Background: Orthotopic heart transplantation (OHT) is associated with a high incidence of conduction disturbances (CD) leading to permanent pacemaker (PPM) implantation. However, the improved posttransplant survival raises the question about the pacemaker dependence (PD) in a prolonged follow-up. Hypothesis: The prevalence of PPM in OHT is high but not all patients are PD in a very long-term follow-up. Device implantation has no prognostic relevance. Methods: We performed a retrospective analysis of patient medical records focusing on device interrogation data at the most recent follow-up. Results: The study population consisted of 183 patients with a mean follow-up of 15.0 ± 6.8 years. One-fourth of the patients had undergone PPM implantation (n = 49, 26.8%). Among these, two-thirds were PD at last follow-up (n = 32, 65.3%). PPM was more often in biatrial OHT and cardiac allograft vasculopathy (OR 3.0, 95% CI 1.26–7.29, p = .013 and OR 2.0, 95% CI 1.03–3.87, p = .041, respectively). Early sinus node dysfunction (SND) was the most persistent CD. PPM was associated with a poorer outcome in OHT (HR 1.9, 95% CI 1.06–3.46, p = .031) and a higher rate of fatal septicemia (HR 5.1, 95% CI 1.41–18.14, p = .013). Conclusions: One-fourth of the OHT recipients develop CD requiring PPM implantation, although one-third among these are not PD in follow-up. Early SND is associated with a higher rate of PD. PPM is associated with an inferior prognosis.