Pacemaker Implantation in New-Generation TAVI

van Rosendael PJ, Delgado V, Bax JJ.
Pacemaker Implantation Rate After Transcatheter Aortic Valve Implantation With Early and New-Generation Devices: A Systematic Review. Eur Heart J 2018;Feb 6:[Epub ahead of print].

The following are key points to remember from this review about pacemaker implantation rate after transcatheter aortic valve implantation (TAVI) with early and new-generation devices:

  1. The incidence of new-onset conduction abnormalities requiring permanent pacemaker implantation (PPI) after TAVI with new-generation prostheses remains controversial.
  2. This systematic review analyses the incidence of PPI after TAVI with new-generation devices and evaluates the electrical, anatomical, and procedural factors associated with PPI. In addition, the incidence of PPI after TAVI with early-generation prostheses was reviewed and compared with newer devices.
  3. For balloon-expandable prostheses, the PPI rate remained low when using an early-generation SAPIEN device (ranging between 2.3% and 28.2%), and with the new-generation SAPIEN 3 device, the PPI rate was between 4.0% and 24.0%.
  4. For self-expandable prostheses, the PPI rates were higher with the early-generation CoreValve device (16.3ā€“37.7%), and despite a reduction in PPI rates with the new Evolut R, the rates remained relatively higher (14.7ā€“26.7%).
  5. When dividing the studies according to the highest (>26.0%) and the lowest (<12.1%) quintile of PPI rate, patients within the highest quintile were more frequently women when compared with the lowest quintile group (50.9% vs. 46.3%, pā€‰<ā€‰0.001).
  6. Pre-existent conduction abnormalities (electrical factor), calcification of the left ventricular outflow tract (anatomical factor), and balloon valvuloplasty and depth of implantation (procedural factors) were associated with an increased risk of PPI.
  7. Overall, the rate of PPI after TAVI with new-generation devices is highly variable.
  8. Of importance, PPI also has been associated with a significant decrease in the left ventricular function, which may have an impact on survival at long-term follow-up.
  9. Specific recommendations for implantation of each prosthesis, taking into consideration the presence of pre-existent conduction abnormalities and anatomical factors, are needed to reduce the risk of PPI.
  10. Furthermore, additional data on the time course of new-onset conduction abnormalities may help to refine the indication for PPI. Some studies have shown that conduction disturbances are not always permanent and patients may not be pacemaker dependent during follow-up.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Arrhythmias, Cardiac, Balloon Valvuloplasty, Calcification, Physiologic, Heart Valve Diseases, Pacemaker, Artificial, Prostheses and Implants, Risk, Secondary Prevention, Transcatheter Aortic Valve Replacement, Ventricular Function, Left

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