Background: Approximately 10% of heart transplants (HTx) recipients require permanent pacemaker (PPM) implantation. Prolonged graft ischaemic time may contribute to conduction system injury and PPM requirement. Ex-vivo preservation of heart allografts using either normothermic or hypothermic organ preservation systems (OPS) facilitate long-distance procurements and use of marginal donors including donation after circulatory death (DCD). Implantation technique for orthotopic HTx are either biatrial or bicaval. Purpose: We sought to determine if the use of OPS and right atrial anastomosis type reduced PPM implantation in HTx recipients. Methods: This was a single-centre retrospective study of 405 consecutive HTx recipients between July 2014 and March 2023. Baseline demographics, utilisation of OPS, anastomosis type, donor ischaemic times and history of graft dysfunction were collected. The primary outcome was PPM implantation. Results: Of 405 HTx performed, an OPS was utilised in 118 (29.1%) patients. The remaining 287 (70.9%) organs underwent cold ischaemic storage (CIS). Apart from male sex (81% in OPS group versus 69% in the CIS group), there were no significant differences in baseline demographics. Two of 118 (1.7%) patients in the OPS group required PPM implantation, compared to 27/287 (9.4%) in the CIS group (Chi-Square 7.5, p = 0.006). Kaplan-Meier analysis demonstrated a significantly lower rate of PPM implantation in the OPS arm (Log Rank 6.975, p = 0.008). Of the 29 patients who required pacing, 12/29 (41.4%) had AV block and 17/29 (58.6%) had sinus node dysfunction. Six of 29 patients (20.7%) were pacing dependent at last follow up. In the period of 2014-2019, 40% of HTx implants were bicaval vs 80% in the 2020-2023 period, corresponding to a significantly reduced PPM rate from 11.0% to 3.7%. Conclusion: HTx performed utilising an OPS as well as bicaval anastomosis were independently associated with lower PPM rates.