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Implantation depth, prosthesis oversizing may predict conduction abnormalities, pacemaker need post-TAVR
In patients undergoing transcatheter aortic valve replacement with a next-generation valve, deeper implantation and prosthesis oversizing appear to be associated with a higher rate of new conduction abnormalities or need for permanent pacemaker implantation, according to study findings.
Researchers identified 244 consecutive patients (mean age, 81 years) with a logistic EuroSCORE of 16% who underwent TAVR with the next-generation valve (Sapien 3, Edwards Lifesciences) at Technische Universität München, Munich, Germany. After excluding patients with a previous pacemaker, atypical valvular anatomy and degenerated biological prosthesis, 208 patients were eligible for inclusion. TAVR was performed using the 23-mm Sapien 3 valve in 44% of patients while the 26-mm valve was used in 38% of patients and the 29-mm valve was used in 18% of patients.
The endpoints were defined as permanent pacemaker implantation (PPI) before discharge in patients without a pacemaker (n = 208) and new or increasingly severe conduction abnormalities or PPI in patients without bundle branch blocks or pacemaker at baseline (n = 184).
After TAVR with the Sapien 3 valve, 16% (34/208) of patients underwent PPI before hospital discharge. Patients who underwent PPI had a higher prevalence of baseline atrial fibrillation (44%) vs. those who did not (24%; P = .017). Compared with those who did not have PPI, patients who underwent PPI before discharge also had a higher rate of baseline complete right bundle branch blockage (27% PPI vs. 5% no PPI; P = .001) and bradycardia less than 60 beats per minute (38% PPI vs. 21% no PPI; P = .034). There was a trend toward deeper implantation in patients who underwent PPI, particularly at the nonseptal side. There was no association between postdilation and PPI (32% PPI vs. 35% no PPI; P = .762).
The overall prevalence of new-onset or increasingly severe conduction abnormalities or PPI was 31%. The following factors were identified as independently predictive of new or worsened CA or PPI: implantation depth at septal side (OR = 1.063; 95% CI, 1.017-1.11), oversizing (OR = 3.489; 95% CI, 1.236-9.848) and QRS duration (OR = 1.033; 95% CI, 1.011-1.056).
“In a large population of patients undergoing TAVR with the Sapien 3 valve, we found an overall incidence of new or worsened [conduction abnormalities] or PPI in 1 of 3 patients and a clear relationship to implantation depth and out-of-range extreme oversizing,” the researchers wrote. “An adjustment of implantation height and careful adherence to the sizing algorithms may result in a reduction of new or worsened [conduction abnormalities] or PPI.” – by Jennifer Byrne
Disclosure: One researcher reports receiving minor travel grants from Edwards Lifesciences; two researchers report serving as proctors/consultants for Edwards Lifesciences.