Prevalence of permanent pacemaker implantation after conventional aortic valve replacement—a propensity-matched analysis in patients with a bicuspid or tricuspid aortic valve: a benchmark for transcatheter aortic valve replacement

Abstract

OBJECTIVES Elective treatment of aortic valve disease by transcatheter aortic valve replacement (TAVR) is becoming increasingly popular, even in patients with low risk and intermediate risk. Even patients with a bicuspid aortic valve (BAV) are increasingly considered eligible for TAVR. Permanent pacemaker implantation (PMI) is a known—frequently understated—complication of TAVR affecting 9–15% of TAVR patients with a potentially significant impact on longevity and quality of life. BAV patients are affected by the highest PMI rates, although they are frequently younger compared to their tricuspid peers. The aim of the study is to report benchmark data—from a high-volume centre (with a competitive TAVR programme) on PMI after isolated surgical aortic valve replacement (SAVR) in patients with BAV and tricuspid aortic valve (TAV). METHODS We performed a retrospective single-centre analysis on 4154 patients receiving isolated SAVRs (w/o concomitant procedures), between 2000 and 2019, of whom 1108 had BAV (27%). PMI rate and early- and long-term outcomes were analysed. For better comparability of these demographically unequal cohorts, 1:1 nearest neighbour matching was performed. RESULTS At the time of SAVR, BAV patients were on average 10 years younger than their TAV peers (59.7 ± 12 vs 69.3 ± 9; P < 0.001) and had less comorbidities; all relevant characteristics were equally balanced after statistical matching. Overall PMI rate was significantly higher in BAV patients (5.4% vs 3.8%; P = 0.03). BAV required PMI exclusively (100%) and TAV required predominately (96%) for persistent postoperative high-degree atrioventricular block. After matching, the PMI rate was similar (5.1% vs 4.4%, P = 0.5). In-hospital mortality in the matched cohort was 1% in both groups. Long-term survival was more favourable in BAV patients (94% vs 90% in TAV at 5 years; 89% vs 82% in TAV at 9 years; P = 0.013). CONCLUSIONS With SAVR, the overall incidence of PMI among BAV patients seems significantly higher; however, after propensity matching, no difference in PMI rates between BAV and TAV is evident. The PMI rate was remarkably lower among BAV patients after SAVR compared to the reported incidence after TAVR.

Stentless valves for bicuspid and tricuspid aortic valve disease

“…Specifically, our study found no difference in the rate of complete heart block or need for pacemaker implantation after stentless AVR in both the BAV and TAV groups. This differs from the findings of a recent study by Haunschild and colleagues, 4 who reported a higher pacemaker implantation rate in BAV patients compared with TAV patients (5.1% vs 4.4%) after isolated AVR with a bioprosthesis (86%) or mechanical valve (14%) for aortic stenosis. 4 Interestingly, the surgical technique was modified aortic root implantation for all of our patients, and the pacemaker implantation rate of 2.1% in the BAV group is lower than the rate reported by Haunschild and colleagues (5.1%), whereas our pacemaker implantation rate in TAV patients was similar to the rate reported in that study (3.6% vs 4.4%).…”

“…Our results are consistent with the findings reported from 2 studies of matched BAV and TAV patients with isolated AVR. 4,7 Both of those studies and our present study showed better Kaplan-Meier survival in BAV patients and similar The underlying mechanisms for better long-term survival in BAV patients after stentless valve implantation is unclear. The BAV develops calcification and aortic stenosis owing to the intrinsic anatomy of the valve.…”

“…Few previous studies have examined the short-and longterm outcomes of BAV patients after surgical AVR. 3,4 Our short-term results from the propensity-matched sample suggest that the difference in native valve morphology between a BAV and a TAV does not affect the risk of most postoperative complications or short-term survival. Specifically, our study found no difference in the rate of complete heart block or need for pacemaker implantation after stentless AVR in both the BAV and TAV groups.…”

Novel Method for Implantation of Balloon Expandable Transcatheter Aortic Valve Replacement to Reduce Pacemaker Rate—Line of Lucency Method

“…The existing literature suggests that despite improvements in valve design over multiple generations, permanent pacemaker implantation (PPMI) is required in 9-15% of cases following TAVR, a significantly higher risk than in patients undergoing SAVR. [21][22][23] Importantly, implantation of a permanent pacemaker following TAVR is associated with longer hospital and intensive care unit (ICU) stays, increased overall cost, risk of heart failure, and rehospitalization. 24,25 Independent predictors of PPMI in previous reports have included preexisting conduction abnormalities, implant depth, and need for repositioning of self-expanding implants.…”

Evaluation and Management of Heart Block After Transcatheter Aortic Valve Replacement

“…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.…”