Mortality after cardiac resynchronization therapy or right ventricular pacing in transcatheter aortic valve replacement recipients

Abstract

Background Permanent pacemaker implantation (PMI) is associated with increased morbidity after transcatheter aortic valve replacement (TAVR). Cardiac resynchronization-therapy (CRT) is recommended for patients if left ventricular ejection fraction (LVEF) is ≤ 40% and ventricular pacing is expected in favor to sole right ventricular (RV) pacing. Meanwhile, LVEF may recover after TAVR in patients with aortic valve disease and the benefit of CRT is unknown. Objective To analyze the impact of CRT implantation as compared to RV pacing after TAVR. Methods and Results Between 2012 and 2022, 4385 patients (53.1% female, mean age 81 ± 6 years) without prior PMI undergoing TAVR were retrospectively identified in our institutional registry. After stratification of patients in LVEF ≤ 40%, 41–49% and ≥ 50%, Kaplan–Meier analysis revealed significantly different survival rates in each subgroup at 5 years (37.0% vs. 43.5% vs. 55.1%; P ≤ 0.021). At multivariate regression, LVEF and new PMI after TAVR were not relevant for survival. A total of 105 patients with LVEF ≤ 40% received PMI after TAVR (86 patients with RV pacing and 19 with CRT). At 5 years, all-cause mortality was significantly lower in patients with CRT-device as compared to patients without CRT-device (Kaplan Meier estimate of 21.1% vs. 48.8%; HR 0.48, CI 0.204 – 1.128; log rank p = 0.045). In multivariate analysis CRT remained a significant factor for 5-year survival in these patients (HR 0.3, CI 0.095–0.951, p = 0.041). Conclusion In patients undergoing TAVR, PMI did not influence 5-year survival. In patients with LVEF ≤ 40%, CRT-device implantation was associated with improved survival compared to non-CRT-device implantation. Graphical Abstract Impact of right ventricular pacing and cardiac resynchronization therapy on patient survival in patients with transcatheter aortic valve replacement. CI = confidence interval, CRT = cardiac resynchronization therapy, HR = hazard ratio, LVEF = left ventricular ejection fraction, RV = right ventricular, TAVR = transcatheter aortic valve replacement