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Outcomes of Pacemaker Implantation After TAVR
Study Questions:
What are the incidence, predictors, and outcomes of permanent pacemaker (PPM) implantation in patients treated with transcatheter aortic valve replacement (TAVR)?
Methods:
This registry examined 9,785 patients from 229 sites treated with TAVR, and evaluated the rates, predictors, and outcomes in patients requiring a PPM.
Results:
Of the 9,785 patients in the registry, 651 (6.7%) required a PPM within 30 days of TAVR. PPM implantation was more common in patients with self-expanding versus balloon-expandable valves (25.1% vs. 4.3%). On multivariable analysis, variables associated with risk of PPM implantation included increased age (odds ratio [OR], 1.1 per 5 years; p = 0.03), prior conduction defect (OR, 1.9; p < 0.001), valve area when ≤0.75 cm2 (OR, 1.2 per 0.25 cm2; p = 0.045), self-expanding device (OR, 7.6; p < 0.001), prior aortic valve procedure (OR, 0.7; p = 0.02), home oxygen use (OR, 0.7; p = 0.01), and procedure time (OR, 0.95 per 30 minutes; p = 0.02). PPM implantation was associated with increased median hospital stay (7 vs. 6 days, p < 0.001). After multivariable adjustment, PPM implantation was associated with increased risk of mortality (hazard ratio [HR], 1.3; p = 0.003) and a composite of mortality or heart failure admission (HR, 1.3; p < 0.001) at 1 year.
Conclusions:
PPM implantation after TAVR is a common complication of the procedure, and is associated with increased mortality.
Perspective:
Consistent with prior studies, this registry finds a large increase in the rate of PPM implantation in patients treated with a self-expanding TAVR prosthesis. While other factors were also associated with the need for a PPM, the choice of prosthesis type remains one of the largest modifiable risk factors for a PPM. What is new about this study is that it finds that PPM implantation after TAVR is associated with a 33% increased risk of mortality at 1 year. While this was not observed in prior smaller studies, the larger sample size of this study provides more statistical power to detect differences in outcomes between groups. These results should be interpreted cautiously given the inherent limitations of registry data, and further study is needed to investigate these findings.
Keywords: Arrhythmias, Cardiac, Cardiac Surgical Procedures, Heart Conduction System, Heart Failure, Heart Valve Diseases, Length of Stay, Pacemaker, Artificial, Prostheses and Implants, Risk Factors, Transcatheter Aortic Valve Replacement, Treatment Outcome
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