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Predictors of Permanent Pacemaker Implantation in Patients With Severe Aortic Stenosis Undergoing TAVR: A Meta-Analysis
Study Questions:
What are the effect estimates for clinically useful predictors of permanent pacemaker (PPM) implantation after transcatheter aortic valve replacement (TAVR)?
Methods:
A systematic search for studies that reported the incidence of PPM implantation after TAVR was performed. Data on study, patient, and procedural characteristics were abstracted. Crude risk ratios (RRs) and 95% confidence intervals for each predictor were calculated by use of random-effects models. Stratified analyses by type of implanted valve were performed.
Results:
Data were obtained from 41 studies that included 11,210 TAVR patients, of whom 17% required PPM implantation after intervention. The rate of PPM ranged from 2% to 51% in individual studies (with a median of 28% for the Medtronic CoreValve Revalving System [MCRS] and 6% for the Edwards SAPIEN valve [ESV]). The summary estimates indicated increased risk of PPM after TAVR for men (RR, 1.23; p < 0.01); for patients with first-degree atrioventricular (AV) block (RR, 1.52; p < 0.01), left anterior hemiblock (RR, 1.62; p < 0.01), or right bundle branch block (RR, 2.89; p < 0.01) at baseline; and for patients with intraprocedural AV block (RR, 3.49; p < 0.01). These variables remained significant predictors when only patients treated with the MCRS bioprosthesis were considered. The data for ESV were limited. Unadjusted estimates indicated a 2.5-fold higher risk for PPM implantation for patients who received the MCRS than for those who received the ESV.
Conclusions:
Male sex, baseline conduction disturbances, and intraprocedural AV block emerged as predictors of PPM implantation after TAVR.
Perspective:
The requirement for PPM remains a major complication following TAVR, especially after implantation of the Medtronic CoreValve. There is a lack of consensus about early PPM implantation. Some AV conduction abnormalities resolve, and, on the other hand, there may be delayed progression of AV block due to edema and the self-expanding nature of some prosthesis. PPM implantation after TAVR does not necessarily signify complete AV block in the pooled studies, as PPM implantation decisions may be influenced by the intensity of ‘physician anxiety,’ logistic considerations, and other factors. Future studies should prospectively examine the rates of progression or regression of AV conduction abnormalities after TAVR and the effects the PPM implantation have on outcomes.
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