Permanent pacemaker implantation following transcatheter aortic valve implantation using self-expandable, balloon-expandable, or mechanically expandable devices: a network meta-analysis

Abstract

Aims Permanent pacemaker implantation (PPI) still limits the expansion of indications for transcatheter aortic valve implantation (TAVI). Comparison between different systems remains scarce. We aimed to determine the impact of the device type used on post-TAVI PPI. Methods and results A systematic literature review was performed to identify studies reporting the use of balloon-expandable valve (BEV), self-expandable valve (SEV), and mechanically expandable valve (MEV) and post-TAVI PPI. A network meta-analysis was used to compare TAVI mechanisms (Analysis A) and transcatheter heart valves (Analysis B) with respect to post-TAVI PPI. Analysis A included 40 181 patients with a pooled PPI rate of 19.2% in BEV, 24.7% in SEV, and 34.8% in MEV. Balloon-expandable valve showed lower risk compared to either SEV or MEV and SEV demonstrated lower risk for PPI than MEV. Implantation of BEV was associated with 39% and 62% lower PPI rate with respect to SEV and MEV. Implantation of SEV was associated with 38% lower PPI rate with respect to MEV. Analysis B included 36.143 patients with the lowest pooled PPI rate of 9.6% for Acurate Neo or others, and the highest pooled PPI rate of 34.3% for Lotus. CoreValve, Evolut Portico, and Lotus influenced significantly PPI rate, while Sapien group did not. Conclusion Implantation of BEV and also SEV were associated with lower post-TAVI PPI rate, while MEV were associated with higher post-TAVI PPI. Patient tailored-approach including devices characteristics may help to reduce post-TAVI PPI and to allow TAVI to take the leap towards extension of use in younger patients. Prospero number CRD42021238671.

Neutrophil to lymphocyte ratio predicts permanent pacemaker implantation in TAVR patients

“…TAVR is an established alternative to surgical valve replacement for high and low surgical risk patients with severe AS but is associated to an increased risk of high‐grade AVB requiring PPI 4 . The incidence of PPI has been reported as 6.6%–34.8% depending on the use of balloon expandable or self‐expandable valves 5–7 …”

“…4 The incidence of PPI has been reported as 6.6%-34.8% depending on the use of balloon expandable or self-expandable valves. [5][6][7] Several aspects affecting the occurrence of PPI have been identified, some of which depend on the procedure itself and can be prevented, such as depth of valve implantation 13 and use of There is an established relationship between inflammation and calcific aortic valve disease. 14 Nevertheless, the identification of a biochemical marker of disease progression has not been achieved, so far.…”

“…Indeed, it has been recently reported that PPI incidence ranges from 6.6% to 34.8% depending on the use of balloon expandable or self-expandable valves. [5][6][7] It is well established that inflammation burden in AS plays a key role in the progression from aortic sclerosis to calcification and that the increased inflammatory activity is closely related to the hemodynamic severity of the disease. 8 Neutrophil/lymphocyte ratio (NLR) has been proposed as a marker of inflammation and its ability to predict outcomes has been tested in several cardiac diseases.…”

“…Nevertheless, despite growing evidence show good clinical outcomes in AS patients undergoing TAVR, conduction abnormalities (CAs) and the risk of permanent pacemaker implantation (PPI) still rise concerns about TAVR safety. Indeed, it has been recently reported that PPI incidence ranges from 6.6% to 34.8% depending on the use of balloon expandable or self‐expandable valves 5–7 …”

Outcome of permanent pacemaker implantation in transcatheter or surgical aortic valve replacement: A still unsolved problem

“…The prevalence of PPI in TAVR patients is high. A recent meta‐analysis 3 showed, in 40,181 patients, a PPI rate of 19.2% in balloon‐expandable, 24.7% in self‐expandable, and 34.8% in mechanically‐expandable valves. In SAVR patients, on the contrary, PPI prevalence is 4%, as found analyzing 5600 patients who underwent SAVR in Netherlands from 2013 to 2019 4 .…”