Aortoventricular annulus shape as a predictor of pacemaker implantation following transcatheter aortic valve replacement

Predictors for the risk of permanent pacemaker implantation after transcatheter aortic valve replacement: A systematic review and meta-analysis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is a less invasive treatment than surgery for severe aortic stenosis. However, its use is restricted by the fact that many patients eventually require permanent pacemaker implantation (PPMI). This meta-analysis was performed to identify predictors of post-TAVR PPMI.

METHODS

The PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched. Relevant studies that met the inclusion criteria were included in the pooling analysis after quality assessment.

RESULTS

After pooling 67 studies on post-TAVR PPMI risk in 97,294 patients, balloon-expandable valve use was negatively correlated with PPMI risk compared with self-expandable valve (SEV) use (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.37-0.53). Meta-regression analysis revealed that history of coronary artery bypass grafting and higher Society of Thoracic Surgeons (STS) risk score increased the risk of PPMI with SEV utilization. Patients with pre-existing cardiac conduction abnormalities in 28 pooled studies also had a higher risk of PPMI (OR: 2.33, 95% CI: 1.90-2.86). Right bundle branch block (OR: 5.2, 95% CI: 4.37-6.18) and first-degree atrioventricular block (OR: 1.97, 95% CI: 1.38-2.79) also increased PPMI risk. Although the trans-femoral approach was positively correlated with PPMI risk, the trans-apical pathway showed no statistical difference to the trans-femoral pathway. The approach did not increase PPMI risk in patients with STS scores >8. Patient-prosthesis mismatch did not influence post-TAVR PPMI risk (OR: 0.88, 95% CI: 0.67-1.16). We also analyzed implantation depth and found no difference between patients with PPMI after TAVR and those without.

CONCLUSIONS

SEV selection, pre-existing cardiac conduction abnormality, and trans-femoral pathway selection are positively correlated with PPMI after TAVR. Pre-existing left bundle branch block, patient-prosthesis mismatch, and implantation depth did not affect the risk of PPMI after TAVR.

Long-term implications of left atrial appendage thrombus identified incidentally by pre-procedural cardiac computed tomography angiography in patients undergoing transcatheter aortic valve replacement

AIMS

The prevalence and prognostic implications of left atrial appendage (LAA) thrombus (LAAT) in patients considered for transcatheter aortic valve replacement (TAVR) are incompletely defined. We, therefore, studied pre-procedural cardiac computed tomography angiography (CCTA) scans of TAVR candidates to determine the prevalence of LAAT and its association with late outcomes.

METHODS AND RESULTS

Baseline clinical variables and CCTA findings from a prospective TAVR registry were analysed for the prevalence of pre-procedural LAAT and its impact on in-hospital outcomes and late mortality. LAAT was differentiated from LAA filling defects (LAAFD) reflecting stasis without clot. Patients (n = 561) with complete in-hospital and late mortality data were included in the study (median follow-up 31.6 months). LAAT and LAAFD were evidenced on pre-procedural CCTA in 24 (4.3%) and 26 (4.6%) patients, respectively. One hundred fourteen (20.3%) patients died during the study period. Though in-hospital adverse event rates (including stroke) did not differ among groups, mortality at long-term follow-up was higher among LAAT patients compared with those with or without LAAFD (58.3% vs. 11.5% vs. 19.0%, respectively; P < 0.003). By multivariable analysis, LAAT (but not LAAFD) was independently associated with all-cause mortality [hazard ratio (HR) = 3.33 (1.83-6.00), P < 0.001]. In patients with LAAT, oral anticoagulation at discharge was associated with lower mortality risk, independently of atrial fibrillation status.

CONCLUSIONS

LAAT visualized by pre-procedural CCTA is an independent predictor of late mortality following TAVR, but not peri-procedural stroke. When reporting TAVR-CCTA, particular note should be made of LAA features and presence of LAAT which may have prognostic and management implications.

Predictors of pacemaker implantation after transcatheter aortic valve implantation according to kind of prosthesis and risk profile: a systematic review and contemporary meta-analysis

AIMS

Permanent pacemaker implantation (PPI) may be required after transcatheter aortic valve implantation (TAVI). Evidence on PPI prediction has largely been gathered from high-risk patients receiving first-generation valve implants. We undertook a meta-analysis of the existing literature to examine the incidence and predictors of PPI after TAVI according to generation of valve, valve type, and surgical risk.

METHODS AND RESULTS

We made a systematic literature search for studies with ≥100 patients reporting the incidence and adjusted predictors of PPI after TAVI. Subgroup analyses examined these features according to generation of valve, specific valve type, and surgical risk. We obtained data from 43 studies, encompassing 29 113 patients. Permanent pacemaker implantation rates ranged from 6.7% to 39.2% in individual studies with a pooled incidence of 19% (95% CI 16-21). Independent predictors for PPI were age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01-1.09], left bundle branch block (LBBB) (OR 1.45, 95% CI 1.12-1.77), right bundle branch block (RBBB) (OR 4.15, 95% CI 3.23-4.88), implantation depth (OR 1.18, 95% CI 1.11-1.26), and self-expanding valve prosthesis (OR 2.99, 95% CI 1.39-4.59). Among subgroups analysed according to valve type, valve generation and surgical risk, independent predictors were RBBB, self-expanding valve type, first-degree atrioventricular block, and implantation depth.

CONCLUSIONS

The principle independent predictors for PPI following TAVI are age, RBBB, LBBB, self-expanding valve type, and valve implantation depth. These characteristics should be taken into account in pre-procedural assessment to reduce PPI rates. PROSPERO ID CRD42020164043.