Cardiac pacing has undergone major changes in the areas of manpower, technology, and cost over the past 10 years. Arguments have been made to eliminate cardiac surgical involvement in pacing on the basis of these three areas of change: implantations are increasingly performed by nonsurgeons, surgeons have not kept up with the technologic advances in pacing, and consolidation of bradypacing resources is necessary during a time when reimbursement has declined significantly. This study examined two eras of pacing therapy at an institution where pacemaker implantation has always been performed by cardiothoracic surgeons. The purpose of the study was to critically analyze (1) the current role (if any) of cardiothoracic surgeons in delivery of pacemaker therapy and (2) the current results of cardiothoracic surgical involvement in pacemaker implantation. In 1,562 procedures performed between 1986 and 1992, the infection rate was 0.51% and the overall complication rate (both short-term and long-term) was 5.2%. During era 1 (1/1/86 to 6/30/89), 80% of implants were single-chamber and follow-up was incomplete and dependent in many instances on the referring cardiologist/internist. For the implantations performed in the second era (7/1/89 to 12/31/92) as part of an established Pacemaker Service, complete clinical and transtelephonic follow-up services were provided by this coordinated medical-surgical approach. During era 2, 53.9% of implants were dual-chamber (79% during 1992). Total and infectious complication rates remained low in era 2 despite this change in technology. These data mitigate against the arguments made above to eliminate surgical involvement in bradypacing, and demonstrate that cardiothoracic surgical expertise can be integrated into and significantly contribute to a ''Center of Excellence'' approach to pacemaker therapy. These issues should be considered as government, third-party payers, and hospitals consider bradypacing therapy as a target for health care reform.
