A best evidence topic in cardiac surgery was written according to a structured protocol. The question was to determine what preoperative, perioperative and postoperative factors influence the requirement for permanent pacemaker (PPM) implantation postisolated aortic valve replacement (AVR). Transcatheter aortic valve intervention was not included in this analysis. Using the reported search method outlined below, 705 papers were found. No randomised controlled trials, meta-analyses or registries were identified. Seven single-centre retrospective observational studies represent the best evidence on the subject. The author, journal, date and country of publication, level of evidence, patient group studied, study type, outcomes and results were tabulated. The incidence of PPM implantation following AVR varied from 3.0% to 11.8% (mean 7.0%, median 7.2%). Current best available evidence suggests that baseline evidence of conducting system disease - first degree atrioventricular block (AVB), left anterior hemiblock, right bundle branch block (RBBB) or left bundle branch block (LBBB) is the most powerful independent predictor of PPM requirement following AVR. Other important predictors are surgery for aortic regurgitation, preoperative myocardial infarction and longer perioperative cardiopulmonary bypass time. No consistent postoperative factors were identified. The mean time to PPM implant postAVR ranged from 6 to 13 days in the four studies that reported it. Current European Society of Cardiology guidelines recommend a period of seven days of persistent AVB postsurgery prior to PPM implantation.

A best evidence topic was written according to a structured protocol. The issue was to determine the incidence and predictors of postoperative permanent pacemaker (PPM) implantation in patients undergoing trans-catheter aortic valve implantation (TAVI) for symptomatic calcific aortic stenosis and to compare this to the known risks of this complication following surgical aortic valve replacement (AVR). Using the reported search method 3071 articles were identified, of which 94 were relevant to the procedure of TAVI and 14 were deemed to represent the best evidence. All 14 studies, including both multi-centre registries and single-centre retrospective case series containing ≥30 patients, reported incidence of postoperative PPM implantation. Five of these studies also assessed predictors of the need for postoperative PPM implantation. The author, journal, date and country of publication, study type, level of evidence, patient group, outcomes and results were tabulated for these studies. We conclude that the current best available evidence suggests that the mean incidence of PPM implantation following TAVI is 14.2% (range 0-34%, median 9.7%), although this appears higher with the CoreValve prosthesis (five studies, mean 20.8%, range 9.3-30.0%) than with the Edwards-Sapien prosthesis (six studies, mean 5.4%, range 0-10.1%). The mean incidences of PPM implantation overall and when using the CoreValve prosthesis are higher than the mean incidence of 7.0% (range 3-11.8%, median 7.2%) following conventional AVR and may be explained by distinct differences between the patient groups involved and the procedure performed. Indications for PPM implantation appear to occur early in the postoperative period following TAVI and there is little evidence of recovery following atrioventricular block (AVB). New onset persistent left bundle branch block is common following TAVI but the significance and follow-up required is unclear. Independent predictors of PPM requirement following TAVI include use of the CoreValve prosthesis and evidence of conduction system dysfunction, either pre-existing right bundle branch block or AVB at the time of TAVI. All patients should be made aware of the high risk of PPM implantation with TAVI.

Background: Measurement of fractional flow reserve (FFR) has an established role in guiding percutaneous coronary intervention. We tested the hypothesis that, at the stage of diagnostic invasive coronary angiography, systematic FFR-guided assessment of coronary artery disease would be superior, in terms of resource use and quality of life, to assessment by angiography alone. Methods: We performed an open-label, randomized, controlled trial in 17 UK centers, recruiting 1100 patients undergoing invasive coronary angiography for the investigation of stable angina or non–ST-segment–elevation myocardial infarction. Patients were randomized to either angiography alone (angiography) or angiography with systematic pressure wire assessment of all epicardial vessels >2.25 mm in diameter (angiography+FFR). The coprimary outcomes assessed at 1 year were National Health Service hospital costs and quality of life. Prespecified secondary outcomes included clinical events. Results: In the angiography+FFR arm, the median number of vessels examined was 4 (interquartile range, 3–5). The median hospital costs were similar: angiography, £4136 (interquartile range, £2613–£7015); and angiography+FFR, £4510 (£2721–£7415; P =0.137). There was no difference in median quality of life using the visual analog scale of the EuroQol EQ-5D-5L: angiography, 75 (interquartile range, 60–87); and angiography+FFR, 75 (interquartile range, 60–90; P =0.88). The number of clinical events was as follows: deaths, 5 versus 8; strokes, 3 versus 4; myocardial infarctions, 23 versus 22; and unplanned revascularizations, 26 versus 33, with a composite hierarchical event rate of 8.7% (48 of 552) for angiography versus 9.5% (52 of 548) for angiography+FFR ( P =0.64). Conclusions: A strategy of systematic FFR assessment compared with angiography alone did not result in a significant reduction in cost or improvement in quality of life. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01070771.

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The Newcastle age-adjusted thresholds led to more referrals in comparison to NICE guidelines but are more sensitive in diagnosing heart failure. Using ESC recommended thresholds results in a similar diagnostic yield to our age-adjusted thresholds, but has the potential to significantly increase the referrals in patients ≥ 75 years, which may result in a lower diagnostic yield.