Conduction recovery following pacemaker implantation after transcatheter aortic valve replacement

Abstract

Background Transcatheter aortic valve replacement (TAVR) is increasingly used to treat severe aortic stenosis. A frequent complication of TAVR is high‐grade or complete atrioventricular (AV) block requiring a permanent pacemaker (PPM). There are little data on the long‐term dependency on pacing after TAVR. The objective of this study was to determine the proportion of patients receiving a PPM for high‐grade or complete AV block after TAVR who remain dependent on the PPM in follow‐up and to determine any risk factors for, particularly the effect of postballoon dilation (PBD) on, pacemaker dependency. Methods Of 594 consecutive patients without prior PPM undergoing TAVR (81.9% balloon‐expandable, 18.1% self‐expandable valve), 67 (13.1%) received a PPM after TAVR. PPM dependency was defined as AV block with a ventricular escape rate of ≤ 40 beats/min. Patient and procedural characteristics were examined according to PPM dependency status. Results Of the 67 patients who received a PPM within 10 days after TAVR, 27/67 (40.3%) were dependent at first follow‐up and only 9/41 (21.9%) at 1 year. PPM dependency was more common after a self‐expanding valve (76.9% vs 31.5%, P < 0.01), in those who underwent PBD (66.7% vs 24.4%, P < 0.01), and in patients in persistent complete AV block at PPM implantation (62.5% vs 7.4%, P < 0.01). Conclusions Fewer than half of patients who receive a new PPM following TAVR are pacemaker dependent at early follow‐up (< 30 days). The use of self‐expanding valves and PBD are associated with a markedly increased risk of PPM dependency.

Factors predicting persistence of AV nodal block in post‐TAVR patients following permanent pacemaker implantation

“…Intra‐procedural balloon aortic valvuloplasty differs from prosthesis post‐dilation in that a larger balloon inflated to higher pressures is utilized for the latter procedure. Likely as a consequence, post‐dilation of a percutaneous prosthesis is clearly associated with a continued need for right ventricular pacing in other cohorts . It is also important to note that balloon aortic valvuloplasty was not associated with an increased risk of peri‐procedural stroke in our cohort.…”

“…In the analysis published by Gaede et al, 14.7% of patients received a PPM post‐TAVR, while 22.4% implanted for complete AV block (the indication for implantation in 74.5% of cases) remained in this rhythm at a median of 73 (IQR 62‐85) days; in the study by Sharma et al, eight of 20 patients (40%) implanted for complete AV block (the indication for implantation in 80% of cases) remained in this rhythm at 30 days . In the most recent study by Kaplan et al, 27 of 67 patients implanted for high‐grade or complete AV block (40.3%) were dependent at first follow‐up . The most significant difference between our data and previous studies is likely the prosthesis design utilized: in our data‐set, all patients received a self‐expanding prosthesis.…”

“…AV block following TAVR may not be permanent, however the natural history and predictors of conduction recovery are not well understood. Recently reported factors predicting persistence of AV block and continued dependence on ventricular pacing in this setting in three cohorts of primarily balloon‐expandable prostheses include right bundle branch block, bifascicular block, and prosthesis postdilation . Predictors of persistent AV block in patients who develop AV block following TAVR with self‐expanding prostheses are unclear.…”

“…1,[8][9][10] Conversely, mechanical factors sheltering the conduction system (existing sewing ring from previous bioprosthetic aortic valve replacement) may be protective. 11 AV block following TAVR may not be permanent, [11][12][13] however the natural history and predictors of conduction recovery are not well understood. Recently reported factors predicting persistence of AV block and continued dependence on ventricular pacing in this setting in three cohorts of primarily balloon-expandable prostheses include right bundle branch block, bifascicular block, and prosthesis postdilation.…”

“…Recently reported factors predicting persistence of AV block and continued dependence on ventricular pacing in this setting in three cohorts of primarily balloon-expandable prostheses include right bundle branch block, bifascicular block, and prosthesis postdilation. [11][12][13] Predictors of persistent AV block in patients who develop AV block following TAVR with self-expanding prostheses are unclear. The aim of the current study was to evaluate the incidence and predictors of clinically significant AV block following TAVR with a self-expanding CoreValve (Medtronic, Minneapolis, MN) system.…”