Abstract
ObjectivesTranscatheter aortic valve implantation is a recognized treatment for patients with severe aortic stenosis at all risk groups. However, permanent pacemaker rates remain high for self expandable transcatheter valves and permanent pacemaker implantation has been associated with increased morbidity. In this analysis we aim to evaluate short term clinical outcomes post self expandable transcatheter aortic valve implantation and determine risk factors for permanent pacemaker implantation.Methods88 patients with severe aortic stenosis with transcatheter aortic valve implantation performed between the year 2016–2018 were retrospectively analyzed. Outcomes of interest included 1- year all cause mortality, 30-day major adverse cardiovascular events, permanent pacemaker and paravalvular leak rates. Survival analysis was performed with Kaplan Meier analysis and risk factors for survival and permanent pacemaker rates were identified with log rank test and regression analysis.ResultsThe mean age of the cohort was 80.3 +/− 6.9 years. The mean STS score was 9.25. The 30 day all-cause mortality was 5.7% and 1-year all cause mortality was 16.7%. 80 patients had transfemoral transcatheter aortic valve implantation, and a majority of the patients (85.2%) were implanted with Corevalve Evolut R device. The device success rate was 88.6%. Multivariate analysis identified concomitant severe coronary artery disease (OR = 18.2 +/− 0.9; P = 0.002), pre transcatheter aortic valve implantation atrial fibrillation (OR = 8.6 +/− 0.91; P = 0.02) and post procedural disabling stroke (OR = 32.6 +/− 1.35; P = 0.01) as risk factors for 1-year mortality. The 30-day pacemaker rate was 17.6%. The presence of right bundle branch block (OR 11.1 +/− 0.86; P = 0.005), non-coronary cusp implantation depth (OR = 1.34 +/− 0.15; P = 0.05) and a non coronary cusp implantation depth / membranous septal length ratio of more than 50% were associated with post procedural pacemaker implantation (OR = 29.9 +/− 1.72; P = 0.05). Among the 15 patients with post procedural pacemaker implantation, 40% were found to be non-pacemaker dependent at 1 year.ConclusionShort term outcomes of transcatheter aortic valve implantation in severe aortic stenosis patients are promising. Pacemaker rates remain high. More studies are needed to evaluate the factors that influence pacemaker rates and dependence to further improve transcatheter aortic valve implantation outcomes.
Highlights
The emergence of Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of patients with severe aortic stenosis (AS)
Randomized controlled trials have not demonsrated that the need for permanent pacemakers (PPM) negatively impacted survival comparing to surgical aortic valve replacement (SAVR), a recent 21 study meta-analysis on 42,927 patients have found that new onset left bundle branch block (LBBB) and PPM implantation after TAVI were associated with an increased risk of all cause death and heart failure hospitalization at 1 year of follow up
Pacemaker rates remain high and there is a need to improve TAVI outcomes in order to fully realize the potential of TAVI in younger patients at low risk for SAVR
Summary
The emergence of Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of patients with severe aortic stenosis (AS). The Partner III trial and the Evolut R low risk trial have demonstrated superiority and equipoise of TAVI over surgical aortic valve replacement (SAVR) with respect to short term survival and procedural outcomes, and has firmly established TAVI as an acceptable and effective treatment of severe AS in patients at low risk for SAVR [1, 2]. The role of TAVI in younger patients is less clear, as important issues such as valve durability,the need for permanent pacemakers (PPM) and bicuspid aortic valves remain to be studied and substantiated [3]. The need for PPM post TAVI is important given the added morbidity and negative impact on survival a permanent pacemaker entails to younger patients with life expectancy of more than 10 years. We aim to evaluate short term outcomes and efficacy of selfexpandable (SE) TAVI valves in our center and identify associating factors that influence PPM rates post TAVI
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