PO-05-049 OPTIMAL TIMING OF PERMANENT PACEMAKER IMPLANTATION FOLLOWING TRANSCATHETER AORTIC VALVE REPLACEMENT

Abstract

Atrioventricular nodal block (AVB) is a common complication following transcatheter aortic valve replacement (TAVR). The timing of permanent pacemaker (PPM) implantation with respect to conduction disease and recovery is not well established. The purpose of this study is to determine the optimal timing of PPM implantation for AVB following TAVR. Patients were retrospectively reviewed for AB and pacemaker (PPM) implantation by ECG and progress note data in the electronic medical record following TAVR implantation, and PPM interrogation data was reviewed for long-term pacing requirements. Pacemaker dependence was defined as absence of underlying rhythm at < 40 bpm. Definite/probable pacing need was defined as 2nd degree AVB, complete heart block (CHB), or atrial fibrillation with bradycardia and pacing burden > 40%. A total of 458 consecutive patients who underwent TAVR were retrospectively identified. Of these, 99 had a previously implanted PPM and were excluded, leaving 359 total patients. CHB or 2nd degree AVB was noted in 73 patients (20%). On day 0 post-TAVR, 67 patients had CHB (92%) and 6 patients had 2nd degree AVB (8%), and of these, 21 patients (28%) had subsequent recovery of conduction with no clear long-term pacing need. At day 1 post-TAVR, 10 patients (14%) demonstrated recovery of AV conduction and did not require PPM; 48 patients (66%) had persistent CHB; and 15 patients (20%) had intermittent CHB or 2nd degree AVB, for a total of 63 patients who underwent PPM placement. PPM interrogation was performed 7-30 days following implantation. Of the 48 patients with persistent CHB at post-TAVR day 1, 42 had follow-up after >7d. Of these, 36 (86%) remained pacemaker-dependent, and 6 (14%) had no clear pacing need. Of the 14 patients with intermittent CHB or 2nd degree AVB at day 1 who had later follow-up, 9 (64%) had no clear pacing need, and only 5 (36%) had definite/probable pacing need (Fig 1). A significant number of patients with CHB after TAVR will demonstrate conduction recovery, and PPM implantation on the same day may not be justified. Of those with no conduction recovery after 1 day, relatively few patients had subsequent conduction recovery, and PPM implantation could be considered then. However, patients with intermittent CHB or 2nd degree AVB one day after TAVR had a high rate of subsequent return of conduction, and longer observation may be appropriate before proceeding with PPM implantation.