Need For Permanent Pacemaker Research Articles

A New Technique to Implant a Transcatheter Inflatable, and Fully Repositionable Prosthesis in Aortic Stenosis with Severe Asymmetric Calcification

Objective: In contrast to standard TAVI valves, the Direct Flow Medical valve (DFM) (DFM, Santa Rosa, California, United States) is a unique non-metallic bovine aortic bioprosthesis. Extreme asymmetric calcification could cause residual trans-aortic pressure gradient. Here, we report a new valvuloplasty supported implant (VSI) technique, which we developed in our laboratory to optimize DFM implantation. Methods: Between January 2014 and May 2015, 55 patients underwent TAVI with the DFM valve at our institution, 4 patients were implanted using the VSI technique, due to residual intra-operative trans-aortic gradient above 15 mm Hg. VSI technique was used in 3 transfemoral patients and one direct aortic patient. Results: The mean age of the patients was 70 ± 5,7 years, the mean logistic EuroSCORE was 29%, and the mean Society of the Thoracic Surgeons score 7.5%, with a mean ejection fraction of 31%. After valve implantation, the transvalvular gradient improved immediately after VSI, from 19.7 ± 2.2 to 6.5 ± 1.2 mm Hg, and remained stable out to 30 days at 11.3 mm Hg. Paravalvular aortic regurgitation was none in 3 patients and trace in one patient. There was no need for permanent pacemaker, and stroke did not occur. All patients survived the first 30 days. Conclusion: In a limited series of patients, we demonstrated that implant supported valvuloplasty is a feasible, safe and effective technique in selected patients with severe asymmetric calcification and appears to have no adverse effect on valve structure or performance.

Abstract 14347: Septal Myectomy is Associated With Worse In-Hospital Outcomes than Alcohol Septal Ablation: Data From the Nationwide Inpatient Sample in the United States, 2003-2011

Introduction: Septal myectomy (SM) and alcohol septal ablation (ASA) are performed for treatment of obstructive hypertrophic cardiomyopathy (HCM). Previous studies comparing ASA and SM are limited to single center registries. We aimed to compare in-hospital outcomes after ASA and SM within a large, national inpatient database. Hypothesis: SM is associated with worse in-hospital outcomes than ASA, particularly in low volume centers. Methods: We analyzed all patients who were hospitalized for ASA (n=6,386) or SM (n=4,862) in the Nationwide Inpatient Database from 2003 to 2011. Rates of adverse in-hospital events (death, stroke, bleeding, acute renal failure (ARF) and need for permanent pacemaker (PPM)) were examined. Multivariate adjusted analysis was performed to compare outcomes based on tertiles of hospital volume. Results: Patients undergoing SM were younger, more likely to be female, have anemia, chronic pulmonary disease, diabetes with complications, obesity, peripheral vascular disease and coagulopathy. The incidence of in-hospital death (5.2% vs. 0.7%), post-procedural stroke (1.8% vs. 0%) and ARF (9.7% vs. 3.3%) were greater in SM vs. ASA groups, respectively (all p<0.001). After adjustment for baseline differences and confounders using multivariate propensity-score adjusted logistic regression analysis, SM remained an independent predictor of in-hospital death (OR 5.59, 95%CI 3.71-8.43), stroke (OR 3.81, 95% CI 2.06-7.07) and ARF (OR 2.23, 95% CI 1.77-2.90). In addition, low hospital volume of SM was an independent predictor of mortality (adj OR 3.11, 95% CI 1.98-4.89) and bleeding (adj OR 3.77, 95% CI 2.12-6.70), while low volume of ASA was not independently associated with an increased risk of adverse post-procedural events. Conclusions: In conclusion, SM was associated with worse in-hospital outcomes, including death, stroke and acute renal failure. Low volume status is associated with worse in-hospital outcomes for SM but not for ASA.

Abstract 20126: Associations of Known Complications of Transcatheter Implantation of Balloon-expandable Edwards-Sapien XT Aortic Valves With Peri-procedural Mortality - An Insight From the 2014-2015 Reports From the FDA MAUDE Database

Background: Transcatheter implantation of aortic valves (TAVR) has revolutionized the management of severe aortic stenosis. However, specific complications have been noted with the valves. Details of such were sought from the US Food and Drug Administration (FDA) maintained MAUDE database which houses medical device reports submitted to the FDA by mandatory reporters (manufacturers, importers and device user facilities) and voluntary reporters such as health care professionals, patients and consumers. Methods: A detailed search was conducted in PubMed, Cochrane Library, EMBASE and CINAHL to identify adverse events reported with the implantation of the Edwards-Sapien XT valves. Then the FDA MAUDE database was queried from June 2014 to May 2015 to identify prevalence of the same complications as reported to the FDA. Individual patient reports were identified and relevant data on such complications were abstracted. Finally, mortality outcomes from such patients were abstracted, and associations of these for each individual reported complication were identified in a multivariate logistic regression model. Results: FDA MAUDE revealed 730 unique reports of complications with the first- generation Edwards-Sapien valves. A total of 106 patients died peri-procedurally. The complications most strongly associated with peri-procedural mortality were development of peri-procedural vascular complications, need for permanent pacemaker, renal failure, atrial fibrillation, stroke, need for surgical valve implantation and need for valve in valve procedure. (Table 1) Conclusions: Specific complications with the new Edwards XT valves were strongly associated with mortality, and focused strategies to mitigate these complications may improve outcomes with future generations of this exciting new technology.

Short- and long-term need for permanent pacemaker after transcatheter implantation of the Edwards Sapien aortic valve prosthesis

IntroductionA permanent pacemaker is frequently needed after transcatheter aortic valve implantation, but the available data are mainly on the CoreValve system. ObjectiveTo evaluate the need for new permanent pacemaker after implantation of the Edwards Sapien device, as well as related factors. MethodsWe included the first 100 patients treated with the Edwards Sapien device at our institution. Of these, 12 had a permanent pacemaker before the procedure, and thus our study population was the remaining 88 patients. ResultsA permanent pacemaker was indicated in eight patients (9.1%) during hospitalization or at 30 days. After discharge, another four patients needed a pacemaker (at 42 days and three, 18, and 30 months). Two variables were associated with the need for pacemaker during hospitalization: previous dialysis (13% vs. 1%, p=0.042) and complete right bundle branch block before the procedure (25% vs. 5%, p=0.032). More than one month after the procedure, the characteristics associated with the need for pacemaker were plasma creatinine level (2.5±1.7 vs. 1.3±0.6 mg/dl, p=0.001) and previous myocardial infarction (50% vs. 10%, p=0.013). ConclusionThe rate of pacemaker implantation with the Edwards Sapien device was 9.1%. Right bundle branch block and dialysis were associated with this complication.

Short- and long-term need for permanent pacemaker after transcatheter implantation of the Edwards Sapien aortic valve prosthesis

IntroductionA permanent pacemaker is frequently needed after transcatheter aortic valve implantation, but the available data are mainly on the CoreValve system. ObjectiveTo evaluate the need for new permanent pacemaker after implantation of the Edwards Sapien device, as well as related factors. MethodsWe included the first 100 patients treated with the Edwards Sapien device at our institution. Of these, 12 had a permanent pacemaker before the procedure, and thus our study population was the remaining 88 patients. ResultsA permanent pacemaker was indicated in eight patients (9.1%) during hospitalization or at 30 days. After discharge, another four patients needed a pacemaker (at 42 days and three, 18, and 30 months). Two variables were associated with the need for pacemaker during hospitalization: previous dialysis (13% vs. 1%, p=0.042) and complete right bundle branch block before the procedure (25% vs. 5%, p=0.032). More than one month after the procedure, the characteristics associated with the need for pacemaker were plasma creatinine level (2.5±1.7 vs. 1.3±0.6 mg/dl, p=0.001) and previous myocardial infarction (50% vs. 10%, p=0.013). ConclusionThe rate of pacemaker implantation with the Edwards Sapien device was 9.1%. Right bundle branch block and dialysis were associated with this complication.

Association Between Transcatheter Aortic Valve Implantation Volume and Outcomes in the United States

With the rapid advance of transcatheter aortic valve implantation (TAVI), it is important to evaluate the relationship between TAVI volumes and outcomes. The aim of this study was to analyze in-hospital outcomes after TAVI stratified according to hospital volumes. Using the National Inpatient Sample files from 2012, hospitals performing transfemoral (TF)-TAVI and transapical (TA)-TAVI were divided into high-volume and low-volume centers. A total of 7,660 patients underwent TAVI in 256 hospitals in 2012. In the TF-TAVI cohort, multivariate logistic regression analyses demonstrated that low TF-TAVI volume status was an independent predictor of death and bleeding. In the TA-TAVI cohort, low volume status was a predictor of death, myocardial infarction, and need for permanent pacemaker. In addition, hospitals that performed low TA-TAVI volume were associated with significantly higher rate of death after surgical aortic valve replacement in comparison with the hospitals that perform high TA-TAVI volume (3.6% vs 2.3%, p <0.001). In conclusion, centers with lower volume of TAVI had more frequent adverse events compared with higher volume centers.

TCT-658 Left Bundle Branch Block and Need for Permanent Pacemaker Post TAVR

Cardiac conduction abnormalities, including left bundle branch block (LBBB), are not uncommon after TAVR. We aimed to evaluate the need for permanent pacemaker (PPM) insertion after development of new LBBB. This is a single center study of TAVR patients. Twelve-lead ECGs were acquired pre- and

Transfemoral aortic valve implantation with the repositionable Lotus valve compared with the balloon-expandable Edwards Sapien 3 valve

BackgroundThe rate of paravalvular aortic insufficiency (AI) with transcatheter aortic valve implantation (TAVI) with first generation devices was higher compared with surgical replacement. Residual AI after TAVI has been linked to an increased mortality rate. We compared two second generation TAVI devices — the repositionable Lotus valve with the balloon-expandable Edwards Sapien 3 valve — regarding procedural and 30day outcome. Methods and resultsIn 78 patients with severe aortic stenosis undergoing transfemoral TAVI we evaluated post-procedural paravalvular AI, device success and early safety according to VARC criteria. Valve size was based on a 256-multislice computed tomography. Patients were followed for 30days. The Lotus valve (N=26) and the Edwards Sapien 3 valve (N=52) were implanted under fluoroscopic guidance. Baseline characteristics were similar between groups. Perimeter derived annulus diameter did not differ with 25.7±1.6mm for Lotus and 25.2±2.1mm for Edwards Sapien 3 patients. After TAVI aortography and transthoracic echocardiography revealed no moderate or severe AI. The rate of mild AI was 12% for Lotus and 15% for Edwards Sapien 3 (p=0.62). There were no deaths, stroke, annulus rupture or coronary obstruction. Device success was 96% and 98% (p=0.61), early safety according to VARC 11.5% in both groups (p=1.0) and the need for pacemaker implantation 27% and 4% (p<0.003), respectively. ConclusionsTAVI with second-generation devices was associated with no moderate or severe AI and a low rate of mild AI. Device success was high for Lotus and Edwards Sapien 3 while the need for permanent pacemaker was significantly higher with the Lotus valve.

New conduction disturbances and pacemaker indications after CoreValve® transcatheter aortic valve replacement. Incidence and follow up in a single center experience

Transcatheter aortic valve implantation (TAVI) is currently reserved for patients with symptomatic aortic stenosis and high surgical risk. One major limiting factor related to TAVI procedural complications is conduction abnormalities and the need for permanent pacemaker implantation. Evaluate the incidence of new conduction disturbances and pacemaker indications in patients with TAVI CoreValve® prosthesis (Medtronic Inc. Minneapolis, Minnesota, United States). We included 28 patients, mean age 80 years. ECG parameters were evaluated previous and after implantation. All patients were monitorized during TAVI. Follow up Holter monitoring was performed at one, 6 and 12 months after the procedure and we also evaluated telemetry of implanted pacemaker. In previous ECG we found 7 patients had right bundle branch block and 7 patients had left bundle brunch block (LBBB). The post implant ECG showed 7 new LBBB: 3 during valvuloplasty and 4 on the end of it. Six patients required pacemaker implantation for permanent or paroxysmal complete AV block (CAVB). At one year follow up, 3 patients with LBBB during valvuloplasty had a normal ECG, one still had LBBB and one an asymptomatic CAVB found in Holter monitoring. Conduction abnormalities are frequent after CoreValve® aortic valve prosthesis implantation. The incidence of new LBBB was 25%. CAVB during or post TAVI require PM implantation. New LBBB may need a closer follow up because in a 3% of the cases it may progress to CAVB.

Permanent Pacemaker Implantation after TAVR - Predictors and Impact on Outcomes.

The number of patients undergoing transcatheter aortic valve replacement (TAVR) worldwide is increasing steadily. Atrioventricular conduction disturbances, with or without the need for permanent pacemaker (PPM) implantation, are one of the most common adverse events after TAVR. Among transcatheter heart valves (THV), rates of conduction abnormalities vary from less than 10 % to more than 50 %. Depending on the reported data referred to, historical data showed that up to one-third of the patients required implantation of a PPM following TAVR. Although generally considered as a minor complication, PPM may have a profound impact on prognosis and quality of life after TAVR. Current data support the hypothesis that conduction abnormalities leading to pacemaker dependency result from mechanical compression of the conduction system by the prosthesis stent frame and individual predisposing conduction defects such as right bundle-branch block (RBBB). With several large randomised trials and registry studies having been published recently and second generation THV having been introduced, the debate about predictors for pacemaker implantation and their impact on outcome after TAVR is still ongoing.

A MULTIDISCIPLINARY, MULTIMODALITY, BUT MINIMALIST (3M) APPROACH TO TRANSFEMORAL TRANSCATHETER AORTIC VALVE REPLACEMENT FACILITATES SAFE NEXT DAY DISCHARGE HOME IN HIGH RISK PATIENTS: 1 YEAR FOLLOW UP

Transcatheter aortic valve replacement (TAVR) is an alternative to surgery in high risk operable patients; however, complications and cost currently limit expansion into lower risk populations. Although mortality, morbidity and length of stay (LOS) are expected to improve, we sought to determine if a multidisciplinary, multimodality, but minimalist (3M) approach could improve outcomes with currently available valve technology. Patients considered high risk for surgery, but relatively low risk for TAVR, were rigorously screened with functional and cognitive assessments as well as multi-modality imaging. From a potential pool of 335 accepted transfemoral TAVR patients between August 2011 and March 2014, 73 (22%) were selected and underwent SAPIEN XT (Edwards Lifesciences Inc., CA, USA) valve implantation utilizing percutaneous arterial access and area-based computed tomography sizing. All procedures in the second half of the cohort (38/73) were performed awake with no sedation and only femoral monitoring. Thirty day and one year outcomes were reported according to VARC-2 guidelines. The mean patient age was 83±7 years with a mean STS score of 8.3±3.7%. All-cause mortality or major stroke at 30 days and 1 year was 1.4% (1/73) and 8% (4/50) respectively. Procedural events at 30 days included life-threatening bleeding (1.4%), major vascular complications (2.7%), and need for permanent pacemaker (2.7%). The median LOS was 1 day (IQR1-2) with a mean LOS of 1.7±1.5 days. The mean LOS for the initial intubated cohort (35/73) vs the awake cohort (38/73) was 2.1±2 vs 1.3±1 days respectively (p=0.03). Overall, 50/73 (68%) were discharged home one day post TAVR with 2 readmissions (2.7%) within 30 days. Aortic valve area increased from 0.7±0.14 cm2 to 1.69±0.29 cm2 (p<0.001) at 30 days and 1.5±0.25cm2 (p<0.001) at 1 year; mean trans-aortic gradient decreased from 43±18 mmHg to 9 ± 3 mmHg (p < 0.001) at 30 days and 11±5 mmHg (p < 0.001) at 1 year. At 30 days and 1 year, 98% (71/73) and 92% (46/50) were NYHA class I or II with mild or less paravalvular regurgitation. Rigorous patient screening as well as improvements in procedural guidance, device selection, and adherence to the 3M clinical pathway permits safe next day discharge home in high risk patients with a 92% survival rate at 1 year. The 3M approach may facilitate significant cost savings and thus allow TAVR to be delivered to a broader range of lower risk patients.

Depth of valve implantation, conduction disturbances and pacemaker implantation with CoreValve and CoreValve Accutrak system for Transcatheter Aortic Valve Implantation, a multi-center study

BackgroundTranscatheter Aortic Valve Implantation (TAVI) is now considered an indispensable treatment strategy in high operative risk patients with severe, symptomatic aortic stenosis. However, conduction disturbances and the need for Permanent Pacemaker (PPM) implantation after TAVI with the CoreValve prosthesis still remain frequent. Methods and resultsWe aimed to evaluate the implantation depth, the incidence and predictors of new conduction disturbances, and the need for PPM implantation within the first month after TAVI, using the new Accutrak CoreValve delivery system (ACV), compared to the previous generation CoreValve (non-ACV). In 5 experienced TAVI-centers, a total of 120 consecutive non-ACV and 112 consecutive ACV patients were included (n=232). The mean depth of valve implantation (DVI) was 8.4±4.0mm in the non-ACV group and 7.1±4.0mm in the ACV group (p=0.034). The combined incidence of new PPM implantation and new LBBB was 71.2% in the non-ACV group compared to 50.5% in the ACV group (p=0.014). DVI (p=0.002), first degree AV block (p=0.018) and RBBB (p<0.001) were independent predictors of PPM implantation. DVI (p<0.001) and pre-existing first degree AV-block (p=0.021) were identified as significant predictors of new LBBB. ConclusionDVI is an independent predictor of TAVI-related conduction disturbances and can be reduced by using the newer CoreValve Accutrak delivery system, resulting in a significantly lower incidence of new LBBB and new PPM implantation.

Open issues in transcatheter aortic valve implantation. Part 2: procedural issues and outcomes after transcatheter aortic valve implantation.

This article provides an overview on procedure-related issues and uncertainties in outcomes after transcatheter aortic valve implantation (TAVI). The different access sites and how to select them in an individual patient are discussed. Also, the occurrence and potential predictors of aortic regurgitation (AR) after TAVI are addressed. The different methods to quantify AR are reviewed, and it appears that accurate and reproducible quantification is suboptimal. Complications such as prosthesis-patient mismatch and conduction abnormalities (and need for permanent pacemaker) are discussed, as well as cerebrovascular events, which emphasize the development of optimal anti-coagulative strategies. Finally, recent registries have shown the adoption of TAVI in the real world, but longer follow-up studies are needed to evaluate the outcome (but also prosthesis durability). Additionally, future studies are briefly discussed, which will address the use of TAVI in pure AR and lower-risk patients.

Mid-term results of aortic valve surgery in redo scenarios in the current practice: results from the multicentre European RECORD (REdo Cardiac Operation Research Database) initiative

Although commonly reported as single-centre experiences, redo aortic valve replacement (RAVR) has overall acceptable results. Nevertheless, trans-catheter aortic valve replacement has recently questioned the efficacy of RAVR. Early-to-mid-term results and determinants of mortality in 711 cases of RAVR from seven European institutions were assessed in the entire population and in selected high-risk subgroups [elderly >75 years, urgent/emergent procedures, preoperative New York Heart Association (NYHA) functional Class IV and endocarditis]. Hospital mortality was 5.1%, major re-entry cardiovascular complications (MRCVCs) 4.9%, low cardiac output syndrome (LCOS) 15.3%, stroke 6.6%, acute respiratory failure (ARF) 10.6%, acute renal insufficiency (ARI) 19.3% and need for continuous renal replacement therapy (CRRT) 7.2%, transfusions 66.9% and for permanent pacemaker (PMK) 12.7%. Mid-term survival, freedom from acute heart failure (AHF), reinterventions, stroke and thrombo-embolisms were 77.2 ± 2.7, 84.4 ± 2.6, 97.2 ± 0.8, 97.2 ± 0.9 and 96.3 ± 1.2%, respectively; 87.5% of patients were in NYHA functional Class I-II. Preoperative left ventricular ejection fraction of <30% [odds ratio (OR) 8.7, 95% confidence interval (CI) 2.1-35.6], MRCVCs (OR 20.9, 95% CI 5.6-78.3), cardiopulmonary bypass time (OR 1.1, 95% CI 1.0-1.1), perioperative LCOS (OR 17.2, 95% CI 5.1-57.4) and ARI (OR 5.1, 95% CI 1.5-18.1) predicted hospital death. Endocarditis (OR 7.5, 95% CI 2.9-19.1), preoperative NYHA functional Class IV (OR 4.7, 95% CI 1.0-24.0), combined RAVR + mitral surgery (OR 5.1, 95% CI 1.5-17.3) and AHF at follow-up (OR 2.8, 95% CI 1.3-6.0) predicted late death at the Cox proportional hazard regression model. Elderly >75 years had similar hospital mortality (P = 0.06) and major morbidity, except for a higher need for PMK (P = 0.03), as well as comparable mid-term survival (P = 0.89), freedom from AHF (P = 0.81), reinterventions (P = 0.63), stroke (P = 0.21) and thrombo-embolisms (P = 0.09). Urgent/emergent indication resulted in higher hospital death, LCOS, transfusions, MRCVCs, intra-aortic balloon pumping (IABP), stroke, prolonged (>48 h) ventilation, pneumonia, ARI, CRRT, lower mid-term survival and freedom from AHF (P ≤ 0.03). Preoperative NYHA functional Class IV correlated with higher LCOS, IABP, prolonged ventilation, pneumonia, ARF, ARI, CRRT and MRCVCs and lower mid-term survival, freedom from AHF, reinterventions and stroke (P ≤ 0.02). Endocarditis demonstrated higher hospital mortality, MRCVCs, LCOS, IABP, stroke, ARF, prolonged intubation, pneumonia, ARI, CRRT, transfusions and PMK and lower mid-term survival and freedom from AHF and reinterventions (P ≤ 0.04). RAVR achieves overall satisfactory results. Baseline risk factors and perioperative complications strongly affect outcomes and mandate improvements in perioperative management. New emerging strategies might be considered in selected high-risk cases.

Reduction of pacemaker implantation rates after CoreValve® implantation by moderate predilatation

We investigated the impact of the diameter of the valvuloplasty balloon (VB) used for predilation before transcatheter aortic valve implantation (TAVI) on atrioventricular block formation with consecutive need for permanent pacemaker (PP) implantation. TAVI was performed in 269 consecutive patients using the CoreValve prosthesis (Medtronic) via transfemoral access under local anaesthesia with mild analgesic medication. After exclusion of 32 patients with previously implanted PP, 237 patients were included in a retrospective analysis of the impact of VB size on subsequent PP incidence. Implantation success rate was 99.3%. Periprocedural mortality was 0%, and 30-day mortality was 5.9%. PP implantation after TAVI was required by 21.1%. Of 114 patients treated by 25 mm balloon valvuloplasty, a PP was implanted in 27.1%. In 123 patients, who were treated by VB with a ≤23 mm diameter, the PP implantation rate decreased to 15.4% (p=0.04). In univariate analysis, larger VB size resulted in a greater prevalence of PP implantation after TAVI. After adjustment by multivariate analysis for baseline clinical and operative characteristics, VB size remained an independent predictor of PP implantation. Moderate balloon predilation in patients undergoing TAVI with the Medtronic CoreValve prosthesis reduces the PP rate without affecting procedural success.

The Utility of Atrioventricular Pacing via Pulmonary Artery Catheter During Transcatheter Aortic Valve Replacement

HE DEVELOPMENT OF TRANSCATHETER aortic valve replacement (TAVR) has led to the treatment of calcific aortic stenosis in patients whose condition might otherwise be considered inoperable if relegated to traditional aortic valve surgery. Although the ability to replace a patient’s aortic valve in this manner represents an important advancement in the treatment of aortic valve disease, there remain many challenges associated with successfully performing the procedure. One of these challenges is the ability to maintain hemodynamic stability during valve positioning and then recover stability after its deployment. Several factors can complicate this mission. The most obvious relate to the patient’s underlying aortic valve pathology as well as other concomitant cardiac disease. During valve positioning, the interposition of the deployment system across an already compromised aortic valve will further limit the native valve’s effective orifice area and also can promote regurgitation. Mechanical or functional mitral regurgitation also may occur during this process, producing additional strain on the myocardium. The cardiovascular system is further burdened by the need for cardiac “stand-still” during valve deployment. This is achieved by inducing rapid ventricular pacing (V-pacing). Hemodynamic recovery after this may be difficult, particularly if the pacing runs are protracted or successive. Delayed recovery can promote further myocardial ischemia, initiating a downward spiral that may prove intractable without significant intervention, including the need for mechanical circulatory support. Management can be complicated further by the development of conduction abnormalities (CA) after TAVR. This association has been well documented, but most of the literature has discussed them in regard to postoperative management, particularly the potential need for permanent pacemaker (PPM) placement. 1–4 However, CAs typically present during or immediately after valve deployment 5 and their acute hemodynamic effects have, in contrast, largely been ignored in published reports. This may be an important omission because the acute loss of atrioventricular (AV) synchrony may be tolerated poorly given the common association of ventricular hypertrophy and diastolic dysfunction in patients with aortic stenosis. In addition, because of the percutaneous nature of the procedure there are limited intraoperative rhythm management options available should the CA be associated with hemodynamic instability. Because of these concerns, all patients undergoing TAVR at this institution have percutaneous right atrial (RA) and right ventricular (RV) endocardial pacing wires placed via a specialized pulmonary artery catheter (PAC), unless they already have a PPM or have pre-existing atrial fibrillation (Fig 1). What follows is the discussion of a case that exemplifies the important benefits of this technique. CASE A 91-year-old woman with progressive dyspnea on exertion secondary to critical aortic stenosis presented for TAVR. The patient’s medical history also was significant for coronary artery disease with drug-eluting stents placed 2 years earlier, non–insulin-dependent diabetes mellitus, and temporal arteritis. Preoperative echocardiography revealed normal left ventricular function but with severe concentric hypertrophy, moderate mitral valve stenosis and regurgitation, and moderate-to-severe tricuspid regurgitation. The baseline electrocardiogram (ECG) was notable for sinus rhythm at 76 beats/min with an incomplete right bundle-branch block (RBBB) and a PR interval of 156 ms. A transaortic surgical approach was chosen because of the presence of a small and tortuous aorta with significant atheroma as well as the patient’s small body size, the combination of which limited both transapical and transfemoral deployment. After the induction of general anesthesia, a thermodilution PAC with two additional ports allowing the introduction of endocardial pacing wires into both the RA and RV (A-V Paceport Catheter, Edwards Lifesciences Corp., Irvine, CA) was inserted through a 9- French introducer sheath that had been placed into the right internal jugular vein (IJV). In order to properly position the pacing wires, the PAC was advanced while the pressure waveforms of both the catheter tip and the RV Paceport orifice were simultaneously monitored. Once the catheter tip entered the pulmonary artery (PA), it was further advanced until an RV pressure waveform was seen from the RV Paceport orifice, which indicated that this port had crossed the tricuspid

TCT-120 Need for Permanent Pacemaker Following Implantation of the Repositionable Second-Generation LOTUS(tm) Device for Transcatheter Aortic Valve Replacement: Results From the Pivotal REPRISE II Trial

TCT-120 Need for Permanent Pacemaker Following Implantation of the Repositionable Second-Generation LOTUS(tm) Device for Transcatheter Aortic Valve Replacement: Results From the Pivotal REPRISE II Trial

An Update On Complications Associated With Transcatheter Aortic Valve Implantation: stroke, Paravalvular leak, Atrioventricular Block and Perforation

Transcatheter aortic valve implantation (TAVI) has become an alternative therapeutic option for patients with symptomatic severe aortic stenosis at high surgical risk and the standard of care in patients who are inoperable for open aortic valve replacement. With technological evolution and increasing experience, the procedure has become more predictable. Complications of TAVI, however, are not infrequent, and can range from minor to life-threatening events. Stroke, paravalvular leak, various forms of atrioventricular block, including the need for permanent pacemakers and aortic annular and ventricular perforation will be the focus of the present review. Other complications associated with TAVI (such as vascular injury, acute kidney injury, coronary obstruction, valve malpositioning or migration) are clinically important, but are beyond the scope of this article. Understanding the occurrence and pathophysiology of these complications may provide insights into the improvement of the transcatheter devices and techniques, and aid in extending the application of TAVI to a broader population.

The Impact of Drug Discontinuation in Patients Treated with Temporary Pacemaker Due to Atrioventricular Block

Patients treated with a temporary pacemaker (TPM) due to atrioventricular (AV) block are often monitored after discontinuation of AV node blocking drugs to evaluate the indication for permanent pacing. However, the impact of drug discontinuation is sparsely documented. We investigated to what extent drug discontinuation abolished the need for permanent pacemaker (PPM) implantation. All hospital records of patients who received a TPM at Aalborg Hospital, Denmark, between January 2000 and March 2011 (n = 575) were retrospectively reviewed. Patients with AV block who were treated with a TPM and concomitant cessation of drug therapy were included if there was no other underlying mechanism causing the AV block. AV blocking drugs included antiarrhythmic agents classes II-IV and digoxin. Fifty-five patients fulfilled our inclusion criteria. Forty-seven patients had an indication for a PPM at the initial hospital admission, despite drug discontinuation. Of the remaining 8 patients who were discharged without a PPM, 3 subsequently experienced events: 2 had recurrence of AV block requiring a PPM, and 1 experienced syncope. Thus, in total, 49 (89%) patients had a final indication for a permanent pacemaker (PPM). Of patients receiving beta-blocker monotherapy, 26 (96%) had an indication for a PPM. TPM implantation was complicated by infection or displacement in 11% of cases. The vast majority of patients treated with a TPM due to AV block and who receive beta-blockers alone or in combination with digoxin have a final indication for a PPM despite cessation of drug treatment. TPM are frequently associated with complications.

Conduction disorders in the setting of transcatheter aortic valve implantation: a clinical perspective

The presence of periprocedural conduction disorders (CDs) and the need for permanent pacemaker (PPM) after transcatheter aortic valve implantation (TAVI) are frequent findings in clinical practice. Notwithstanding, robust information on the prognostic and therapeutic implications of these complications are lacking. The newly occurrence of CD after TAVI seems related to the trauma of the conduction system during procedure. On the contrary, major predictors for PPM implantation after TAVI seem to be the use of CoreValve prosthesis (Medtronic, Minneapolis, MN) and the presence of CD before TAVI. An accurate pre-TAVI screening, careful valve implantation, as well as post-TAVI monitoring must be pursued to prevent avoidable PPM implantation. The aim of this report is to analyze the available data on this field and to propose some practical clinical tips to prevent or to manage these complications.