Short and long-term survival in patients over ninety years-old undergoing pacemaker implantation
Authors: Zecchin M , Bessi R , Baggio C , Trevisan B , Longaro F , Salvatore L , Bianco E , Saitta M , Zorzin-Fantasia A , Piccicin F , Del Monte G , Carriere C , Sinagra G 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
According to the Italian National Statistical Institute, the 12-month probability of survival in the 90-94 years-old general population is 26%. In very old patients (pts) the benefit of pacemaker (PM) implantation in terms of quality and duration of life is unclear and could be considered futile.

Purpose
To analyze clinical characteristics, outcome and factors associated with survival in pts who had turned 90 at the time of the first PM implant.

Methods
All the PM implants performed in our Centre from 1/1/2019 to 1/31/2020 in pts ≥90 year-old at the time of the procedure were analyzed. Clinical parameters, device characteristics and follow-up data until 31/3/2022 were extrapolated from the SuitEstensa Ebit reporting system; the exitus was verified by analyzing data from the Regional Health System.

Results
During the study interval, among the 554 pts undergoing PM implantation in our Center, 69 (12%) were ≥90 years-old at the date of implantation (mean age 92±2 years, 46% male; complete/advanced AV block in 76%). Twenty-six (38%) pts had history of atrial fibrillation and 19 (28%) ischemic heart disease. A cardiological co-morbidity (excluding AF) was present in 23 pts (33%). Oncological, pneumological and neurological comorbidities were present in 12 (18%), 19 (28%) and 32 (46%) respectively. Renal impairment was present in 25 pts (36%). In 47 pts (68%) at least 2 co-morbidities were present. After implantation (VVIR in 36, DDDR in 25 and VDD in 8 patients) a pneumothorax developed in 2 pts and lead dislodgment in 1. Remote monitoring was activated in 57 pts (83%). Within 31/3/2022 (median follow-up 17 months, IQR: 13-24) 33 pts died (37%, in median 12 months after implant, IQR: 3-16), with 12-month survival probability of 75.4% (95% CI: 65.9-86.2). According to the Regional Health System database, no pts died for cardiac reason or device malfunction. Three pts died because of COVID-19 pneumonia. Renal dysfunction (Hazard Ratio-HR 2.64, p=0.006), the presence of 2 or more co-morbidities (HR 6.19; p= 0.003), diabetes (HR 2.53; p=0.009), ejection fraction (HR 0.88 for a difference of 5%; p=0.035), walking impairment (HR 3.64, p&lt;0.001), the presence of oncological (HR 2.62; p=0.019), pneumological (HR 2.05; p=0.049), neurological (HR 4.57, p&lt;0.001) and cardiovascular (HR: 2.20; p=0.015) comorbidities were associated with a higher risk of death at univariate analysis. Presence of oncological and neurological comorbidities were significant at multivariable analysis. Moreover, truncating the outcome at 6 months, renal dysfunction, anticoagulant therapy and ischemic disease were associated with short-term mortality.

Conclusions
At our Center, pts over the age of ninety undergo PM implantation mainly for advanced AVB. The good survival does not seem to justify particularly conservative attitudes, in the presence of clear indications for the implantation of the PM.