Despite decreasing rates of permanent pacemaker implantation (PPI) after TAVR, substantial site-level variation persists, suggesting the need for quality improvement initiatives like replicating best practices from high-performing sites and increased guideline-based education, according to a recent study published in JACC: Cardiovascular Interventions.

Using data captured by the STS/ACC TVT Registry, Amit N. Vora, MD, MPH, FACC, et al., included 184,452 TAVR procedures across 653 sites from 2016 to 2020, looking to investigate site-level variation and temporal trends of in-hospital and 30-day PPI after TAVR.

The overall rate of PPI was 11.3% and trended downward over time. Patients who underwent PPI were older and more likely to be male, have diabetes, prior atrial fibrillation, prior conduction defects, or higher STS Predicted Risk of Mortality scores when compared to those who did not experience the complication (p<0.001 for all).

Wide variation was noted across sites with the PPI rate ranging from 0%-36.4%. After adjusting for annualized volume, the authors identified 34 sites with PPI rates above the 95th percentile confidence interval (CI), 28 sites with rates below and wide variation among the remaining sites.

Even after accounting for patient-level factors, site variation in the probability of PPI persisted (median odds ratio, 1.39; 95% CI, 1.35-1.43; p<0.001). While some variation was explained by the addition of valve type, residual variation remained prevalent in additional models incorporating site-level covariates like annualized volume, region, teaching status and hospital beds. The study’s analysis did not reveal specific site-level indicators of higher rates of PPI.

“Our study highlights the importance of collecting more granular procedure-specific data, specifically with respect to accurate implantation depth, to develop more accurate risk-prediction models,” state the authors. “Additionally, more granular data collection with respect to the precise indication for [PPI] may be helpful to characterize why [PPI] is occurring.”

In an accompanying editorial comment, François Philippon, MD, agrees that “the [PPI] rate post-TAVR should be a performance metric and that the value of these prospective registries could be improved by adding more granular data on conduction disturbances, [electrocardiogram] analysis, and [permanent pacemaker] interrogation over time.”