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Atrial Pacing Predicts Pacemaker Need After TAVR
Study Questions:
Can right atrial pacing immediately after transcatheter aortic valve replacement (TAVR) predict the need for permanent pacemaker implantation (PPI)?
Methods:
Consecutive patients undergoing TAVR at two centers were included. After valve implantation in patients without a pacemaker and who did not have complete heart block or atrial fibrillation, the temporary pacemaker was withdrawn from the right ventricle and placed in the right atrium. Right atrial pacing was performed from 70 to 120 bpm and patients were assessed for development of Wenckebach atrioventricular block. Patients were followed for clinical outcomes including the need for PPI.
Results:
From among 284 patients, 130 (45.8%) developed Wenckebach. There was a higher rate of PPI within 30 days of TAVR among the group who developed Wenckebach (13.1 vs. 1.3%, p < 0.001) with a negative predictive value for PPI in the no Wenckebach group of 98.7%. A greater percentage of those patients receiving a self-expanding valve (SEV) required PPI than those receiving a balloon-expandable valve (BEV) (15.9% vs. 3.7%, p = 0.001), although these rates were still relatively low among patients who did not develop Wenckebach (2.9% and 0.8%).
Conclusions:
Atrial pacing post-TAVR is easily performed and can help identify those patients who may benefit from extended rhythm monitoring. Those patients who did not develop pacing-induced Wenckebach demonstrate an extremely low likelihood of PPI.
Perspective:
Some risk factors for the PPI requirement post-TAVR are pre-existing right-bundle branch block, intraprocedural complete heart block, the degree of left ventricular outflow tract calcification, new left bundle branch block, and use of self-expandable valves. Some cases of sudden death after TAVR are related to the development of advanced heart block. The current study suggests that lack of right atrial pacing-induced Wenckebach up to 120 bpm block is associated with very low risk for post-TAVR PPI. The utility of this study is limited because almost half of patients developed Wenckebach. The positive predictive value was not provided in the manuscript, but must have been exceedingly poor.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease
Keywords: Arrhythmias, Cardiac, Atrial Appendage, Atrial Fibrillation, Atrioventricular Block, Bundle-Branch Block, Cardiac Surgical Procedures, Death, Sudden, Cardiac, Heart Valve Diseases, Heart Valve Prosthesis, Pacemaker, Artificial, Transcatheter Aortic Valve Replacement
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