56-40: Utility of Permanent-Temporary Pacemaker in the Management of Patients Undergoing Transcatheter Aortic Valve Implantation

Abstract

Introduction: Transcatheter Aortic Valve Implantation (TAVI) has emerged as an important intervention for patients with aortic stenosis. Damage to the cardiac conduction system is a known adverse outcome of this procedure. A group of these patients develop conduction abnormalities that do not meet conventional criteria for permanent pacemaker (PPM) implantation. Permanent-temporary pacemaker (PTPM) is an active fixation RV lead attached to an externalized pulse generator taped to the skin. At our institute, we have used PTPM as a bridge measure in post TAVI patients with conduction abnormalities not sufficient to indicate PPM implantation immediately. This technique allows for safe treatment of post TAVI patients until further evaluation. Methods: We gathered data for all patients who received PTPM after TAVI from January 01, 2013 to December 31, 2015 at Cedars Sinai Medical Center, retrospectively. Baseline demographics, comorbidities, and type and size of the valve were determined. Pre-TAVI, post-TAVI, one month and 6 months follow up ECGs and echocardiograms and PTPM interrogation results were reviewed. Results: Among 1,130 patients who underwent TAVI in the study period 72 patients received PTPM immediately after TAVI. The types of the aortic valves were: 44% (n = 21) Medtronic CoreValve/ Evolute valve, 53% (n = 38) Edwards Sapien valves, 33% (n= 24), and others were 14% (n = 10). The most common indication for PTPM was transient complete heart block (49%, n = 35), followed by new LBBB (17%, n = 12). The PTPM remained in place for 2.2 +/- 2.3 days after TAVI. Only 32 patients (44%) received PPM before discharge (50% with Sapien valves, 31% Medtronic valves). QRS duration increased from pre-TAVI (108 +/- 24 ms) to post-TAVI (135 +/- 29 ms) p < 0.0001. The increase in QRS duration was 34 +/- 27 ms in those who received PPM before discharge and 23 +/- 25 ms in those who did not receive PPM (P = 0.09). Only 49% of those patients with PTPM indication of transient complete heart block (n = 17) and 42% of patients with PTPM indication of new LBBB (n = 5) received PPM before hospital discharge. Among 50% (n = 16) of the patients with PPM who had 6 months follow up, 81% (n = 13) showed evidence of being paced on device interrogation or ECG. Conclusion: In post TAVI patients who develop conduction abnormalities that do meet conventional PPM implant indications, PTPM safely provides a time period for further assessment and prevents unnecessary PPM implantation. The degree of post TAVI increase in QRS duration may be one predictive factor of requiring PPM.