Permanent Pacing After Transcatheter Aortic Valve Implantation: Incidence, Predictors and Evolution of Left Ventricular Function

Abstract

BackgroundTranscatheter aortic valve implantation (TAVI) is a well-established procedure; however, atrioventricular block requiring permanent pacemaker implantation (PPI) is a common complication.ObjectivesTo determine the incidence, predictors and clinical outcomes of PPI after TAVI, focusing on how PPI affects left ventricular ejection fraction (LVEF) after TAVI.MethodsThe Brazilian Multicenter TAVI Registry included 819 patients submitted to TAVI due to severe aortic stenosis from 22 centers from January/2008 to January/2015. After exclusions, the predictors of PPI were assessed in 670 patients by use of multivariate regression. Analysis of the ROC curve was used to measure the ability of the predictors; p < 0.05 was the significance level adopted.ResultsWithin 30 days from TAVI, 135 patients (20.1%) required PPI. Those patients were older (82.5 vs. 81.1 years; p = 0.047) and mainly of the male sex (59.3% vs 45%; p = 0.003). Hospital length of stay was longer in patients submitted to PPI (mean = 15.7 ± 25.7 vs. 11.8 ± 22.9 days; p < 0.001), but PPI affected neither all-cause death (26.7% vs. 25.6%; p = 0.80) nor cardiovascular death (14.1% vs. 14.8%; p = 0.84). By use of multivariate analysis, the previous presence of right bundle-branch block (RBBB) (OR, 6.19; 3.56-10.75; p ≤ 0.001), the use of CoreValve® prosthesis (OR, 3.16; 1.74-5.72; p ≤ 0.001) and baseline transaortic gradient > 50 mm Hg (OR, 1.86; 1.08-3.2; p = 0.025) were predictors of PPI. The estimated risk of PPI ranged from 4%, when none of those predictors was present, to 63%, in the presence of all of them. The model showed good ability to predict the need for PPI: 0.69 (95%CI: 0.64 - 0.74) in the ROC curve. The substudy of 287 echocardiograms during the 1-year follow-up showed worse LVEF course in patients submitted to PPI (p = 0.01).ConclusionBRD prévio, gradiente aórtico médio > 50 mmHg e CoreValve® são preditores independentes de implante de MPD pós-TAVI. Ocorreu implante de MPD em aproximadamente 20% dos casos de TAVI, o que prolongou a internação hospitalar, mas não afetou a mortalidade. O implante de MPD afetou negativamente a FEVE pós-TAVI.

Impact of Bundle Branch Block on Permanent Pacemaker Implantation after Transcatheter Aortic Valve Implantation: A Meta-Analysis

“…Table 1 shows the baseline characteristics of the included studies. The 36 studies included a total of 55,851 patients in the final analysis, from 2005 to 2018 [ 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 ]. The mean age of the patients was 81.9 years, with a mean STS score of 8.3.…”

Comparison of Procedural and 1-Year Clinical Results of Transcatheter Aortic Valve Implantation Using Prostheses with Different Design of Support Frame

“…10) It has been well demonstrated that the incidence of PPI was higher in TAVI patients using Medtronic CoreValve than those using Edwards SAPIEN. [28][29][30] Gaede, et al 24) analyzed a cohort with 1025 patients who underwent TAVI procedure, which showed that the implantation of a CoreValve device is an independent predictor of PPI. A similar result was observed by Monteiro, et al 30) A possible reason why the patients who were treated with Medtronic CoreValve had a higher incidence of high-degree AV block than those treated with Edwards SAPIEN may be that the support frame of CoreValve prostheses could provide greater radial force, which continually exerts mechanical stress on the heart conduction system, than the stent of balloonexpandable SAPIEN devices.…”

“…[28][29][30] Gaede, et al 24) analyzed a cohort with 1025 patients who underwent TAVI procedure, which showed that the implantation of a CoreValve device is an independent predictor of PPI. A similar result was observed by Monteiro, et al 30) A possible reason why the patients who were treated with Medtronic CoreValve had a higher incidence of high-degree AV block than those treated with Edwards SAPIEN may be that the support frame of CoreValve prostheses could provide greater radial force, which continually exerts mechanical stress on the heart conduction system, than the stent of balloonexpandable SAPIEN devices. 24) Moreover, THVs with a long self-expandable stent such as CoreValve prosthesis will be deployed in a deeper position in the left ventricular outlet flow than that with short cylinder stent (Edwards SAPIEN or J-Valve) during TAVI procedure, which may increase the probability to compress cardiac conduction system.…”

“…Although PPI did not affect perioperative mortality, a negative effect of PPI on LVEF was observed during 1-year follow-up. 30) The longterm survival rate is an important indicator for evaluating the efficacy of THVs in TAVI treatment. The published evidence showed that the all-cause mortality was very high in TAVI patients.…”

Leadless pacemaker for patients following cardiac valve intervention

“…Acute surgical trauma and perioperative ischemia following valve intervention can lead to cardiac conduction disturbances requiring pacemaker implantation in 3% to 6% of cases [1][2][3][4]. This incidence can increase to 20-27% after percutaneous/surgical aortic or tricuspid valve replacement [5][6][7][8]. Long term, valve surgery also remains associated with a higher risk of permanent pacemaker implantation with an incidence up to 25.9% at 10 years after triple valve replacement [9].…”