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Permanent pacemaker implantation not linked to poor clinical outcomes
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According to data published in Circulation: Cardiovascular Interventions, both short- and long-term follow-up for patients who received permanent pacemaker implantation after transcatheter aortic valve replacement showed no increased risk for all-cause mortality, CV mortality stroke or MI, but there was an association with impaired left ventricular ejection fraction recovery.
Although TAVR has become the standard for treating inoperable patients with symptomatic severe aortic stenosis, it frequently requires permanent pacemaker implantation due to complications from conduction abnormalities, according to the study background.
The primary outcome was all-cause mortality at 1 year.
Secondary outcomes included all-cause mortality at 30 days, CV mortality at 30 days and 1 year, stroke at 30 days and 1 year, MI at 30 days and 1 year, improvement in LVEF and all-cause mortality at longest follow-up.
To summarize the effect of postprocedural permanent pacemaker implantation on echocardiographic outcomes, the researchers used meta-regression techniques to evaluate the effect of baseline characteristics on morality outcomes.
The researchers found 23 studies published between 2010 and 2016 that included 20,287 patients and 2,553 permanent pacemaker implantations.
According to the findings, at 30 days, patients with and without permanent pacemaker implantation had similar all-cause mortality (RR = 0.85; 95% CI, 0.7-1.03), CV mortality (RR = 0.84; 95% CI, 0.59-1.18), MI (RR = 0.47; 95% CI, 0.2-1.11) and stroke (RR = 1.26; 95% CI, 0.7-2.26).
Results were similar for all-cause mortality (RR = 1.03; 95% CI, 0.92-1.16), CV mortality (RR = 0.69; 95% CI, 0.39-1.24), MI (RR = 0.58; 95% CI, 0.3-1.13) and stroke (RR = 0.7; 95% CI, 0.47-1.04) at 1 year.
Patients without permanent pacemaker implantation had a significantly greater improvement in LVEF vs. those with permanent pacemaker implantation (standardized mean difference, 0.22; 95% CI, 0.12-0.32).
In a related editorial, Anna Franzone, MD, PhD, and Stephan Windecker, MD, from the department of cardiology at Bern University Hospital in Switzerland, wrote the findings “are an important contribution to the field because of the reassurance that [permanent pacemaker] implantation after [TAVR] among octogenarians seems not to be associated with a measurable adverse impact on long-term clinical outcome,” they wrote. “Continued efforts should aim to refine our ability to identify patients at risk before [TAVR] to modify the procedure with the aim to minimize injury to the atrioventricular conduction system during the intervention, to design transcatheter aortic bioprosthetic devices that minimize the risk for periprocedural atrioventricular conduction block and careful clinical guidance for appropriate indications for [permanent pacemaker] implantation after [TAVR].” – by Dave Quaile
Disclosures: The researchers and Franzone report no relevant financial disclosures. Windecker reports receiving institutional research grants from Boston Scientific, Edwards Lifesciences and Medtronic.
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