Permanent Pacemaker Implantation After TAVI
Two-hundred-and-fifty-eight consecutive patients underwent TAVI during the study period. Twenty-three patients had a preexisting PPM and 1 patient had a third-degree AVB, but no PPM, prior to the TAVI procedure. These 24 patients were excluded from the analysis, leaving a total of 234 patients. The baseline characteristics are shown in Table 1.
Sixty-four patients (27.4%) received a PPM within the first 30 days of TAVI, and 53 of them had a TAVI-related PPM indication. Forty-six patients (19.7%) had a TAVI-related absolute indication and 7 patients (3.0%) had a TAVI-related relative indication (Figure 1).
(Enlarge Image)
Figure 1.
Flow chart of study patients. Indications for permanent pacemaker (PPM) in all the patients without a prior PPM before transcatheter aortic valve implantation (TAVI). AVB = atrioventricular block; LBBB = left bundle branch block.
The median time for a clinical decision and implantation of PPM within the periprocedural period was 5 days (IQR, 2–6 days) and 8 days (IQR, 6–11 days) after the TAVI procedure, respectively.
Six of the 234 TAVI patients (2.6%) had a relative indication for PPM after TAVI during their hospital stay, but did not have a PPM implanted (Figure 1). Five of these patients were alive without the need for a PPM at the data collection time. The sixth patient died of a non-cardiac cause 151 days after the TAVI procedure.
At time of follow-up, a total of 6 of the 64 patients who received a procedure-related PPM had died and 45 of the remaining patients agreed to return for reassessment of their CA (39 patients with a TAVI-related indication and 6 patients with a non-TAVI related indication). The first follow-up was performed at a mean of 371 ± 272 days (range, 64–1187 days) after their TAVI. The reason for not participating in the follow-up study in all 13 patients was the inconvenience of a long travel distance to the hospital.
Of the 46 patients who received a PPM within the first 30 days after the TAVI procedure due to a TAVI-related absolute indication, a total of 41 patients were alive at follow-up and 32 of these patients returned for a review (Figure 2). There was no significant difference in age, prior PR interval and QRS duration, MCV prosthesis size, or valve depth between the patients who completed their follow-up (n = 32) and those who did not (n = 14).
(Enlarge Image)
Figure 2.
Findings from the reevaluation of PPM indication for patients with TAVI-related absolute and relative indications for permanent pacemaker (PPM). F/U = follow-up; N = number.
At the first follow-up assessment, a total of 19 of these 32 patients (59%) no longer had CA that could be considered a TAVI-related absolute indication for PPM implantation (Figure 2). Six of the 19 patients did not agree for their PPM to be reprogrammed in order to avoid the need to return for a second follow-up visit. The other 13 patients had their PPM reprogrammed to an on-demand pacing rate of 40 bpm (4 patients to the modus VVI and the rest to DDD) and were reassessed 56 ± 18 days later. At the reassessment, 11 of 13 patients (84.6%) showed a persistent resolution of their initial CA with ventricular sensed (v-sense) activities 99.5% of the time (IQR, 98.4%-99.6%) (Figure 2). The other 2 patients were PPM-dependent; 1 had intermittent third-degree AVB and 1 had atrial fibrillation without bundle branch block. Both of these patients required pacing activity from their PPM for more than 3% of the time during the second follow-up period.
Except for higher prevalence of a prior acute myocardial infarction, the patients with resolution of their absolute indication (n = 11) were similar to those with persistent absolute indication (n = 15) in their baseline characteristics, prosthetic sizes, and the depth of valve implantation (Table 2).
Of the 7 patients with a relative indication for PPM after TAVI, a total of 6 no longer had any indication for PPM and 1 developed third-degree AVB when assessed 307 days after the TAVI procedure (Figure 2).
Based on the baseline ECG, the PPM patients had longer PR interval and QRS duration than the non-PPM patients (Table 1). Due to the influence of pacing on PR interval and QRS duration, the progression of these variables over time was only analyzed in 170 non-PPM patients (Figure 3).
(Enlarge Image)
Figure 3.
Electrocardiogram analyses of the patients without the need for a permanent pacemaker ≤30 days after transcatheter aortic valve implantation (TAVI), showing the changes in (A)PR and (B)QRS intervals in milliseconds (ms) during and beyond the periprocedural period compared to those at the baseline levels. *P>.05; †P<.05; ‡P<.001.
The mean PR interval increased after TAVI, reaching a maximum on day 4–6 (204 ± 56 ms vs 177 ± 34 ms; P<.001) before gradually returned to baseline level after the periprocedural period (Figure 3A). A similar trend was observed with the QRS duration, which increased early after TAVI to reach a maximum on day 7–9 (137 ± 49 ms vs 102 ± 21 ms; P<.001) and before returning close to the baseline level after the periprocedural period (Figure 3B).
Results
Two-hundred-and-fifty-eight consecutive patients underwent TAVI during the study period. Twenty-three patients had a preexisting PPM and 1 patient had a third-degree AVB, but no PPM, prior to the TAVI procedure. These 24 patients were excluded from the analysis, leaving a total of 234 patients. The baseline characteristics are shown in Table 1.
Sixty-four patients (27.4%) received a PPM within the first 30 days of TAVI, and 53 of them had a TAVI-related PPM indication. Forty-six patients (19.7%) had a TAVI-related absolute indication and 7 patients (3.0%) had a TAVI-related relative indication (Figure 1).
(Enlarge Image)
Figure 1.
Flow chart of study patients. Indications for permanent pacemaker (PPM) in all the patients without a prior PPM before transcatheter aortic valve implantation (TAVI). AVB = atrioventricular block; LBBB = left bundle branch block.
The median time for a clinical decision and implantation of PPM within the periprocedural period was 5 days (IQR, 2–6 days) and 8 days (IQR, 6–11 days) after the TAVI procedure, respectively.
Relative Indication for PPM Without PPM Implantation
Six of the 234 TAVI patients (2.6%) had a relative indication for PPM after TAVI during their hospital stay, but did not have a PPM implanted (Figure 1). Five of these patients were alive without the need for a PPM at the data collection time. The sixth patient died of a non-cardiac cause 151 days after the TAVI procedure.
Follow-up
At time of follow-up, a total of 6 of the 64 patients who received a procedure-related PPM had died and 45 of the remaining patients agreed to return for reassessment of their CA (39 patients with a TAVI-related indication and 6 patients with a non-TAVI related indication). The first follow-up was performed at a mean of 371 ± 272 days (range, 64–1187 days) after their TAVI. The reason for not participating in the follow-up study in all 13 patients was the inconvenience of a long travel distance to the hospital.
Absolute Indication for PPM
Of the 46 patients who received a PPM within the first 30 days after the TAVI procedure due to a TAVI-related absolute indication, a total of 41 patients were alive at follow-up and 32 of these patients returned for a review (Figure 2). There was no significant difference in age, prior PR interval and QRS duration, MCV prosthesis size, or valve depth between the patients who completed their follow-up (n = 32) and those who did not (n = 14).
(Enlarge Image)
Figure 2.
Findings from the reevaluation of PPM indication for patients with TAVI-related absolute and relative indications for permanent pacemaker (PPM). F/U = follow-up; N = number.
At the first follow-up assessment, a total of 19 of these 32 patients (59%) no longer had CA that could be considered a TAVI-related absolute indication for PPM implantation (Figure 2). Six of the 19 patients did not agree for their PPM to be reprogrammed in order to avoid the need to return for a second follow-up visit. The other 13 patients had their PPM reprogrammed to an on-demand pacing rate of 40 bpm (4 patients to the modus VVI and the rest to DDD) and were reassessed 56 ± 18 days later. At the reassessment, 11 of 13 patients (84.6%) showed a persistent resolution of their initial CA with ventricular sensed (v-sense) activities 99.5% of the time (IQR, 98.4%-99.6%) (Figure 2). The other 2 patients were PPM-dependent; 1 had intermittent third-degree AVB and 1 had atrial fibrillation without bundle branch block. Both of these patients required pacing activity from their PPM for more than 3% of the time during the second follow-up period.
Except for higher prevalence of a prior acute myocardial infarction, the patients with resolution of their absolute indication (n = 11) were similar to those with persistent absolute indication (n = 15) in their baseline characteristics, prosthetic sizes, and the depth of valve implantation (Table 2).
Relative Indication for PPM
Of the 7 patients with a relative indication for PPM after TAVI, a total of 6 no longer had any indication for PPM and 1 developed third-degree AVB when assessed 307 days after the TAVI procedure (Figure 2).
ECG Findings
Based on the baseline ECG, the PPM patients had longer PR interval and QRS duration than the non-PPM patients (Table 1). Due to the influence of pacing on PR interval and QRS duration, the progression of these variables over time was only analyzed in 170 non-PPM patients (Figure 3).
(Enlarge Image)
Figure 3.
Electrocardiogram analyses of the patients without the need for a permanent pacemaker ≤30 days after transcatheter aortic valve implantation (TAVI), showing the changes in (A)PR and (B)QRS intervals in milliseconds (ms) during and beyond the periprocedural period compared to those at the baseline levels. *P>.05; †P<.05; ‡P<.001.
The mean PR interval increased after TAVI, reaching a maximum on day 4–6 (204 ± 56 ms vs 177 ± 34 ms; P<.001) before gradually returned to baseline level after the periprocedural period (Figure 3A). A similar trend was observed with the QRS duration, which increased early after TAVI to reach a maximum on day 7–9 (137 ± 49 ms vs 102 ± 21 ms; P<.001) and before returning close to the baseline level after the periprocedural period (Figure 3B).
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