Permanent Pacing After Transcatheter Aortic Valve Implantation: Incidence, Predictors and Evolution of Left Ventricular Function

Leadless pacemaker implantation following tricuspid interventions: multicenter collaboration of feasibility and safety

BACKGROUND

Permanent pacing is often required following valve intervention (either surgical or percutaneous); however, tricuspid interventions pose specific challenges to conventional pacing. Therefore, leadless pacemaker (LP) implantation may be the preferred strategy when permanent pacing is required after tricuspid valve intervention.

PURPOSE

To report periprocedural outcomes and follow-up of patients undergoing implantation of a LP system following tricuspid valve interventions.

METHODS

Patients with previous tricuspid valve intervention at the time of attempted implantation of a LP (MicraTM, Medtronic, Minneapolis, MN, USA) were included.

RESULTS

Between 2019 and 2022, 40 patients underwent LP implantations following tricuspid interventions in 5 large tertiary centers. The mean age was 68.9 ± 13.7 years, and 48% patients were male. The indication for pacing was as following: AVB in 27 (68%) patients, AF with slow ventricular response in 10 (25%) patients, and refractory rapid atrial fibrillation (AF) referred to AV junction ablation in 3 (7%) patients. Most of the patients received Micra VR (78%). The procedure was successful in all patients. The mean procedural time is 58 ± 32 min, and the median fluoroscopy time is 7.5 min. Electrical parameters were within normal range (threshold: 1.35 ± 1.2 V@0.24 ms, impedance: 772 ± 245 Ohm, R-wave: 6.9 ± 5.4 mV). No acute complications were observed. During a mean follow-up of 10 months, electrical parameters remained stable, and 4 deaths were occurred (not related to the procedure).

CONCLUSION

A LP is a safe and efficient option following tricuspid valve interventions.

Temporal Trends in Transcatheter Aortic Valve Implantation: 10-Year Analysis of the TAVIDOR Registry

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has established itself as the preferential strategy to approach severe aortic stenosis. Information on procedural improvements and nationwide results obtained with the technique throughout the past decade are unknown.

OBJECTIVES

To assess the temporal variation of the demographic profile, procedural characteristics, and in-hospital outcomes of patients undergoing TAVI procedures at the Rede D'Or São Luiz.

METHODS

Observational registry comprising 29 national institutions, comparing the characteristics of the TAVI procedures performed from 2012 to 2017 (Group 1) to those performed from 2018 to 2023 (Group 2). The statistical significance level adopted was p < 0.05.

RESULTS

This study assessed 661 patients, 95 in Group 1 and 566 in Group 2, with a mean age of 81.1 years. Group 1 patients had a higher prevalence of New York Heart Association functional class III or IV and STS risk score > 8%. In addition, they more often underwent general anesthesia, transesophageal echocardiographic monitoring, and access through femoral dissection. Group 2 patients had a higher success rate of the TAVI procedure (95.4% versus 89.5%; p = 0.018), lower mortality (3.9% versus 11.6%; p = 0.004), and less often needed permanent pacemaker implantation (8.5% versus 17.9%; p = 0.008).

CONCLUSIONS

The 10-year temporal trends analysis of the TAVIDOR Registry shows a reduction in patients' clinical complexity over time. Furthermore, the advance to minimalistic implantation techniques, added to the technological evolution of the devices, may have contributed to the favorable outcomes observed among those whose implantation occurred in the last 5 years studied.

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.

Permanent pacemaker dependency in patients with new left bundle branch block and new first degree atrioventricular block after transcatheter aortic valve implantation

Conduction disorders with need for permanent pacemaker (PPM) implantation remain frequent complications after transcatheter aortic valve implantation (TAVI). Up to 22% of PPM after TAVI are implanted for new onset left bundle branch block (LBBB) and atrioventricular block (AVB) I. However, clinical benefit and predictors of ventricular pacing in TAVI patients receiving PPM for this indication remain unclear. We retrospectively evaluated pacemaker interrogation data of patients who received a PPM post TAVI for new LBBB and new AVB I. The primary endpoint of this study was relevant ventricular pacing (ventricular pacing rate: Vp ≥ 1%) at the first outpatient pacemaker interrogation. Secondary endpoints were predictors for relevant ventricular pacing. At the first pacemaker interrogation (median follow up at 6.23 [2.8–14.8] months), median ventricular pacing frequency was 1.0% [0.1–17.8]. Out of 61 patients, 36 (59%) had Vp rates ≥ 1%. Patients with frequent ventricular pacing showed longer QRS duration (155 ms ± 17 ms vs. 144 ms ± 18 ms, p = 0.018) at the time of PPM implantation and were less likely treated with a balloon-expandable Edwards Sapiens Valve (39% vs. 12%, p = 0.040). Our findings suggest that the majority of patients with new LBBB and new AVB I after TAVI show relevant ventricular pacing rates at follow up. Further prospective studies are necessary to identify patients at higher risk of pacemaker dependency.

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.

Comparison of Procedural and 1-Year Clinical Results of Transcatheter Aortic Valve Implantation Using Prostheses with Different Design of Support Frame

Our study aimed to investigate whether the frame design of transcatheter heart valve (THV) affects the procedural and clinical results of transcatheter aortic valve implantation (TAVI).We retrospectively reviewed 163 patients with aortic stenosis who underwent TAVI using different types of THV (Edwards SAPIEN, n = 31; Venus-A, n = 63; and J-Valve, n = 69). The procedural outcomes and follow-up results for 1-year were compared among groups.The patients who underwent TAVI using J-Valve had a higher mean transaortic pressure gradient than those using SAPIEN or Venus-A after TAVI (1-year follow-up; P = 0.017, P < 0.001, respectively), whereas no difference was observed between the patients with SAPIEN and Venus-A prosthesis (P = 0.150). The incidence of permanent pacemaker implantation was highest in patients with Venus-A (19.0%), followed by SAPIEN (9.7%), and lowest in J-Valve (4.3%) (P = 0.025). No difference was observed in the 30-day mortality rate among the groups (P = 1.000). Moreover, Kaplan-Meier survival analysis revealed that there was no significant difference in the 1-year cumulative patient survival rate among three patient cohorts (log-rank, P = 0.850).The frame design of THVs could affect the valve-related hemodynamics and the incidence of permanent pacemaker implantation in TAVI, whereas it did not influence the survival rate of TAVI patients during 1-year follow-up period. All three THVs provided a convincing short-term outcome for TAVI patients.

Conduction disturbances in low-surgical-risk patients undergoing transcatheter aortic valve replacement with self-expandable or balloon-expandable valves

Despite a considerable improvement in TAVR devices and procedures, together with a reduction in procedural complications, the rate of conduction disturbances (CD) remained stable over the years. Indeed, the CD rate is still significantly higher than in surgical aortic valve replacement, and represents one of the main limitations to the expansion of TAVR to younger low-risk patients. The aim of the present study was to assess the incidence and predictors of CD in low-risk patients undergoing TAVR. Among 637 patients without preexisting CD who underwent TAVR, 116 (18.2%) were considered at low surgical risk. Up to 25% of low-risk patients presented with persistent CD at discharge. The pacemaker implantation rate was similar in the low-risk group compared to the intermediate-/high-risk group (8.7% vs 10.6%, p = 0.55). Moreover, the rate of new persistent left bundle branch block (LBBB) following TAVR was also similar between both groups (18.1% vs 22.1%, p = 0.34). At 1-year follow-up, LBBB was persistent in 62.5% of patients and 3 of them required a pacemaker implantation. Depth of valve implantation, baseline QRS duration and mean aortic transvalvular gradient were identified as independent predictors of CD in low-risk patients. Patients at low surgical risk showed an equivalent CD rate than intermediate-/high-risk patients. The depth of valve implantation was the main predictor of CD in low-risk patients undergoing TAVR. Baseline QRS duration and mean aortic transvalvular gradient were also associated with increased CD.