Predictors for the risk of permanent pacemaker implantation after transcatheter aortic valve replacement: A systematic review and meta‐analysis

Abstract

Background: Transcatheter aortic valve replacement (TAVR) is a less invasive treatment than surgery for severe aortic stenosis. However, its use is restricted by the fact that many patients eventually require permanent pacemaker implantation (PPMI). This meta-analysis was performed to identify predictors of post-TAVR PPMI. Methods:The PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched. Relevant studies that met the inclusion criteria were included in the pooling analysis after quality assessment. Results:After pooling 67 studies on post-TAVR PPMI risk in 97,294 patients, balloon-expandable valve use was negatively correlated with PPMI risk compared with self-expandable valve (SEV) use (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.37-0.53). Meta-regression analysis revealed that history of coronary artery bypass grafting and higher Society of Thoracic Surgeons (STS) risk score increased the risk of PPMI with SEV utilization. Patients with pre-existing cardiac conduction abnormalities in 28 pooled studies also had a higher risk of PPMI (OR: 2.33, 95% CI:1.90-2.86). Right bundle branch block (OR: 5.2, 95% CI: 4.37-6.18) and first-degree atrioventricular block (OR: 1.97, 95% CI: 1.38-2.79) also increased PPMI risk. Although the trans-femoral approach was positively correlated with PPMI risk, the trans-apical pathway showed no statistical difference to the trans-femoral pathway.The approach did not increase PPMI risk in patients with STS scores >8. Patientprosthesis mismatch did not influence post-TAVR PPMI risk (OR: 0.88, 95% CI: 0.67-1.16). We also analyzed implantation depth and found no difference between patients with PPMI after TAVR and those without.Conclusions: SEV selection, pre-existing cardiac conduction abnormality, and transfemoral pathway selection are positively correlated with PPMI after TAVR. Preexisting left bundle branch block, patient-prosthesis mismatch, and implantation depth did not affect the risk of PPMI after TAVR.

Utility of rapid atrial pacing before and after TAVR with balloon‐expandable valve in predicting permanent pacemaker implantation

“…16 In this study, the rate of PPM at 30 days was 11% (6817/62,083), with most PPM implanted before discharge (90%; 6137/6817). 16 Similar to previous studies, [5][6][7][8][9][10] pre-existing RBBB, postprocedural new persistent LBBB, and balloon post-dilation were independent predictors for PPM implantation at 30 days following TAVR in our study. Pre-existing first-degree AV block was identified as an independent predictor of PPM implantation in prior studies, 5,7,9,10 but that association was not demonstrated in our study.…”

“…The use of SEV in TAVR is a known independent predictor for PPM following TAVR. 5,6,[8][9][10] This is one potential explanation for the differences in the rates of post-TAVR RAP-induced Wenckebach AV block and its association with 30-day PPM between the two studies.…”

“…Predictors of PPM implantation after TAVR include pre‐existing right bundle branch block (RBBB), use of SEV compared with BEV, calcification at the device landing zone, intraprocedural complete AV block, and new‐onset left bundle branch block (LBBB) 5–10 . In a recent prospective study at two large tertiary referral hospitals, post‐TAVR rapid atrial pacing (RAP) induced Wenckebach AV block was identified as an independent predictor for PPM at 30 days following TAVR 11 .…”

“…In this study, RAP performed immediately following TAVR had a negative predictive value of 98.7% for PPM in patients who did not develop Wenckebach AV, suggesting that post‐TAVR RAP can be used to identify patients who could benefit from extended rhythm monitoring following TAVR. Both BEV and SEV were used in the study, 11 the latter being a known independent predictor for PPM implantation 5,6,8–10 . In the present single‐center prospective study, we investigated the utility of both pre‐ and post‐TAVR RAP in predicting 30‐day PPM after TAVR using only BEV.…”

Evolving Devices and Material in Transcatheter Aortic Valve Replacement: What to Use and for Whom

“…Complete heart block requiring PPI within 30 days still occurs in around 10–15% of patients undergoing TAVR, even with newer generation devices. Despite notable advances in THV design and procedural technique, the rates of post-TAVR conduction disturbances have not significantly decreased over time, ranging from 4.0% to 24.0% with the Sapien 3 and from 14.7% to 26.7% with the Evolut R [ 68 ], even in the most recent years [ 69 , 70 ].…”