Dataset Information

Predictors of ventricular pacing burden after permanent pacemaker implantation following transcatheter aortic valve replacement.

ABSTRACT:

Background

In the era of an expanding use of transcatheter aortic valve replacement (TAVR), conduction disturbances and the requirement for permanent pacemaker (PPM) implantation remains a clinical concern.

Hypothesis

Using a single-center experience, we sought to identify predictors of ventricular pacing burden after TAVR in patients who required PPM implantation.

Methods

We conducted a retrospective study of 359 consecutive patients with symptomatic severe aortic valve stenosis who underwent TAVR at our institution between September 2013 and July 2019. Thirty patients (8.4%) required a PPM within 30 days after TAVR. Pre and post-TAVR electrocardiograms, pre-TAVR echocardiograms and computed tomography (CT), TAVR procedural details and post-TAVR device interrogation records at 1, 3, and 6 months were reviewed.

Results

Mean percentage of ventricular pacing (VP%) at 1, 3, and 6 months was 58%, 59%, and 56% respectively. Using univariate logistic regression analysis, patients who had low VP% < 5% at 6 months were more likely to have a prosthesis/echocardiography-derived left ventricular outflow tract (LVOT) diameter ratio < 1.3 (OR 7.00, P-value .048), prosthesis/CT-derived aortic annulus diameter ratio < 1.02 (OR 7.11, P-value .047), post-TAVR new-onset LBBB (OR 16.80, P-value .019), time to PPM implantation greater than 2 days post-TAVR (OR 9.38, P-value .026) and pre-TAVR use of a beta blocker (OR 9.40, P-value .026).

Conclusions

In patients who required a PPM implantation post-TAVR, a lower TAVR prosthesis/LVOT or aortic annulus diameter ratio, post-TAVR new-onset LBBB and later time of PPM implantation showed a trend toward predicting a low VP% at 6 months.

SUBMITTER: Elzeneini M

PROVIDER: S-EPMC7661645 | biostudies-literature | 2020 Nov

REPOSITORIES: biostudies-literature

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Publications

Predictors of ventricular pacing burden after permanent pacemaker implantation following transcatheter aortic valve replacement.

Elzeneini Mohammed M Assaf Yazan Y Aalaei-Andabili Seyed Hossein SH Mahmoud Ahmad A Hamburger Robert R Goel Ramil R Bavry Anthony A AA

Clinical cardiology 20200904 11

<h4>Background</h4>In the era of an expanding use of transcatheter aortic valve replacement (TAVR), conduction disturbances and the requirement for permanent pacemaker (PPM) implantation remains a clinical concern.<h4>Hypothesis</h4>Using a single-center experience, we sought to identify predictors of ventricular pacing burden after TAVR in patients who required PPM implantation.<h4>Methods</h4>We conducted a retrospective study of 359 consecutive patients with symptomatic severe aortic valve st ...[more]

PMID: 32886389

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Project description:ImportanceThe literature is inconsistent regarding the impact of permanent pacemaker implantation after transcatheter aortic valve replacement.ObjectiveTo evaluate clinical and economic outcomes in patients who required permanent pacemaker implantation during the index hospitalization after transcatheter aortic valve replacement.Design, setting, and participantsThis retrospective, population-based cohort study using data from a multicenter registry included patients who underwent a transcatheter aortic valve replacement procedure from April 1, 2010, to March 31, 2015, in Ontario, Canada, with follow-up to March 31, 2017. Patients who had a previously implanted permanent pacemaker or who died during the index hospitalization were excluded. Inverse probability of treatment weighting using the propensity score was used to adjust for baseline differences between the pacemaker and nonpacemaker groups.ExposuresPatients received a permanent pacemaker during the index hospitalization after transcatheter aortic valve replacement.Main outcomes and measuresAll-cause mortality, readmission, readmission for heart failure, emergency department visits, and cumulative 1-year health care costs.ResultsThe study cohort consisted of 1263 patients (mean [SD] age, 82.3 [7.2] years; 595 [47.1%] female; 137 [10.8%] rural), of whom 186 (14.7%) required permanent pacemaker insertion during the index hospitalization after transcatheter aortic valve replacement. Mean follow-up was 990 days. After propensity score weighting, over the entire follow-up period, pacemaker implantation was associated with significantly higher all-cause mortality (43.9% vs 31.7%; hazard ratio [HR], 1.40; 95% CI, 1.01-1.94; P?=?.04), all-cause readmission (80.9% vs 70.6%; HR, 1.28; 95% CI, 1.15-1.43; P?<?.001), and emergency department visits (95.5% vs 87.3%; HR, 1.28; 95% CI, 1.08-1.52; P?=?.004). Pacemaker implantation was also associated with significantly greater readmission for heart failure (33.9% vs 19.1%; HR, 1.90; 95% CI, 1.53-2.36; P?<?.001). There were no statistically significant differences between groups in adjusted cumulative health care costs 1 year after discharge.Conclusions and relevanceNew permanent pacemaker implantation after transcatheter aortic valve replacement was associated with significantly greater morbidity and mortality at long-term follow-up. However, this did not translate to a difference in cumulative health care costs after hospital discharge.

Project description:BackgroundAtrioventricular conduction disturbance occurs in a significant number of patients undergoing transcatheter aortic valve replacement (TAVR). However, not all cases are ventricular pacing-dependent. Thus, we aimed to study the incidence, predictors, and outcomes of new ventricular pacing dependency (VpDep) after TAVR.MethodsWe prospectively analyzed 130 consecutive transfemoral TAVR cases performed in Ramathibodi Hospital between 2015 and 2020. Three patients with prior ventricular pacing-dependent on cardiac implantable electronic devices (CIEDs) were excluded. The endpoints were VpDep at 1 month and all-cause mortality at the follow-up period end in 2021. The effects of variables on VpDep and all-cause mortality were evaluated using multivariate binary logistic regression and Cox regression analyses, respectively. First-degree atrioventricular block (AVB) was considered severe when the PR interval was >300 ms.ResultsOf the 127 patients [mean age, 81.8 years; 62.2% females; 67.7% balloon-expandable (BE) device], 7 patients (5.5%) had CIEDs implanted before TAVR that were not ventricular pacing-dependent. TAVR was successfully performed in 126 (99.2%) patients. Periprocedural stroke, cardiac tamponade, and major bleeding occurred in 2 (1.6%), 4 (3.1%), and 4 (3.1%) patients, respectively. The VpDep incidence at 1 month was 7.9% (n=10) among all patients and 34.5% among those with CIEDs (n=29). VpDep was more likely to occur in patients with pre-existing right bundle branch block (RBBB) [odds ratio (OR), 21.38; 95% confidence interval (CI): 3.28-139.33; P=0.001] and severe 1st degree or Mobitz I AVB (OR, 14.79; 95% CI: 1.65-132.74; P=0.016). After a mean follow-up of 25.8 months [standard deviation (SD), 21.2 months], death from any cause occurred in 18 patients (14.2%). However, VpDep was not associated with an increased mortality.ConclusionsIn this real-world cohort, pre-existing conduction abnormalities were significantly associated with a higher risk of VpDep. Mortality was similar between patients with and without VpDep.

Project description:ImportancePrior studies investigating the long-term clinical outcomes of patients who have undergone permanent pacemaker implantation after aortic valve replacement reported conflicting results.ObjectiveTo investigate long-term outcomes after primary surgical aortic valve replacement among patients who underwent postoperative permanent pacemaker implantation.Design, setting, and participantsThis cohort study included all patients who underwent surgical aortic valve replacement in Sweden from 1997 to 2018. All patients who underwent primary surgical aortic valve replacement in Sweden and survived the first 30 days after surgical treatment were included. Patients who underwent preoperative permanent pacemaker implantation, concomitant surgical treatment for another valve, or emergency surgical treatment were excluded. Patients who underwent concomitant coronary artery bypass grafting or surgical treatment of the ascending aorta were included. Follow-up data were complete for all patients. Data were analyzed from October through December 2020.ExposuresPatients underwent implantation of a permanent pacemaker or implantable cardioverter defibrillator within 30 days after aortic valve replacement.Main outcomes and measuresThe primary outcome was all-cause mortality.ResultsAmong 24 983 patients who underwent surgical aortic valve replacement, 849 patients (3.4%) underwent permanent pacemaker implantation within 30 days after surgical treatment and 24 134 patients (96.6%) did not receive pacemakers in that time. The mean (SD) age of the total study population was 69.7 (10.8) years, and 9209 patients were women (36.9%). The mean (SD) and maximum follow-up periods were 7.3 (5.0) years and 22.0 years, respectively. At 10 years and 20 years after surgical treatment, the Kaplan-Meier estimated survival rates were 52.8% and 18.0% in the pacemaker group, respectively, and 57.5% and 19.6% in the nonpacemaker group, respectively. All-cause mortality was statistically significantly increased in the pacemaker group compared with the nonpacemaker group (hazard ratio [HR], 1.14; 95% CI, 1.01-1.29; P = .03), and so was risk of heart failure hospitalization (HR, 1.58; 95% CI, 1.31-1.89; P < .001). No statistically significant increase was found in the risk of endocarditis in the pacemaker group.Conclusions and relevanceThis study found that there were increased risks of all-cause mortality and heart failure hospitalization among patients who underwent permanent pacemaker implantation after surgical aortic valve replacement, suggesting that these risks are important considerations, especially in an era when transcatheter aortic valve replacement is used in younger patients at lower risk of adverse surgical outcomes. These findings further suggest that future research should investigate how to avoid permanent pacemaker dependency after surgical and transcatheter aortic valve replacement.

Dataset Information

Predictors of ventricular pacing burden after permanent pacemaker implantation following transcatheter aortic valve replacement.

Background

Hypothesis

Methods

Results

Conclusions

Publications

Predictors of ventricular pacing burden after permanent pacemaker implantation following transcatheter aortic valve replacement.

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