This article is more than 5 years old. Information may no longer be current.
New permanent pacemaker implantation after TAVR linked to worse clinical outcomes
Click Here to Manage Email Alerts
In the PARTNER trial and registry, 8.8% of patients who underwent transcatheter aortic valve replacement with a balloon-expandable valve required new permanent pacemaker implantation. In those patients, new permanent pacemaker implantation was associated with higher rates of repeat hospitalization and mortality at 1 year and a longer duration of hospitalization.
Researchers evaluated 1,973 patients without a prior pacemaker who underwent TAVR with a balloon-expandable valve (Sapien, Edwards Lifesciences) in the PARTNER trial and registry. The goal was to identify predictors and clinical implications of new permanent pacemaker implantation after TAVR.
Predictors of permanent pacemaker implantation included right bundle branch block (OR=7.03; 95% CI, 4.92-10.06), prosthesis diameter/left ventricular outflow diameter (OR for each 0.1 increment=1.29; 95% CI, 1.1-1.51), LV end-systolic diameter (OR for each 1 cm=0.68; 95% CI, 0.53-0.87) and treatment in the continued access registry (OR=1.77; 95% CI, 1.08-2.92), according to results of a multivariable analysis.
Patients who required permanent pacemaker implantation had a longer mean duration of postprocedure hospitalization compared with those who did not require a pacemaker (7.3 days vs. 6.2 days; P=.001), according to the researchers.
At 1 year, compared with no pacemaker, patients who required a permanent pacemaker had higher rates of repeat hospitalization (23.9% vs. 18.2%; P=.05) and higher mortality/repeat hospitalization (42% vs. 32.6%; P=.007), the researchers wrote. However, there was no significant difference between the groups in all-cause mortality at 1 year (26.3% vs. 20.8%; P=.08). The researchers also reported no between-group differences in LV ejection fraction at 1 year.
“Further research is required to predict pacemaker dependency and to clarify the optimal [permanent pacemaker implantation] indications after TAVR,” Tamim M. Nazif, MD, from Columbia University Medical Center, and colleagues wrote.
Disclosure: The PARTNER study was funded by Edwards Lifesciences. The present analysis was designed and completed through the PARTNER Publications Office, which is supported by an unrestricted grant from Edwards Lifesciences. Nazif reports consulting for Edwards Lifesciences.
Perspective
Back to Top
Jonathan P. Piccini, MD, MHS, FACC, FAHA, FHRS
The PARTNER analysis is an important contribution to the literature. However, it largely confirms what we know from prior studies of pacemaker implantation following TAVR. The most important risk factor for postoperative permanent pacing is presence of right bundle branch block at baseline. Overall, on average, 5% and 10% of patients need a pacemaker after TAVR.
We know that patients who require pacing after TAVR are higher-risk patients. They go on to have more events. We need to be careful about making definitive assessments about increased risk based upon the results from this analysis because most of the outcomes analyses are not adjusted (at least it is not reported in the methods). However, it is clear that these patients are hospitalized more often.
As an electrophysiologist, I emphasize assessment for risk factors for pacing before TAVR. Patient education about the possible need for a pacemaker is important. Naturally, this education should be provided before the procedure.
A key question is, what are the long-term outcomes in these patients? We need prospective studies to help address the optimal methods of pacing in these high-risk patients. If the indication is atrioventricular block, should they all undergo biventricular pacing implantation? Do leadless pacemakers have advantages in this special patient population? These are important questions we need to answer going forward.
Click Here to Manage Email Alerts