantation (odds ratio [OR], 1.75; P=0.04).
• Leadless pacemakers accounted for 20% of implants, and no short-term complications were reported during a median follow-up of 1 year.

The findings suggest that permanent pacemaker implantation after heart transplantation remains uncommon and is not associated with reduced long-term survival. Longer follow-up is needed to clarify the long-term safety and outcomes of leadless pacing devices in this population.