IDENTIFYING PREDICTIVE RISK FACTORS FOR PACEMAKER NEED IN PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT

Abstract

Listen

Translate article

BACKGROUND Transcatheter aortic valve replacement (TAVR) has become an established treatment for patients suffering with aortic stenosis. However, there remains some uncertainty on the risk factors associated with TAVR and conduction disturbances requiring permanent pacemaker insertion (PPI) following the procedure. The aim of this study was to identify risk factors for post-TAVR pacemaker need and examine the effect of PPI on long-term outcomes. METHODS AND RESULTS A retrospective study was performed on all consecutive patients who underwent TAVR at the Saint John Regional Hospital between 2010-2018, excluding those with an existing pacemaker. Risk factors capable of independently predicting post-procedure PPI were identified using two-tailed t-test, χ-square test, and hierarchical logistic regression model. Kaplan-Meier survival analysis was performed to compare all-cause mortality between patients who did or did not receive a pacemaker. A total of 377 patients with no previous pacemaker were included in the study. A total of 42 (11.1%) required PPI post-TAVR and were compared to patients who did not. Univariate analysis suggested that larger valves (>29cm) (p=0.05), renal insufficiency (p=0.03), and ECG abnormalities (p < 0.0001) including right bundle branch block (RBBB) (p < 0.0001), QRS duration >200ms (p=0.0003), and heart rate < 50bpm (p=0.01) were associated with increased PPI. After multivariable analysis, only ECG abnormalities as a combined outcome (OR 5.19, CI 2.52-11.04, p < 0.0001) was identified as an independent predictive risk factor of PPI (Table 1). Valve type was not a predictive risk factor for PPI in our study, with 10.7% of patients with balloon-expanding and 13.6% of patients with self-expanding valves requiring pacemakers post-procedure (p=0.88). Kaplan-Meier survival analysis demonstrated post-TAVI pacemaker insertion had no significant impact on all-cause mortality (Figure 1). CONCLUSION Our study illustrates that permanent pacemaker use in TAVR remains high (>10%) and identifies several ECG abnormalities as the most robust predictors of pacemaker need post-TAVR, in particular RBBB. However, our limited study suggests that post-TAVR pacemaker insertion is not associated with all-cause mortality after discharge. As TAVR becomes a treatment option for lower surgical risk patients, considerations for the need for post-procedural pacemaker insertion may affect clinical decision making and warrant screening for conduction abnormalities in patients undergoing TAVR. Transcatheter aortic valve replacement (TAVR) has become an established treatment for patients suffering with aortic stenosis. However, there remains some uncertainty on the risk factors associated with TAVR and conduction disturbances requiring permanent pacemaker insertion (PPI) following the procedure. The aim of this study was to identify risk factors for post-TAVR pacemaker need and examine the effect of PPI on long-term outcomes. A retrospective study was performed on all consecutive patients who underwent TAVR at the Saint John Regional Hospital between 2010-2018, excluding those with an existing pacemaker. Risk factors capable of independently predicting post-procedure PPI were identified using two-tailed t-test, χ-square test, and hierarchical logistic regression model. Kaplan-Meier survival analysis was performed to compare all-cause mortality between patients who did or did not receive a pacemaker. A total of 377 patients with no previous pacemaker were included in the study. A total of 42 (11.1%) required PPI post-TAVR and were compared to patients who did not. Univariate analysis suggested that larger valves (>29cm) (p=0.05), renal insufficiency (p=0.03), and ECG abnormalities (p < 0.0001) including right bundle branch block (RBBB) (p < 0.0001), QRS duration >200ms (p=0.0003), and heart rate < 50bpm (p=0.01) were associated with increased PPI. After multivariable analysis, only ECG abnormalities as a combined outcome (OR 5.19, CI 2.52-11.04, p < 0.0001) was identified as an independent predictive risk factor of PPI (Table 1). Valve type was not a predictive risk factor for PPI in our study, with 10.7% of patients with balloon-expanding and 13.6% of patients with self-expanding valves requiring pacemakers post-procedure (p=0.88). Kaplan-Meier survival analysis demonstrated post-TAVI pacemaker insertion had no significant impact on all-cause mortality (Figure 1). Our study illustrates that permanent pacemaker use in TAVR remains high (>10%) and identifies several ECG abnormalities as the most robust predictors of pacemaker need post-TAVR, in particular RBBB. However, our limited study suggests that post-TAVR pacemaker insertion is not associated with all-cause mortality after discharge. As TAVR becomes a treatment option for lower surgical risk patients, considerations for the need for post-procedural pacemaker insertion may affect clinical decision making and warrant screening for conduction abnormalities in patients undergoing TAVR.