Impact of postprocedural permanent pacemaker implantation on clinical outcomes after transcatheter aortic valve replacement: A systematic review and meta-analysis

Abstract

Background: The incidence of conduction disturbances requiring permanent pacemaker (PPM) implantation following transcatheter aortic valve replacement (TAVR) have remained a common concern. The purpose of this study was to evaluate the impact of postprocedural PPM implantation following TAVR on clinical outcomes. Methods: We performed a systematic search in PubMed and EMBASE databases for studies that reported raw data on clinical outcomes of patients with and without PPM implantation after TAVR and followed up patients for 10 months or longer. The primary endpoint was all-cause death. The secondary endpoints were cardiovascular death, heart failure and a composite of stroke and myocardial infarction (MI). Results: Data from 20 studies with a total of 21666 patients undergoing TAVR, of whom 12.5% required PPM implantation after intervention, were analysed and the mean duration follow-up was 16.9 months. The rate of PPM ranged from 6.2% to 32.8% among different studies. A total of 6753 (31.2%) patients underwent TAVR with self-expandable prosthesis and 14913 (68.8%) with balloon-expandable prosthesis. The incidence of postprocedural PPM implantation was higher with the self-expandable prosthesis (n=1717, 25.4%) compared with the balloon-expandable prosthesis (n=996, 6.7%). PPM after TAVR was associated with a higher risk of all-cause death (RR: 1.13; 95% CI: 1.01-1.25; P=0.03) but not incidence of stroke and MI (RR: 0.85; 95% CI: 0.64-1.13; P=0.27). Conclusions: In patients undergoing TAVR, the PPM implantation after intervention was associated higher all-cause mortality but not cardiovascular mortality, heart failure and stroke or MI, which remain an unsolved issue of TAVR.

One-year pacing dependency after pacemaker implantation in patients undergoing transcatheter aortic valve implantation: Systematic review and meta-analysis

“…27 Faroux and colleagues 5 show the negative impact of PPI after TAVI on survival and heart failure hospitalization within the year following TAVI. Xi and colleagues 7 also show a greater all-cause mortality in TAVI patients receiving a PPI. In this systematic review, only 4 studies addressed the PPI-related complications and only 8 studies reported the 30-day mortality, making the overall appraisal of the impact of PPI on patient outcome likely underestimated, as emphasized by the Danish experience of Kirkfeldt and colleagues.…”

Long‐term outcomes of patients undergoing mechanical versus bioprosthetic aortic root replacement

“…Rates of PPM implantation were significantly higher in the VIVTAVR group versus the SAVR group (5.7% vs. 18.4% p < .0001) in the study by Deharo 22 . A meta‐analysis of 21,666 patients from 20 studies demonstrated PPM implantation following TAVR was associated with increased all‐cause mortality, so the complication of PPM following TAVR cannot be taken lightly 23 . Thirdly, coronary obstruction continues to be a major challenge when pursuing VIVTAVR strategy as the risk of coronary obstruction is nearly 10‐fold when compared to native TAVR 24 …”

“…22 A meta-analysis of 21,666 patients from 20 studies demonstrated PPM implantation following TAVR was associated with increased all-cause mortality, so the complication of PPM following TAVR cannot be taken lightly. 23 Thirdly, coronary obstruction continues to be a major challenge when pursuing VIVTAVR strategy as the risk of coronary obstruction is nearly 10-fold when compared to native TAVR. 24 The limitations of this study include its retrospective nature as well as that it represents the results from a single institution.…”

Commentary: Pacemaker dependency after transcatheter aortic valve implantation: Only half as bad?

“…Not surprisingly, the need for PPI has been associated with decreased survival also after TAVI. 2,3 Thus, in differential decision making between TAVI and conventional surgery, the need for PPI should be taken into consideration. This requires precise information; for example, whether all patients who require PPI after TAVI will automatically be exposed to chronic ventricular stimulation.…”