Predicting need for pacemaker implantation early and late after transcatheter aortic valve implantation

Abstract

Objectives To identify associations with either early or late permanent pacemaker (PPM) implantation after transcatheter aortic valve replacement (TAVR) in order to develop an easily interpretable management algorithm. Background Injury to the conduction system after TAVR occasionally requires PPM. There is limited data on how to identify which patients will require PPM, particularly after discharge from index hospitalization after TAVR. Methods All patients having undergone TAVR at the University of North Carolina through August 2019 were identified and records were manually reviewed. Multivariable analyses were performed to identify associations with post‐TAVR PPM due to high‐degree atrioventricular block (HAVB). Comparisons were made between patients with no PPM (n = 304) and PPM required, stratified into early (during index hospitalization, n = 32) and late (during subsequent hospitalization, n = 11) PPM cohorts. Results Of the 347 patents included for analysis, 43 (12.4%) underwent post‐TAVR PPM. In multivariable regression models, early PPM was associated with baseline bifascicular block (OR: 42.16; p < .001), requiring any pacing on first post‐TAVR electrocardiogram (ECG) (OR: 31.55; p < .001), and valve oversizing >15% (OR: 3.61; p < .05). Late PPM was associated with baseline right bundle branch block (RBBB) (OR 12.62; p < .001) and history of atrial fibrillation/flutter (OR 4.83; p < .05). Conclusions Bifascicular block, any pacing on first post‐TAVR ECG, and >15% valve oversizing are associated with early PPM, while RBBB and history of atrial fibrillation/flutter are associated with late PPM. We suggest a management strategy for post‐TAVR surveillance and management of HAVB.

Evaluation and Management of Heart Block After Transcatheter Aortic Valve Replacement

“…Demographic and clinical characteristics that have been associated with post-TAVR PPM implantation include male gender and a history of AF. [ 12 , 19 , 20 ] Our group previously analysed 62,083 TAVR patients from 2012 to 2017 from the Nationwide Readmissions Database in the US which further demonstrated that a history of diabetes, acute kidney injury, chronic kidney disease, dementia and hypertension were independently associated with PPM implantation within 30 days of TAVR ( Figure 2 ). [ 16 ] Pacemaker implantations post-TAVR were also stratified by whether they occurred early (prior to discharge from TAVR hospitalisation) or late (after discharge).…”

“…Most of this transient pacing requirement resolves on its own but it has also been shown to be associated with higher risk of the need for long-term pacing. [ 12 , 26 ] Patients suspected to be in need of temporary pacing after the TAVR procedure should be considered for an internal jugular approach for the temporary pacing wire. This can improve patient comfort as observation periods with temporary pacing wires in place can go extend to 48 hours.…”

“…This can improve patient comfort as observation periods with temporary pacing wires in place can go extend to 48 hours. [ 7 , 12 ]…”

“…[ 6 , 7 ] Our group has previously published our approach to conduction defects after TAVR, which primarily uses the presence of pre-existing RBBB and the need for immediate pacing requirement to provide risk stratification for patients and provides recommendations on duration of observation with temporary pacemaker wires in place ( Figure 5 ). [ 12 ] Some groups have also used intraprocedural rapid atrial pacing at the time of TAVR to uncover those with concealed intranodal conduction disease, as well as longer observation periods after TAVR using more durable screw-in temporary pacing systems. [ 39 , 40 ] Recent expert consensus documents emphasise that electrophysiology studies (EPS) do not have a clear role in the risk stratification and management of heart block after TAVR.…”

“…[ 6 , 7 ] Risk stratification tools to predict HAVB post-TAVR have been developed, but these are mostly based on data from single-centre studies and focus on the immediate post-TAVR setting. [ 8 – 12 ]…”