Clinical and Echocardiographic Outcomes Following Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement

Abstract

Background— Transcatheter aortic valve replacement has become the procedure of choice for inoperable, high-risk, and many intermediate-risk patients with aortic stenosis. Conduction abnormalities are a common finding after transcatheter aortic valve replacement and often result in permanent pacemaker (PPM) implantation. Data pertaining to the clinical impact of PPM implantation are controversial. We used meta-analysis techniques to summarize the effect of PPM implantation on clinical and echocardiographic outcomes after transcatheter aortic valve replacement. Methods and Results— Data were summarized as Mantel–Haenszel relative risk (RR) and 95% confidence intervals (CIs) for dichotomous variables and as standardized mean difference and 95% CI for continuous variables We used the Higgins I 2 statistic to evaluate heterogeneity. We found that patients with and without PPM have similar all-cause mortality (RR, 0.85; 95% CI, 0.70–1.03), cardiovascular mortality (RR, 0.84; 95% CI, 0.59–1.18), myocardial infarction (RR, 0.47; 95% CI, 0.20–1.11), and stroke (RR, 1.26; 95% CI, 0.70–2.26) at 30 days. The groups were also comparable in all-cause mortality (RR, 1.03; 95% CI, 0.92–1.16), cardiovascular mortality (RR, 0.69; 95% CI, 0.39–1.24), myocardial infarction (RR, 0.58; 95% CI, 0.30–1.13), and stroke (RR, 0.70; 95% CI, 0.47–1.04) at 1 year. We observed that the improvement in left ventricular ejection fraction was significantly greater in the patients without PPM (standardized mean difference, 0.22; 95% CI, 0.12–0.32). Conclusions— PPM implantation is not associated with increased risk of all-cause mortality, cardiovascular mortality, stroke, or myocardial infarction both at short- and long-term follow-up. However, PPM is associated with impaired left ventricular ejection fraction recovery post-transcatheter aortic valve replacement.

Incidence of arrhythmias and impact of permanent pacemaker implantation in hospitalizations with transcatheter aortic valve replacement

“…A meta-analysis concluded that there was a reduced mortality rate from sudden death 30 days post-TAVR in patients receiving PPM. 27…”

The Conundrum of Permanent Pacemaker Implantation After Transcatheter Aortic Valve Implantation

“…19,20 The Figure provides an overview of our current understanding related to the need and impact of PPM implantation among patients undergoing TAVI and identifies areas of ongoing research efforts. In this context, the findings of the study by Mohananey et al 13 are an important contribution to the field because of the reassurance that PPM implantation after TAVI among octogenarians seems not to be associated with a measurable adverse impact on long-term clinical outcomes. Continued efforts should aim to refine our ability to identify patients at risk before TAVI to modify the procedure with the aim to minimize injury to the atrioventricular conduction system during the intervention, to design transcatheter aortic bioprosthetic devices that minimize the risk for periprocedural atrioventricular conduction block, and careful clinical guidance for appropriate indications for PPM implantation after TAVI…”

“…10 At variance with these studies, long-term survival after TAVI was unaffected by PPM implantation in most other reports. 11,12 In this issue of Circulation: Cardiovascular Interventions, Mohananey et al 13 provide more clarity by presenting new data of a meta-analysis including 23 studies with 20 287 patients who underwent TAVI stratifying outcomes by the need for new PPM implantation after the intervention. As important strength of the present analysis, patients with PPM implantation before TAVI were excluded.…”

Prevalence, predictors, and prognosis of tricuspid regurgitation following permanent pacemaker implantation

“…Data regarding the prognostic impact of PM implantation after valve intervention are somewhat controversial. A few studies demonstrated no prognostic impact of PM implantation after valve implantation [19,22]; however, some studies showed worse outcome in patients who received permanent PM implantation [21,23]. These discrepancies may possibly be related to the involvement of the occurrence of PMTR between the PM implantation and clinical outcome.…”