Early Pacemaker Implantation after Transcatheter Aortic Valve Replacement: Impact of PlasmaBlade™ for Prevention of Device-Associated Bleeding Complications

Abstract

Background and Objectives: Permanent pacemaker implantation (PPI) is frequently required following transcatheter aortic valve replacement (TAVR). Dual antiplatelet therapy (DAPT) or oral anticoagulation therapy (OAK) is often necessary in these patients since they are at higher risk of thromboembolic events due to TAVR implantation, high incidence of coronary artery diseases (CAD) with the necessity of coronary intervention, and high rate of atrial fibrillation with the need of stroke prevention. We sought to evaluate the safety, efficiency, and clinical outcomes of early PPI following TAVR using the PlasmaBlade™ (Medtronic Inc., Minneapolis, MN, USA) pulsed electron avalanche knife (PEAK) for bleeding control in patients under DAPT or OAK. Materials and Methods: This retrospective single-center study included patients who underwent PPI after transfemoral TAVR (TF) at our center between December 2015 and May 2020. All PPI were performed using the PlasmaBlade™ Device. Results: The overall PPI rate was 14.1% (83 of 587 patients; 82.5 ± 4.6 years; 45.8% male). The PPI procedures were used to treat high-grade atrioventricular block (81.9%), severe sinus node dysfunction (13.3%), and alternating bundle branch block (4.8%). At the time of the procedure, 35 (42.2%) patients received DAPT, and 48 (57.8%) patients received OAK (50% with vitamin K antagonist (VKA) and 50% with novel oral anticoagulants (NOAK)). One device-pocket hematoma treated conservatively occurred in a patient (1.2%) receiving NOAK. Two re-operations were necessary in patients due to immediate lead dislocation (2.4%). Conclusions: The results of this study illustrate that the use of PlasmaBlade™ for PPI in patients after a TAVR who require antithrombotic treatment is feasible and might result into lower rates of severe bleeding complications compared to rates reported in the literature. Use of the PlasmaBlade device may be considered in this specific group of patients because of their high risk of bleeding.

Infections of cardiac implantable electronic devices: Epidemiology, mechanisms, and preventive measures

“…Minimizing trauma by respecting tissue architecture and ensuring good wound closure is extremely important. Electrocautery is widely implemented in most centers, but the use of a plasma electron avalanche knife has been shown to be associated with a reduced incidence of hematoma compared to electrocautery in high-risk patients [74]. Some observational studies advocate for the use of hemostatic agents such as tranexamic acid [75].…”

Low-temperature electrocautery for high-risk cardiac implantable electronic device procedures

“…Of 150 procedures performed in the current analysis with the use of low-temperature electrocautery, no clinically significant pocket hematoma developed, although almost 40% of patients were on anticoagulants. A recent study focused on the risk of bleeding in patients on anticoagulants after transcatheter aortic valve implantation demonstrated that the risk of pocket hematoma with low-temperature electrocautery was 1.2% [ 10 ]. As none of the patients from the studied group developed a clinically significant pocket hematoma, and the rates of hematomas from the prior studies with low-temperature electrocautery did not exceed 3.4%, it could be concluded that low-temperature electrocautery allows maintaining low risk of pocket hematoma and lead-related complications [ 4 , 7 ].…”