Permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) is associated with increased mortality at six years, particularly in patients who are pacemaker dependent. At an abstract session at PCR London Valves 2019 (17–19 November, London, UK), Giuliano Costa (Policlinico – Vittorio Emanuele Hospital, Catania, Italy) presented an algorithm with recommendations on when to perform implantations, developed from findings on predicting the need for permanent pacing after TAVI.
Costa et al also found that, among patients undergoing PPI after TAVI, the rate of pacemaker dependency was between 33 and 36% after one year. Patients who experienced severe conduction disturbances that persisted for 24 hours had a higher likelihood of pacemaker dependency at follow up if PPI was carried out on day one following TAVI or on the same day as the TAVI procedure if they had right bundle branch block (RBBB) at baseline.
Costa pointed out that although a number of predictors of permanent pacemaker implantations after TAVI have been established in studies, it remains poorly investigated whether pacemakers implanted in this setting are really necessary. He explained: “The aim of our prospective study was to assess the appropriateness of permanent pacemaker implantation through an analysis of pacemaker dependency at follow up and to assess long-term outcomes of patients undergoing PPI after TAVI.”
Investigators assessed all consecutive patients at the centre undergoing TAVI from June 2007 to February 2018. From these, they identified 1,116 (89.8%) patients who did not have a prior pacemaker, of whom 145 (13%) had PPI within 30 days after TAVI. These were then assessed at one, six and 12 months’ post-TAVI for pacemaker dependency, predictors for dependency, and survival rates at six years. as well as predictors of PPI at 30 days and survival rates at six years for the overall cohort of 1,116 participants. Patients were treated with both balloon and self-expandable devices.
At 30 days, there were no differences in the outcome measures of all-cause death, cardiovascular death or myocardial infarction between the three cohorts (overall, n=1,116; no PPI within 30 days n=971; PPI within 30 days n=145).
Costa said: “We found that about one-third of patients were PM dependent at one, six, and 12 months’ follow up. We assessed predictors of permanent pacemaker implantation after the procedure … [and] found on multivariate analysis that right bundle branch block and a higher degree of oversizing predicts permanent implantation of a pacemaker. PPI timing was demonstrated to be a predictor of dependency, particularly when PPI was performed on day one after TAVI … at six and 12 months, and with a trend towards statistical significance at one month.”.
From their analysis, the researchers developed an algorithm for recommendations on PPI timing after TAVI. In patients who have baseline RBBB and a high degree of conduction disturbances following TAVI, they suggest immediate PPI—either on day zero or on day one—after the procedure. For patients without pre-existing RBBB, in cases where 24 hours’ rhythm monitoring has established persistent high-degree conduction disturbances, PPI could be performed on day one following TAVI with high chances that the PM is really necessary on a mid-term period; in those with intermittent or transient high degree conduction disturbances they suggest PPI be postponed, and patients have rhythm monitoring for at least 72 hours.
The key point said Costa, “is that a lot of TAVI patients had an already present disease of conduction disturbances before the procedure. They probably should undergo PPI independent of the procedure.”