AbstractIntroductionMitral valve surgery has developed into a strong subspecialty of cardiac surgery with operative techniques and outcomes constantly improving. The development of bradyarrhythmias after mitral valve surgery is not completely understood.MethodsWe investigated a cohort of 797 patients requiring mitral valve surgery with and without concomitant procedures. Incidences and predictors of pacemaker requirement as well as survival were analyzed.ResultsIn the complete follow‐up period (median follow‐up time: 6.09 years [95% confidence interval [CI]: 5.94–6.22 years, maximum 8.77 years) 80 patients (10% of the complete cohort) required pacemaker implantation for bradyarrhythmia. The cumulative rate of pacemaker implantation was 6.4% at 50 days (48 patients) with most (54.2%) requiring pacing for atrioventricular block. Mitral valve replacement (odds ratio [OR]: 1.905; 95% CI: 1.206–3.536; p = .041) and tricuspid ring annuloplasty (OR: 2.348; 95% CI: 1.165–4.730, p = .017) were identified as operative risk factors of pacemaker requirement after mitral valve surgery. Insulin‐dependent diabetes mellitus was also identified as a predictor of pacemaker requirement (OR: 4.665; 95% CI: 1.975–11.02; p = .001). There was no difference in survival in the paced and unpaced groups.ConclusionsAfter mitral valve surgery, a relevant subgroup of patients requires pacemaker implantation—most for atrioventricular block. We identified mitral valve replacement and tricuspid ring annuloplasty as significant operative risk factors and insulin‐dependent diabetes mellitus as a demographic risk factor. While anatomic relationships help explain the operative risk factors the role of diabetes mellitus is not completely understood.