Utility of rapid atrial pacing before and after TAVR with balloon‐expandable valve in  predicting permanent pacemaker implantation

Abstract

BackgroundHigh‐grade or complete atrioventricular block (AVB) requiring permanent pacemaker (PPM) implantation is a known complication of transcatheter aortic valve replacement (TAVR). Wenckebach AVB induced by rapid atrial pacing (RAP) after TAVR was previously demonstrated in an observational analysis to be an independent predictor for PPM. We sought to investigate the utility of both pre‐ and post‐TAVR RAP in predicting PPM implantation.MethodsIn a single‐center, prospective study, 421 patients underwent TAVR with balloon‐expandable valves (BEV) between April 2020 and August 2021. Intraprocedural RAP was performed in patients without a pre‐existing pacemaker, atrial fibrillation/flutter, or intraprocedural complete AVB to assess for RAP‐induced Wenckebach AVB. The primary outcome was PPM within 30 days after TAVR.ResultsRAP was performed in 253 patients, of whom 91.3% underwent post‐TAVR RAP and 61.2% underwent pre‐TAVR RAP. The overall PPM implantation rate at 30 days was 9.9%. Although there was a numerically higher rate of PPM at 30 days in patients with RAP‐induced Wenckebach AVB, it did not reach statistical significance (13.3% vs. 8.4%, p = 0.23). In a multivariable analysis, RAP‐induced Wenckebach was not an independent predictor for PPM implantation at 30 days after TAVR. PPM rates at 30 days were comparable in patients with or without pre‐TAVR pacing‐induced Wenckebach AVB (11.8% vs. 8.2%, p = 0.51) and post‐TAVR pacing‐induced Wenckebach AVB (10.2% vs. 5.8%, p = 0.25).ConclusionIn patients who underwent TAVR with BEV, there were no statistically significant differences in PPM implantation rates at 30 days regardless of the presence or absence of RAP‐induced Wenckebach AVB. Due to conflicting results between the present study and the prior observational analysis, future studies with larger sample sizes are warranted to determine the role of RAP during TAVR as a risk‐stratification tool for significant AVB requiring PPM after TAVR.

Transcatheter Aortic Valve Implantation and Conduction Disturbances: Focus on Clinical Implications

“…Indeed, the absence of Wenckebach heart block upon RAP from 70 to 120 bpm was associated with a nearly 99% negative predictive value for post-TAVI PPM requirement [50]. On the other hand, this approach did not show any added predictive value in another observational study, leaving questions about the proper application of these potentially promising tests, revealing the need for further research [51]. This individualized approach allows for a degree of safety for early post-TAVI discharge.…”

Utility of rapid atrial pacing before and after transcatheter aortic valve replacement to predict permanent pacemaker implantation: A valuable piece of the puzzle?

“…In this issue of Cardiovascular Catheter Intervention , Tan et al 4 evaluate the utility of rapid atrial pacing (RAP) as a risk stratification tool for prediction of subsequent high‐grade atrioventricular (AV) block and need for a PPM after TAVR. In a single‐center, prospective series of 253 consecutive patients treated with balloon‐expandable valves (BEV), RAP was performed both pre and post valve deployment using a temporary pacemaker in 61.2% (156/253) and 91.3% (231/253) of patients respectively.…”