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Post-TAVR permanent pacemaker implantation linked to adverse long-term outcomes
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New data indicate that permanent pacemaker implantation after transcatheter aortic valve replacement is associated with increased rehospitalization for HF and less improvement in left ventricular ejection fraction in the long term.
The multicenter study included 1,629 patients without pacemakers undergoing TAVR — of whom 19.8% required permanent pacemaker implantation within 30 days of the procedure.
At a median follow-up of 4 years, up to 86% of patients with permanent pacemakers exhibited pacing more than 1% of the time, with 51% of patients exhibiting pacing more than 40% of the time and 27.4% exhibiting pacing 100% of the time.
Also at follow-up, HF-related rehospitalization rates were higher in patients with permanent pacemakers (22.4% vs. 15.5%; adjusted HR = 1.42; 95% CI, 1.06-1.89), as were rates of the combined endpoint of mortality or HF rehospitalization (59.6% vs. 51.9%; aHR = 1.25; 95% CI, 1.05-1.48). There was also less improvement over time in LVEF in patients with permanent pacemaker implantation (P = .051). Differences in LVEF were most pronounced in patients with LVEF dysfunction at baseline (P = .005).
However, between patients with vs. without permanent pacemaker implantation, there were no differences in total mortality (48.5% vs. 42.9%; aHR = 1.15; 95% CI, 0.95-1.39) or CV mortality (14.9% vs. 15.5%; aHR = 0.93; 95% CI, 0.66-1.3) at follow-up, according to the data.
Of the 322 patients who required permanent pacemaker implantation after TAVR, more patients had received the self-expandable CoreValve system (Medtronic), as compared with the balloon-expandable Edwards system (Edwards Lifesciences; P < .001). Patients with permanent pacemaker implantation also were older (82 vs. 81 years; P = .011), more likely to have CAD (44.1% vs. 42%; P = .029), tended to have a higher Society of Thoracic Surgeons Risk of Mortality score (7.4% vs. 6.9%; P = .051) and more often had a right bundle branch block at baseline (26% vs. 6.5%; P < .001).
The median time from TAVR to implantation was 2 days, the most common indication was high-degree or complete atrioventricular block (71.4%) and 56.8% of pacemakers were dual-chamber.
In an accompanying editorial, John G. Webb, MD, and Janarthanan Sathananthan, MBChB, MPH, both from the Centre for Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, highlighted the need to reduce risks for complications and left bundle branch block after TAVR as well as the importance of considering various patient factors, such as right bundle branch block, before the procedure.
“Where these concerns are important, special attention should be paid to modifiable procedural (technique) and device (valve selection) factors,” they wrote. “The right valve, for the right patient, with the right implantation technique will lead to a reduction in [permanent pacemaker implantation] rates.” – by Melissa Foster
Disclosures: Chamandi reports receiving a fellowship grant from Edwards Lifesciences. Please see the study for all other authors’ relevant financial disclosures. Webb reports he is a consultant for Edwards Lifesciences and Abbott Vascular. Sathananthan reports no relevant financial disclosures.
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