Predictors of pacemaker dependency after transcatheter aortic valve replacement

Abstract

Abstract Funding Acknowledgements Type of funding sources: None. Background Conduction disturbances after transcatheter aortic valve replacement (TAVR) are common with a variable risk of long-term pacemaker dependency (PD), being influenced by patient- and procedure-specific factors. As pacemaker (PM) implantation is associated with potential complications, our aim was to assess predictors of PD requirement after TAVR. Methods Retrospective analysis of consecutive patients (P) who underwent TAVR with a self-expanding valve from 2009 to 2020 at our institution. All P had pre-procedural clinical evaluation, cardiac computed tomographic angiography, transthoracic echocardiography and electrocardiography performed. Cumulative percentage of ventricular pacing (%Vp) was determined from stored PM data. P with a PM implanted previous to TAVR were excluded. PM implantation post-TAVR was defined as a device implant performed during hospital stay in the context of TAVR or during the first month after discharge. PD was defined as a %Vp > 80% at one-year follow-up. Multivariate analysis for the prediction of PD was done using Cox regression. Results A total of 474 P (57% male, age 81.7±6.5 years, left ventricular ejection fraction 51.5±14.6%) were analysed. Mean follow-up was 18.7 months. Mean baseline gradient was 51.7 mmHg with a mean aortic valve area of 0.71 cm2. One hundred and four P (21.9%) required PM implantation after TAVR, with a mean %Vp of 65.3±43.4%, presenting PD in 60% of the cases at one-year follow-up. A glomerular filtration rate > 60 ml/min (OR 0.87, CI 95% 0.74-0.96, p=0.021) and mean aortic annulus perimeter (OR 0.89, CI 95% 0.80-0.98, p=0.029) were independent predictors of a PD < 5%. Arterial hypertension (OR 7.00, CI 95% 1.31-37.40, p=0.023), baseline right bundle branch block (OR 10.2, CI 95% 1.21-18.45, p=0.033), and the EUROSCORE II (OR 1.05, CI 95% 1.01-1.10, p=0.044) were predictors of PD > 80%. Baseline left bundle branch block, implantation depth and aortic valve calcium score were not predictors of PD. Conclusion Predictors of PD after TAVR may influence PM implantation, as well as device selection and programming. P with a higher aortic annulus perimeter and preserved kidney function may undergo a more expectant management, as PD rates are low after 1 year follow-up.