Permanent Pacemaker Insertion After CoreValve Transcatheter Aortic Valve Implantation: Incidence and Contributing Factors (the UK CoreValve Collaborative)

Study Questions:

What are the incidence and determinants of permanent pacemaker (PPM) need in patients undergoing transcatheter aortic valve implantation (TAVI) using CoreValve?

Methods:

The authors evaluated the use of PPM in 270 patients undergoing CoreValve-based TAVI at 10 centers in the United Kingdom.

Results:

The study population consisted of 243 patients after excluding those with a pre-existing pacemaker (n = 25) or those with incomplete data (n = 2). QRS duration increased from 105 ± 23 to 135 ± 29 milliseconds (p < 0.01), and a new left bundle branch block developed in 105 (56.8%). A PPM was required in one third of patients (n = 81) in the first 30 days. Need for a pacemaker varied based on pre-existing electrocardiogram (ECG) abnormalities with 65% of patients with a right bundle branch block and 43% of those with a left bundle branch block needing a PPM compared with 27% of those with a normal baseline ECG. The median time to insertion was 4.0 days, with nine patients undergoing PPM on the day of TAVI. Independent predictors of PPM need were periprocedural atrioventricular block (odds ratio [OR], 6.29; 95 confidence interval [CI], 3.55-11.15), balloon predilatation (OR, 2.68; 95% CI, 2.00-3.47), use of the larger (29 mm) CoreValve prosthesis (OR, 2.50; 95% CI, 1.22-5.11), interventricular septum diameter (OR, 1.18; 95% CI, 1.10-3.06), and prolonged QRS duration (OR, 3.45; 95% CI, 1.61-7.40).

Conclusions:

PPM implantation is common in patients undergoing TAVI, especially in patients with pre-existing conduction abnormalities.

Perspective:

The need for PPM is so common in patients undergoing CoreValve TAVI that it should be considered a consequence, rather than a complication of the procedure. This is likely related to the constant outward pressure exerted by the nitinol frame of the valve and the resultant impingement of the conduction system. This study provides an easy tool to identify patients who are at risk for a PPM, and may be considered for prolonged observation after TAVI.

Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, EP Basic Science

Keywords: Prostheses and Implants, Atrioventricular Block, Great Britain, Pacemaker, Artificial, Electrocardiography


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