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

Abstract

Introduction A common complication of transcatheter aortic valve repair (TAVR) is development of conduction defects requiring pacemaker (PPM) implantation. These defects are not universally permanent. Objective To determine the incidence and predictors of persistent device dependency in patients with PPM implantation following TAVR with a self‐expanding prosthesis. Methods Records of patients who underwent post‐TAVR PPM implantation were reviewed. Patients with persistent complete AV block (AVBIII) one month post‐TAVR were compared to those regaining conduction. Results Between September 2014 and March 2017, 485 patients underwent TAVR with a self‐expanding prosthesis; 77 (15.9%) underwent PPM implantation for AVBIII. Device interrogation at one month was available for 61 patients (79%): 22 (36.1%) had resolution of AVBIII while 39 (63.9%) remained pacemaker‐dependent. Pre‐TAVR right bundle branch block was more frequent in device‐dependent patients (19 of 38, 50% vs 4 of 22, 18%; RR 2.75; P = .01). Device‐dependence was associated with AVBIII as the first postprocedural rhythm (37 of 39, 95% vs 12 of 22, 55%; RR 1.74; P < .0001), earlier implantation (median 1d, IQR: 0‐1.5d vs 2d, IQR: 1.0‐4.0d, P = .0004), and a shorter duration of hospitalization (median 3d, IQR: 2‐3.5d vs 4d, IQR: 2‐5.75d, P = .03). Pacemaker dependence was also associated with a higher prosthesis‐to left ventricular outflow tract (LVOT) diameter (1.45 ± 0.11 vs 1.39 ± 0.07; P = .02) and the lack of prior aortic valvuloplasty (5 of 39, 13% vs 8 of 22, 36%; RR 0.35; P = .03). Conclusions In patients receiving a PPM following self‐expanding TAVR, a long‐term pacing requirement can be predicted from the timing of AV block, existing conduction‐system disease, larger prosthesis‐to‐LVOT diameter, and the lack of aortic valvuloplasty.

Predictors of ventricular pacing burden after permanent pacemaker implantation following transcatheter aortic valve replacement

“…The incidence rate of PPM implantation within 30 days after TAVR in our institution (8.4%) is comparable to that reported by the PARTNER 1, 2, and 3 trials that used balloon‐expandable valves (6.6%‐8.8%) 3,5,7 . It is lower however than a lot of recently reported single institutional experiences that used both self‐expanding and balloon expandable valves (incidence rates between 11% and 28%) 10,11,13,14,16,17 . These interinstitutional differences may be partly explained by our higher use of balloon‐expandable valves (77%) which are generally associated with a lower risk of PPM implantation due to their higher level of implantation, 18 as well as our use of newer generation self‐expanding Evolut valves rather than first generation CoreValves which have a lower risk of PPM implantation 19 .…”

“…3,5,7 It is lower however than a lot of recently reported single institutional experiences that used both self-expanding and balloon expandable valves (incidence rates between 11% and 28%). 10,11,13,14,16,17 These interinstitutional differences may be partly explained by our higher use of balloon-expandable valves (77%) which are generally associated with a lower risk of PPM implantation due to their higher level of implantation, 18 as well as our use of newer generation self-expanding Evolut valves rather than first generation Cor-eValves which have a lower risk of PPM implantation. 19 However despite these factors, there is still a high variability between institutional experiences with rates of PPM implantation after TAVR 19 which in the atrioventricular node and interventricular conduction system.…”

“…The significance of pre-TAVR RBBB is especially important, as it is the most persistently reported predictor of PPM requirement in the literature, 7,9,17 as well as often being reported as a predictor of PPM dependency. 10,11,14…”

“…[10][11][12][13][14][15] A better understanding of the natural course of these rhythm disturbances and identifying predictors of their recovery can be particularly useful in helping the clinical decision-making process when a PPM is being considered for certain disturbances where a strong consensus is not available. Recent institutional experiences have identified factors as a pre-TAVR right bundle branch block (RBBB), 10,11,14 higher prosthesis/LVOT diameter ratio, 14 and earlier time to PPM implantation within 1 to 2 days post-TAVR 10,13,14 as predictors of pacemaker dependency. In this study, we aimed to use our institutional experience to identify predictors of post-TAVR ventricular pacing burden with time, and investigate predictors of a low-ventricular pacing percent over a 6 month follow-up period that may suggest pacemaker independency.…”

“…Recent studies have shown a trend in recovery of some of these conduction disturbances, resulting in a decrease in the percentage of patients who are PPM dependent with time 9 . Persistence of PPM dependency has been reported to be somewhere between 22% and 64% in recent single‐center studies 10‐15 . A better understanding of the natural course of these rhythm disturbances and identifying predictors of their recovery can be particularly useful in helping the clinical decision‐making process when a PPM is being considered for certain disturbances where a strong consensus is not available.…”