Date Published: October 17, 2018
Publisher: Public Library of Science
Author(s): Tobias Tichelbäcker, Leonard Bergau, Miriam Puls, Tim Friede, Tobias Mütze, Lars Siegfried Maier, Norbert Frey, Gerd Hasenfuß, Markus Zabel, Claudius Jacobshagen, Samuel Sossalla, Marc W. Merx.
Permanent pacemaker implantation (PPI) following TAVR is a frequent post interventional complication and its management remains controversial.
We sought to elucidate the electrophysiological, procedural, and clinical baseline parameters that are associated with and perhaps predict the need for PPI after TAVR in a heterogeneous-valve-type real-world cohort.
Overall, 494 patients receiving TAVR at our center from April 2009 to August 2015 were screened. ECG analyses and clinical parameters were collected prospectively.
Overall, 401 patients in this all-comers real-world TAVR cohort with a PPI rate of 16% were included. The mean age was 82 years, and the mean duration to PPI was 5.5 days. A large proportion of Edwards SAPIEN valves (81%), DirectFlow, CoreValve, and Portico were implanted. The main indications for PPI were atrioventricular (AV) block III, AV-block Mobitz type II, bradycardic atrial fibrillation and persistent sinus bradycardia. Between groups with and without PPI, significant differences were noted in the prevalence of post TAVR balloon dilatation, resting heart rate, QRS interval, PR interval with a cut-off of >178 ms, left anterior fascicular block and RBBB in univariate analyses. In the subsequent multiple regression analysis, post TAVR balloon dilatation and a PR interval with a cut-off of >178 ms were significant predictors of PPI.
This real-world cohort differs from others in its size and heterogeneous valve selection, and indicates for the first time that patients with post balloon dilatation or prolonged PR interval are at a higher risk for pacemaker dependency after TAVR.
Aortic valve stenosis is the most common valvular heart disease in industrialized nations. Transcatheter aortic valve replacement (TAVR) has become a therapeutic option for patients with severe symptomatic aortic stenosis at high surgical risk. In Germany alone, nearly 16,000 patients were treated with TAVR between 2013 and 2015, and implantation rates are increasing worldwide. Excellent results obtained in clinical trials have initiated a reassessment of the recommendations for the treatment of aortic stenosis and hence may trigger a wider use of TAVR.
We investigated predictors of PPI in a large single-center cohort with a heterogeneous valve selection. Post balloon dilatation of the TAVR prosthesis as a novel predictor and a prolonged PR interval were associated with a significant higher risk of PPI. This should be taken into account when post dilatation is considered.