Delayed pacemaker requirement after transcatheter aortic valve implantation with a new-generation balloon expandable valve: Should we monitor longer?

A Systematic Review of Delayed High-Grade Atrioventricular Block After Transcatheter Aortic Valve Implantation

Background

High-grade atrioventricular block (HGAVB) is common after transcatheter aortic valve implantation (TAVI), often necessitating permanent pacemaker (PPM) implantation. Delayed HGAVB has varying definitions but typically refers to onset 48 hours after TAVI or following discharge and may cause syncope and sudden cardiac death. This review estimates the incidence of delayed HGAVB and identifies limitations of current literature.

Methods

A systematic review was performed of the following online databases: Medline, Cochrane, Web of Science, and Scopus. Studies that labelled the outcome of "delayed" or "late" atrioventricular block after TAVI were included; patients with previous PPM or aortic valve surgery were excluded. Initial search yielded 775 studies, which, after screening, was narrowed to 19 studies.

Results

Nineteen studies with 14,898 patients were included. Mean age was 81.7 years, and 46.3% were male. Mean Society of Thoracic Surgeons (STS) score was 5.6%, and 31.3% of patients had known atrial fibrillation. The most common access site was transfemoral (84.8%), whereas balloon-expandable valves were used in 62.1%, self-expanding valves in 34.0%, and mechanically expanding valves in 3.9% of cases. The incidence of delayed HGAVB ranged from 1.7% to 14.6%, with significant methodologic heterogeneity noted among the included studies.

Conclusions

Delayed HGAVB is a common and potentially serious complication of TAVI, with similar risk factors to acute HGAVB. With a move toward an early discharge strategy post-TAVI, further prospective study of delayed HGAVB is warranted to improve understanding of predisposing factors, incidence, timing, and implications.

Transcatheter aortic valve implantation (from inception to standard treatment): a single-center observational study

Background

Treatment of severe aortic stenosis with transcatheter aortic valve implantation (TAVI) was introduced in 2002. Since then, TAVI has become the primary treatment approach worldwide for advanced-age patients and younger patients with severe comorbidities. We aimed to evaluate the changes in patient demographics, complications, and mortality rates within 13 years.

Methods

This retrospective observational study included 867 patients who underwent TAVI at the University Hospital of North Norway in Tromsø from 2008 to 2021. The 13-year period was divided into period 1 (2008-2012), period 2 (2013-2017), and period 3 (2018-2021). The primary objective was to evaluate the changes in periprocedural (30 days), early (30-365 days), and late mortality rates (>365 days) between the periods. The secondary objective was to evaluate late mortality rates by sex and age groups: <70 years, 70-79 years, 80-89 years, and ≥90 years.

Results

The periprocedural mortality rates for periods 1, 2, and 3 were 10.3%, 2.9%, and 1.2%, respectively (P < 0.001). The early mortality rates were 5.6%, 5.8%, and 6.5%, respectively. No significant differences were observed in late mortality by sex or age group (<70, 70-79, and 80-89 years) with a median survival of 5.3-5.6 years. The median survival in patients aged ≥90 years was 4.0 years (P = 0.018).

Conclusion

Our findings indicate that most patients are octogenarians, and the burden of their comorbidities should be highly considered compared to their age when evaluating the procedural outcomes. As the incidence of most complications related to TAVI has decreased, the rates of permanent pacemaker implantation remain high. Important advancements in diagnostics, valve technology, and procedural techniques have improved the periprocedural mortality rates; however, early mortality remains unchanged and poses a clinical challenge that needs to be addressed in the future.

Sex differences in permanent pacemaker implantation after transcatheter aortic valve replacement: a systematic review and meta-analysis

BACKGROUND

There is limited evidence on the effect of sex on permanent pacemaker implantation (PPMI) after transcatheter aortic valve replacement (TAVR). The primary objective of this meta-analysis was to determine the role of sex among patients requiring PPMI post-TAVR.

METHODS

A literature search was conducted using the SCOPUS, MEDLINE, and CINAHL databases for studies published until October 2022. Eligible studies included published randomized controlled trials (RCTs) and Observational Cohort Studies (OCS) articles that reported PPMI as an outcome of pacemaker status following TAVR. This study was performed per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. Publication bias was estimated using a Funnel plot and Egger's test. Data were pooled using a random-effects model. The primary endpoint was the sex difference in PPMI after TAVR, with odds ratios and 95% confidence intervals (CIs) extracted.

RESULTS

Data was obtained from 63 studies, and a total of 79,655 patients were included. The cumulative PPMI rate was 15.5% (95% CI, 13.6%-17.7%). The pooled analysis revealed that while there were more females than males undergoing TAVR (51.6%, 95% CI 50.4%-52.8%), males have a 14.5% higher risk for post-TAVR PPMI than females (OR 1.145, 95% CI 1.047-1.253, P < 0.01).

CONCLUSIONS

Males are more likely to experience PPMI after TAVR than females. Further research needs to be done to better explain these observed differences in outcomes.

Impact of Bundle Branch Block on Permanent Pacemaker Implantation after Transcatheter Aortic Valve Implantation: A Meta-Analysis

Data regarding the impact of infra-Hisian conduction disturbances leading to permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) remain limited. The aim of this study was to determine the impact of right and/or left bundle branch block (RBBB/LBBB) on post-TAVI PPI. We performed a systematic literature review to identify studies reporting on RBBB and/or LBBB status and post-TAVI PPI. Study design, patient characteristics, and the presence of branch block were analyzed. Odds ratios (ORs) with 95% CI were extracted. The final analysis included 36 studies, reporting about 55,851 patients. Data on LBBB were extracted from 33 studies. Among 51,026 patients included, 5503 showed pre-implant LBBB (11.9% (10.4%–13.8%)). The influence of LBBB on post-TAVI PPI was not significant OR 1.1474 (0.9025; 1.4588), p = 0.2618. Data on RBBB were extracted from 28 studies. Among 46,663 patients included, 31,603 showed pre-implant RBBB (9.2% (7.3%–11.6%)). The influence of RBBB on post-TAVI PPI was significant OR 4.8581 (4.1571; 5.6775), p < 0.0001. From this meta-analysis, the presence of RBBB increased the risk for post-TAVI PPI, independent of age or LVEF, while this finding was not confirmed for patients experimenting with LBBB. This result emphasizes the need for pre-operative evaluation strategies in patient selection for TAVI.

Do Women Require Less Permanent Pacemaker After Transcatheter Aortic Valve Implantation? A Meta-Analysis and Meta-Regression

Background

Limited clinical evidence and literature are available about the potential impact of sex on permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI). The aim of this work was to evaluate the relationship between sexes and atrioventricular conduction disturbances requiring PPI after TAVI.

Methods and Results

Data were obtained from 46 studies from PubMed reporting information about the impact of patient sex on PPI after TAVI. Total proportions with 95% Cls were reported. Funnel plot and Egger test were used for estimation of publication bias. The primary end point was 30‐day or in‐hospital PPI after TAVI, with odds ratios and 95% CIs extracted. A total of 70 313 patients were included, with a cumulative proportion of 51.5% of women (35 691 patients; 95% CI, 50.2–52.7). The proportion of women undergoing TAVI dropped significantly over time (P<0.0001). The cumulative PPI rate was 15.6% (95% CI, 13.3–18.3). The cumulative rate of PPI in women was 14.9% (95% CI, 12.6–17.6), lower than in men (16.6%; 95% CI, 14.2–19.4). The risk for post‐TAVI PPI was lower in women (odds ratio, 0.90; 95% CI, 0.84–0.96 [P=0.0022]). By meta‐regression analysis, age (P=0.874) and ventricular function (P=0.302) were not significantly associated with PPI among the sexes. Balloon‐expandable TAVI significantly decrease the advantage of women for PPI, approaching the same rate as in men (P=0.0061).

Conclusions

Female sex is associated with a reduced rate of PPI after TAVI, without influence of age or ventricular function. Balloon‐expandable devices attenuate this advantage in favor of women. Additional investigations are warranted to elucidate sex‐based differences in developing conduction disturbances after TAVI.

Predictors of permanent pacemaker insertion after TAVR: A systematic review and updated meta-analysis

OBJECTIVES

The aim of this analysis was to evaluate the predictors associated with increased risk of permanent pacemaker implantation (PPMI) following transcatheter aortic valve replacement (TAVR).

BACKGROUND

While TAVR has evolved as the standard of care for patients with severe aortic stenosis, conduction abnormalities leading to the need for PPMI is one of the most common postprocedural complications.

METHODS

A systematic literature search was performed to identify relevant trials from inception to May 2020. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints.

RESULTS

Thirty-seven observational studies with 71 455 patients were identified. The incidence of PPMI following TAVR was 22%. Risk was greater in men and increased with age. Patients with diabetes mellitus, presence of right bundle branch block, baseline atrioventricular conduction block, and left anterior fascicular block were noted to be at higher risk. Other significant predictors include the presence of high calcium volume in the area below the left coronary cusp and noncoronary cusp, use of self-expandable valve over balloon-expandable valve, depth of implant, valve size/annulus size, predilatation balloon valvuloplasty, and postimplant balloon dilation.

CONCLUSION

Fourteen factors were found to be associated with increased risk of PPMI after TAVR, suggesting early identification of high-risk populations and targeting modifiable risk factors may aid in reducing the need for this post TAVR PPMI.

Use of Electrophysiological Studies in Transcatheter Aortic Valve Implantation

New conduction disturbances requiring permanent pacemaker implantation remain common complications following transcatheter aortic valve implantation (TAVI). It has been suggested that electrophysiological studies could help identify patients who will require permanent pacemaker implantation after TAVI. This article summarises contemporary data on the use of electrophysiological studies in patients undergoing TAVI.

Late onset of new conduction disturbances requiring permanent pacemaker implantation following TAVI

Background

The timing of onset and associated predictors of late new conduction disturbances (CDs) leading to permanent pacemaker implantation (PPI) following transcatheter aortic valve implantation (TAVI) are still unknown, however, essential for an early and safe discharge. This study aimed to investigate the timing of onset and associated predictors of late onset CDs in patients requiring PPI (LCP) following TAVI.

Methods and results

We performed retrospective analysis of prospectively collected data from five large volume centres in Europe. Post-TAVI electrocardiograms and telemetry data were evaluated in patients with a PPI post-TAVI to identify the onset of new advanced CDs. Early onset CDs were defined as within 48 hours after procedure, and late onset CDs as after 48 hours. A total of 2804 patients were included for analysis. The PPI rate was 12%, of which 18% was due to late onset CDs (>48 hours). Independent predictors for LCP were pre-existing non-specific intraventricular conduction delay, pre-existing right bundle branch block, self-expandable valves and predilation. At least one of these risk factors was present in 98% of patients with LCP. Patients with a balloon-expandable valve without predilation did not develop CDs requiring PPI after 48 hours.

Conclusions

Safe early discharge might be feasible in patients without CDs in the first 48 hours after TAVI if no risk factors for LCP are present.

Late ventricular standstill following an elective TAVI

Transcatheter aortic valve implantations (TAVIs) may be complicated by a need for permanent pacemaker implantation post procedure, usually due to local trauma or compression on the conduction system. There are some features that might help predict that a patient is high risk for developing conduction disease following TAVI, for example, underlying right bundle branch block or use of certain types of TAVI. It might also become apparent during the procedure, or before temporary wire removal post procedure. Higher risk patients may undergo rhythm monitoring for longer periods post TAVI. We present a case where a patient required an unexpected emergency pacemaker following a TAVI, despite low risk clinical features, a low risk baseline ECG, and the use of a low risk TAVI valve. In addition, this very significant conduction disease only became apparent over 72 hours following implantation, despite normal resting ECGs and telemetry up to that point.

[Transcatheter aortic valve implantation and conduction disturbances]

Transcatheter aortic valve implantation (TAVI) is currently becoming the treatment of choice for patients with calcific aortic stenosis. Despite several technical improvements, the incidence of conduction disturbances has not diminished and remains TAVI's major complication. These disturbances include the occurrence of left bundle branch block and/or high-grade atrioventricular block often requiring pacemaker implantation. The proximity of the aortic valve to the conduction system (conduction pathways) accounts for the occurrence of these complications. Several factors have been identified as carrying a high risk of conduction disturbances like the presence of pre-existing right bundle branch block, the type of valve implanted, the volume of aortic and mitral calcifications, the size of the annulus and the depth of valve implantation. Left bundle branch block is the most frequent post TAVI conduction disturbance. Whereas the therapeutic strategy for persistent complete atrioventricular block is simple, it becomes complex in the presence of fluctuating changes in PR interval and left bundle branch block duration. The QRS width threshold value (150-160 ms) indicative of the need for pacemaker implantation is still being debated. Although there are currently no recommendations regarding the management of these conduction disturbances, the extension of TAVI indications to patient at low surgical risk calls for a standardization of our practice. However, a decision algorithm was recently proposed by a group of experts composed of interventional cardiologists, electrophysiologists and cardiac surgeons. There are still uncertainties about the appropriate timing of pacemaker implantation and the management of new onset left bundle branch block.

One-Year Follow-Up of Conduction Abnormalities After Transcatheter Aortic Valve Implantation With the SAPIEN 3 Valve

Long-term evolution of new-onset conduction abnormalities and need of permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) have not been extensively evaluated. We describe the incidence and time course of new conduction abnormalities and the rate of PPI with the new-generation transcatheter aortic valve prosthesis Edwards SAPIEN 3 (S3). In total, 266 patients with severe aortic stenosis who underwent TAVI were retrospectively analyzed. Twelve-lead electrocardiograms at baseline, after TAVI, at discharge, at 1-, 6-, and 12-month follow-up were evaluated to identify conduction abnormalities and PPI requirements to investigate the correlates of PPI. After TAVI, a significant increase in PR interval duration and in QRS complex width was observed. New-onset left bundle branch block was observed in 65 patients (24%) after TAVI. The number of patients with left bundle branch block was maximum at hospital discharge and decreased at 12-month follow-up (39% and 32%, respectively). Thirty-five patients (13%) required PPI during the follow-up. However, paced rhythm was only observed in 7% of the patients with a complete 12-month follow-up. Patients who underwent PPI had a higher prevalence of first-degree atrioventricular block, complete right bundle branch block, and wider QRS complex at baseline. Baseline right bundle branch block and QRS width immediately after TAVI were the only variables independently associated with PPI. In conclusion, conduction disorders have a temporary nature after TAVI and showed a trend toward stabilization during the following months. With this new-generation device, the incidence of new conduction abnormalities requiring PPI is relatively low.