Underwent Permanent Pacemaker Implantation Research Articles

A single-center outcome of choosing catheter ablation as the initial treatment in tachycardia–bradycardia syndrome and a new predictive factor for pacemaker implantation

BackgroundThe relationship between sinus node dysfunction and atrial fibrillation (AF) has been well known. The reversibility of sinus node dysfunction is indeed a critical factor in determining the treatment strategy in patients with tachycardia–bradycardia syndrome (TBS). We aimed to assess the clinical outcome of choosing catheter ablation as the initial treatment in tachycardia–bradycardia syndrome and predictive factors leading to the implantation of a permanent pacemaker (PPM) in these patients.MethodsPatients with TBS who had been taken AF catheter ablation from 2012 to 2021 were reviewed, and 113 patients were enrolled. Patients were divided into two groups based on whether a “sinus pause episode of more than 3 s unrelated to tachyarrhythmia” coexists (Group I, n = 20) or not (Group II, n = 93).ResultsCompared to Group II, baseline characteristics showed that Group I was comprised of more female gender (p = 0.043), with hypertension (p = 0.033), and with enlarged left atrium (p = 0.003). An average three-year follow-up found that eight patients (8/113, 7%) were implanted PPM (5/20, 25% in Group I vs. 3/93, 3.2% in Group II, p = 0.001). Using a multivariate model, a “sinus pause episode unrelated to tachyarrhythmia” was strongly associated with PPM implantation after catheter ablation in patients with TBS (HR 6.765, 95% CI 1.355–33.763, p = 0.020). Only four out of 113 patients (3.5%) progressed to persistent or permanent AF.ConclusionsAfter catheter ablation as the initial treatment in TBS, only 7% underwent PPM implantation, and an isolated sinus pause was a predictive factor for requiring PPM implantation. In addition, even in patients who undergo catheter ablation with subsequent PPM implantation, we can expect to improve the clinical outcome associated with a reduced AF burden.

Permanent Cardiac Pacing of the Right Ventricular Outflow Tract Guided by Real-time Assessment of Electromechanical Synchrony.

Permanent right ventricular apical pacing deteriorates cardiac systolic function in some patients. We investigated an alternative site for permanent pacemaker (PPM) lead positioning with the goal of achieving more physiological pacing. A total of 132 patients with bradyarrhythmias underwent PPM implantation at the right ventricular outflow tract (RVOT) with conventional active-fixation leads. A real-time cross-correlation analysis (CCA) was performed using the Synchromax® software (EXO Health, Seattle, WA, USA) to determine the optimal site for ventricular lead implantation based on the cardiac synchrony index. The follow-up period ranged from 6-36 months, and the following parameters were assessed: pacing capture threshold, lead stability, and the need for lead repositioning. Adequate parameters were achieved in 129 patients (98%), and there were no procedure-related complications. At follow-up, no leads were dislodged, pacing thresholds remained stable, and no lead required repositioning. Using real-time CCA as an intraoperative parameter during PPM implantation at the septal RVOT helps to achieve cardiac synchrony in the vast majority of cases. This technique is a simple, effective, and safe way to simplify and standardize PPM implantation at the RVOT.

Prevalence of transthyretin cardiac amyloidosis in patients with high-degree AV block

ObjectiveTransthyretin amyloid cardiomyopathy (ATTR-CM) is an infiltrative cardiac disorder caused by deposition of wild type or mutated transthyretin. As ATTR-CM is associated with conduction disease, we sought to determine its...

Incidence and Outcomes of New-Onset Right Bundle Branch Block Following Transcatheter Aortic Valve Replacement.

The incidence and prognosis of right bundle branch block (RBBB) following transcatheter aortic valve replacement (TAVR) are unknown. Hence, we sought to characterize the incidence of post-TAVR RBBB and determine associated risks of permanent pacemaker (PPM) implantation and mortality. All patients 18 years and above without preexisting RBBB or PPM who underwent TAVR at US Mayo Clinic sites and Mayo Clinic Health Systems from June 2010 to May 2021 were evaluated. Post-TAVR RBBB was defined as new-onset RBBB in the postimplantation period. The risks of PPM implantation (within 90 days) and mortality following TAVR were compared for patients with and without post-TAVR RBBB using Kaplan-Meier analysis and Cox proportional hazards modeling. The risks of PPM implantation (within 90 days) and mortality following TAVR were compared for patients with and without post-TAVR RBBB using Kaplan-Meier analysis and Cox proportional hazards modeling. Of 1992 patients, 15 (0.75%) experienced new RBBB post-TAVR. There was a higher degree of valve oversizing among patients with new RBBB post-TAVR versus those without (17.9% versus 10.0%; P=0.034). Ten patients (66.7%) with post-TAVR RBBB experienced high-grade atrioventricular block and underwent PPM implantation (median 1 day; Q1, 0.2 and Q3, 4), compared with 268/1977 (13.6%) without RBBB. Following propensity score adjustment for covariates (age, sex, balloon-expandable valve, annulus diameter, and valve oversizing), post-TAVR RBBB was significantly associated with PPM implantation (hazard ratio, 8.36 [95% CI, 4.19-16.7]; P<0.001). No statistically significant increase in mortality was seen with post-TAVR RBBB (hazard ratio, 0.83 [95% CI, 0.33-2.11]; P=0.69), adjusting for age and sex. Although infrequent, post-TAVR RBBB was associated with elevated PPM implantation risk. The mechanisms for its development and its clinical prognosis require further study.

Permanent pacemaker implantations among patients with spinal cord injury in the United States

Abstract Background Acute spinal cord injury (SCI) is associated with severe cardiovascular complications. Information regarding the need for permanent cardiac pacing in SCI patients is scarce and based on case reports and small case series. We aimed to investigate the extent of permanent pacemaker (PPM) implantation procedures as well as to identify predictors for PPM insertion among SCI patients in a U.S contemporary, nationwide, all-comer registry. Methods Using the National Inpatient Sample (NIS) database, patients hospitalized with a primary diagnosis of SCI in the US between 2016-2019 and underwent PPM implantation were identified. Patients with cardiac implantable electronic device in-situ were excluded. Baseline demographics, clinical characteristics, injury type, in-hospital procedures and outcomes including time to PPM implantation, length of stay and mortality were collected. Outcome analysis performed after propensity score matching (PSM). Predictors of PPM implantation were identified via a multivariable logistic regression model. Results A total of 35880 patients, were hospitalized with a primary diagnosis of SCI during the study period, and 240 (0.7%) received a PPM. Median age of patients receiving PPM was 69 years, 75% were males, and 67% had high level SCI injury (level C1-5). Time to PPM implantation was 9 days (IQR 4-19). PPM implantation was associated with higher rates of cervical spine injuries, traumatic brain injury (TBI), chest and upper limbs injuries, respiratory failure and other signs of severe illness. Longer hospital stay and higher in-hospital mortality rate was observed in patients receiving a PPM. Multivariate analysis identified the following independent risk factors for PPM implantation: cervical SCI [OR 77.07 (11.13-553.42), p&amp;lt;0.001], TBI [OR 3.84(1.59-9.28), p=0.003] and tracheostomy/respiratory ventilation&amp;gt; 96 h [OR 31.766(7.91-127.54), p=&amp;lt;0.001]. Conclusion Cervical SCI, need for tracheostomy and prolonged mechanical ventilation were the strongest predictors for PPM implantation in patients hospitalized for SCI in a nationwide registry.

Abstract 18348: Causes and Predictors of 30-Day Readmissions Following Permanent Pacemaker Implantation in Patients With Cardiac Amyloidosis: From National Readmission Database (2016-2020)

Introduction: Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy where local deposition of amyloid fibrils causes heart failure, arrhythmias, and conduction system abnormalities. Involvement of the AV nodal and infra-hisian conduction system increases the need for a permanent pacemaker (PPM). Studies have noted worse outcomes in patients with implantable-cardioverter defibrillator placement in amyloidosis, but a comparison with PPM is lacking. We sought to analyze readmissions in CA patients following PPM placement utilizing National Readmission Database (NRD). Methods: NRD (2016 to 2020) was queried to identify adults with a diagnosis of CA who underwent PPM implantation using ICD-10 CM and PCS codes. The primary outcome was a 30-day readmission rate. Secondary outcomes were in-hospital mortality, length of stay (LOS), total hospital charge (THC), and predictors of readmission. Multivariate/univariate logistic and linear regression analyses were used to analyze the outcomes and adjust for possible confounders. Results: A total of 1,027 encounters of CA who underwent PPM were identified, of which 975 were discharged alive. Within 30 days from discharge, 141 (14.5%) were readmitted. Those readmitted had a longer LOS and higher burden of comorbidities while were similar in age, sex, hospital characteristics, and household income status. Readmissions lead to an additional mean THC of $55,079 and a mean LOS of 6.3 days. The top five causes of readmissions were heart failure (23%), sepsis (6.6%), hypertensive heart disease (4%), bradycardia (3.5%), and acute kidney injury (3.2%). Figure-1 shows the forest plot of a multivariate analysis of independent factors associated with readmissions. Conclusions: Our findings show that up to 15% of patients with CA who undergo PPM implantation get readmitted with heart failure being the most common etiology. Optimizing comorbidities with PPM implantation in CA may provide better outcomes and reduce admissions.

The degree of permanent pacemaker dependence and clinical outcomes following transcatheter aortic valve implantation: implications for procedural technique.

Conduction abnormalities necessitating permanent pacemaker (PPM) implantation remain the most frequent complication post-transcatheter aortic valve implantation (TAVI), yet reliance on PPM function varies. We evaluated the association of right-ventricular (RV)-stimulation rate post-TAVI with 1-year major adverse cardiovascular events (MACE) (all-cause mortality and heart failure hospitalization). This retrospective cohort study of patients undergoing TAVI in two high-volume centers included patients with existing PPM pre-TAVI or new PPM post-TAVI. There was a bimodal distribution of RV-stimulation rates stratifying patients into two groups of either low [≤10%: 1.0 (0.0, 3.6)] or high [>10%: 96.0 (54.0, 99.9)] RV-stimulation rate post-TAVI. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated comparing MACE in patients with high vs. low RV-stimulation rates post-TAVI. Of 4659 patients, 408 patients (8.6%) had an existing PPM pre-TAVI and 361 patients (7.7%) underwent PPM implantation post-TAVI. Mean age was 82.3 ± 8.1 years, 39% were women. A high RV-stimulation rate (>10%) development post-TAVI is associated with a two-fold increased risk for MACE [1.97 (1.20, 3.25), P = 0.008]. Valve implantation depth was an independent predictor of high RV-stimulation rate [odds ratio (95% CI): 1.58 (1.21, 2.06), P=<0.001] and itself associated with MACE [1.27 (1.00, 1.59), P = 0.047]. Greater RV-stimulation rates post-TAVI correlate with increased 1-year MACE in patients with new PPM post-TAVI or in those with existing PPM but low RV-stimulation rates pre-TAVI. A shallower valve implantation depth reduces the risk of greater RV-stimulation rates post-TAVI, correlating with improved patient outcomes. These data highlight the importance of a meticulous implant technique even in TAVI recipients with pre-existing PPMs.

Performance of the 2019 consensus algorithm on the management of conduction disturbances after TAVI in clinical practice

Introduction and objectivesConduction disturbances (CD) after transcatheter aortic valve implantation (TAVI) increase the risk of permanent pacemaker (PPM) implantation and often preclude early-discharge (ED). The aim of this study was to evaluate the performance of the 2019 consensus algorithm on the management of conduction disturbances post-TAVI in a real-world cohort. MethodsRetrospective analysis of patients who underwent transfemoral TAVI between 2016 and 2018. Patients with prior PPM were excluded. The algorithm classified patients as ED or non-ED candidates (due to a higher risk for high-degree atrioventricular block or because they were eligible for PPM). ED was defined as discharge at day-3 post-TAVI. Primary endpoint was the 30-day rate of PPM implantation and secondary endpoints included 6-month pacing rate, 1-year rate of syncope and all-cause mortality and the composite outcome of both, regarding ED eligibility. ResultsA total of 220 patients were included. The algorithm classified 66% of the patients as ED candidates. The 30-day rate of PPM implantation was 3.6% for ED candidates (vs 62.5% for non-ED candidates; P<.001). No differences were found in the secondary endpoints between ED and non-ED candidates. The algorithm identified 16% of the patients as eligible for PPM of whom 97.1% underwent PPM implantation; 18% of the patients were classified as at higher risk of high-degree atrioventricular block. ConclusionsThe 2019 algorithm allowed to safely ED a significant number of patients with conduction disturbances post-TAVI and to identify patients with a clear indication for PPM implantation. However, in high-risk patients, the algorithm does not provide a guiding strategy.

Long-term impact of pacemaker implantation after TAVI: a subgroup analysis according to previous intraventricular conduction disturbances

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Transcatheter aortic valve implantation (TAVI) is a worldwide accepted treatment for severe aortic stenosis (AS). Conduction system disturbances, frequently requiring permanent pacemaker (PM) implantation, remain one of the most common procedural complication. Whether the permanent ventricular pacing has a deleterious impact on the prognosis of this population remains unclear. Objectives To assess the long-term impact of permanent PM implantation in clinical outcomes after TAVI. Methods We performed a retrospective analysis of consecutive patients (P) who underwent TAVI between 2009 and 2021 in a single tertiary center.P with a PM implanted before TAVI or with in-hospital mortality were excluded from the analysis. PM implantation post-TAVI was defined as an implant during hospital stay after TAVI or in the first month after discharge. Kaplan Meier survival curves were used to estimate the impact of permanent PM after TAVI, regarding the composite endpoint of all-cause mortality and heart failure (HF) hospitalization during a 4 years follow-up period, and a comparison performed according to the presence or absence of baseline intraventricular conduction disturbances. Results 549 P (82±6.6 years, 56.8% female, left ventricular ejection fraction 53±10%, peak gradient 51±15.6 mmHg, aortic valve area 0.7± 0.2 cm2) were included. At baseline, 108 P (20%) had intraventricular conduction disturbances on ECG (50 P with right bundle branch block [RBBB] and 58 P with left bundle branch block [LBBB]). 127 P (23%) required PM implantation after TAVI. Baseline characteristics were similar between P with and without PM implantation, except for age, gender, previous valvular surgery and RBBB (Table 1). At 48 months follow-up, 35% (n=193) met the composite endpoint, that was similar between both groups (35.8% vs. 34.1%, p=0.731). Kaplan-Meier survival curves revealed no difference in the composite endpoint between the two groups (log-rank p=0.170). Further analysis of subgroups according to the presence or absence of baseline intraventricular conduction disturbances revealed a significant difference among the subgroup of P without previous intraventricular conduction disturbances that underwent PM implantation after TAVI (log rank p=0.02) (Fig 1). This difference in the composite endpoint after PM was not found in the subgroups of P with RBBB (log rank p=0.656) or LBBB (log rank p=0.975) at baseline (Fig 2).* Conclusions Permanent PM implant after TAVI does not have an impact on long-term HF hospitalization and mortality. However, in the specific subgroup of P without previous intraventricular conduction disturbances, PM implantation seems to be associated with worse prognosis.

Genetic background of sinus node dysfunction requiring permanent pacemaker implantation after atrial fibrillation catheter ablation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Atrial fibrillation catheter ablation (AFCA) improves sinus node function and may defer a permanent pacemaker (PPM) implantation. We explored the clinical and genetic characteristics of the patients with AF and sinus node dysfunction (SND) who eventually needed PPM implantation after AFCA. Methods Among 2,732 AF patients with genome-wide association study (GWAS, PMRA, Thermofisher scientific, MA, USA) data who underwent the first AFCA, 244 patients (65.0, IQR [59.0, 72.0] years, male 58.2%, paroxysmal AF 79.5%) had underlying SND before AFCA (class I indication for PPM). We retrospectively investigated clinical factors, single-nucleotide polymorphisms (SNPs), and their polygenic risk score (PRS) associated with PPM-AFCA. We defined the cut-off of PRS using the Youden index. Results During median 37.9 (IQR 20.3-77.9) months follow-up, 36 out of 244 patients (16.1%) with underlying SND eventually underwent PPM implantation after AFCA (PPM-AFCA). PPM-AFCA group a had a higher body mass index (p=0.013) and large left atrial (LA) dimension (p=0.006) than their counterpart. Among 44 SNPs related to AF and SND, the rs3922844 (p=0.003) near SCN5A and rs9320841 (p=0.011) and rs1015451 (p=0.046) near CJA1 were significantly associated with PPM-AFCA. The rate of PPM-AFCA implantation was significantly higher in the high PRS group (≥1.175, 25.6%) compared to the low PRS group (&amp;lt;1.175, 9.38%, p=0.002, Log-rank p=0.002). LA dimension (adjusted HR 1.06, 95% CI [1.00-1.13], p=0.044) and PRS (adjusted HR 2.69, 95% CI [1.68-4.31], p&amp;lt;0.001) were associated with a higher risk for PPM-AFCA after adjusting clinical factors including age, sex, AF type, beta blocker, and antiarrhythmic drugs after AFCA. Conclusions In AF patients with SND, 16% with the genetic background of SCN5A and CJA1 or large atrium eventually needed PPM implantation after AFCA.

PO-05-019 WHEN RIGHT IS WRONG: INCIDENCE AND OUTCOMES OF RIGHT BUNDLE BRANCH BLOCK FOLLOWING TRANSCATHETER AORTIC VALVE REPLACEMENT

Right bundle branch block (RBBB) following transcatheter aortic valve replacement (TAVR) for aortic stenosis is uncommon. However, its incidence and prognosis have not been well-described. To characterize the incidence of post-TAVR RBBB alongside its associated risk of permanent pacemaker (PPM) implantation and mortality. All patients ≥18 years who underwent TAVR at the Mayo Clinic Enterprise from June 2010 to May 2021 were considered; patients with pre-TAVR RBBB and/or PPM were excluded from the analysis. Clinical history, imaging variables, and electrocardiographic data were abstracted from the electronic medical records. Post-TAVR RBBB, defined as new onset RBBB in the postprocedure period, was manually verified by the study authors. The risks of PPM implantation (within 90-days post-TAVR) and mortality following TAVR were compared between patients with and without post-TAVR RBBB using the Kaplan-Meier method and Cox proportional hazards modeling. Out of 1992 patients included, 15 (0.75%) experienced new RBBB post-TAVR. There was a higher proportion of patients who had valve oversizing among patients with new RBBB post-TAVR versus not (17.9% versus 10.0%, p=0.034). There were no other significant differences in demographics or clinical characteristics between patients with and without post-TAVR RBBB including age at TAVR, sex, type of valve implanted, valve size, aortic valve calcium score, or left ventricular ejection fraction (Table 1). Ten patients (66.7%) with post-TAVR RBBB experienced high-grade atrioventricular block (≥2 consecutive blocked P waves) and subsequently underwent PPM implantation (median 4 days; interquartile range 1-90 days), compared to 268/1977 (13.6%) without RBBB (Figure 1). After adjustment for age, sex, balloon expandable valve, annulus diameter, and valve oversizing, post-TAVR RBBB was significantly associated with PPM implantation (hazard ratio [HR] 8.36, 95% confidence interval [CI] 4.19-16.7; p<0.001). No statistically significant increase in mortality was seen with post-TAVR RBBB (HR 0.83, 95% CI 0.33-2.11; p=0.69) following adjustment for age and sex. Although encountered rarely, post-TAVR RBBB was associated with an elevated risk of PPM implantation. The mechanisms for its development and its clinical prognosis require further study.Tabled 1Table 1: Baseline characteristics of study cohortMedian (IQR) or No. (%) of patientsVariableNNo RBBB (N=1977)New-Onset RBBB (N=15)P-valueAge at TAVR1,99281.3 (75.4, 86.0)82.6 (78.8, 87.4)0.45Sex (Males)1,9921,111 (56.2%)9 (60.0%)0.80Balloon Expandable Valve1,9921,744 (88.2%)12 (80.0%)0.41Valve size1,99226.0 (23.0, 29.0)26.0 (24.5, 29.0)0.49Annulus Area (cmˆ2) based on CT1,8504.7 (4.0, 5.4)4.6 (4.3, 5.1)0.81Annulus Diameter (mm)1,93027.0 (25.0, 29.1)26.0 (25.1, 28.8)0.87Valve Oversizing *1,85010.0 (3.0, 18.5)17.9 (15.4, 23.4)0.034LVEF (%)1,89762.0 (55.0, 66.0)61.5 (54.2, 67.8)0.97AV Peak Velocity1,8974.2 (4.0, 4.6)4.1 (4.0, 4.3)0.42AV Mean Gradient1,89743.0 (38.0, 51.0)41.5 (41.0, 44.8)0.76AV Area1,8970.8 (0.7, 0.9)0.9 (0.8, 1.0)0.33LVOT AV Velocity Ratio1,8970.2 (0.2, 0.2)0.2 (0.2, 0.3)0.47LVOT AV TVI Ratio1,8970.2 (0.2, 0.2)0.2 (0.2, 0.3)0.51LVOT Dimension1,7292.2 (2.1, 2.3)2.2 (2.1, 2.3)0.77LV Geometry9710.64Concentric Hypertrophy359 (37.4%)5 (45.5%)Concentric Remodeling264 (27.5%)2 (18.2%)Eccentric Hypertrophy158 (16.5%)3 (27.3%)Normal Geometry179 (18.6%)1 (9.1%)LVED Dimension1,55649.0 (45.0, 53.0)48.0 (43.0, 53.5)0.64Aortic Valve Calcium Score1,7302,281.0 (1,556.5, 3,169.5)2,729.0 (1,979.1, 3,480.5)0.31Myocardial Infarct1,987137 (6.9%)2 (13.3%)0.28Congestive Heart Failure1,987522 (26.5%)5 (33.3%)0.56Charlson Comorbidity Index1,9872.0 (0.0, 4.0)2.0 (1.0, 4.0)0.61STS Risk Score1,7304.8 (3.0, 8.0)4.0 (3.1, 9.2)0.86P-values result from a Wilcoxon rank sum test (continuous variables) or Fisher’s exact test (categorical variables). *Valve oversizing = (Nominal Area / Annulus area (mm)) -1) *100 AV – aortic valve; CT – computed tomography; IQR – interquartile range; LVEF – left ventricular ejection fraction; LVOT – left ventricular outflow tract; STS – Society of Thoracic Surgeons; TAVR – transcatheter aortic valve replacement; TVI - tissue velocity index Open table in a new tab

PO-03-108 TEMPORAL COURSE OF CONDUCTION ABNORMALITIES AFTER PERCUTANEOUS AND SURGICAL AORTIC VALVE REPLACEMENT

Aortic valve replacement is an increasingly common procedure. With the advent of trans-catheter aortic valve implantation (TAVI), patients that would have previously been denied valve replacement are able to undergo intervention. The anatomic proximity of the aortic valve and the native conduction system can lead to significant conduction abnormalities requiring permanent pacemaker (PPM) implantation. This retrospective study aimed to compare the incidence, temporality and eventual recovery of conduction abnormalities in patients undergoing PPM implantation post TAVI and surgical aortic valve replacement (SAVR). During the 5-year study period, 1012 patients had aortic valve replacement, 746 underwent SAVR and 266 patients underwent TAVI. In this group, patients were screened for pacemaker implantation within 14 days post procedure and were included if the pacemaker implantation was due to new AV conduction abnormalities. Patients were excluded if they had a pacemaker prior to surgery or had alternate reasons for pacemaker implantation such as complications from infective endocarditis. The incidence of new AV conduction abnormalities requiring pacemaker implantation post-operatively was 5.3% (n=14) in TAVI patients and 3.4% (n=26) in SAVR patients. In the TAVI group PPM implantation occurred on average at 3.2 ± 2.1 days (median 3 days) post procedure. In the SAVR group the average time to implantation was 6 ± 3.1 days (median 5 days). To determine conduction recovery 36 patients had complete follow up, 26 patients in SAVR and 10 patients in TAVI group. After a mean follow-up of 3 months, 50% of patients in the TAVI group and 36.1% in SAVR group recovered 1:1 conduction. At 12 months, 60% of patients in the TAVI group and 41% in the SAVR group had improved conduction and by 24 months it was 50% and 34.5%, respectively. In patients who undergo PPM implant post TAVI a high rate of conduction recovery is observed during follow-up, probably emphasizing the need for better selection of pacing candidates.

INCIDENCE AND PREDICTORS OF PERMANENT PACEMAKER IMPLANTATION AFTER TRANS AORTIC VALVE IMPLANTATION (TAVI) – A SINGLE CENTER EXPERIENCE

Objectives: The objective of the study is to evaluate the incidence and predictors of permanent pacemaker (PPM) implantation in patients undergoing transaortic valve implantation (TAVI). Methodology: This study was conducted at the “National Institute of Cardiovascular Diseases (NICVD) Karachi, Pakistan”. All the consecutive patients who underwent TAVI between July 2015 and February 2020 were included in the study. Patient data were extracted from Hospital TAVI Registry. We included patients with severe symptomatic aortic stenosis (AS) with moderate to high surgical risk as per “society of thoracic surgeon score (STS)” and “EURO II score”, underwent TAVI. Patients were stratified into two groups based on the implantation of PPM, demographic characteristics, clinical characteristics, co-morbid conditions, valve pathology, and procedural characteristics were compared between both groups. Results: Among 100 patients included only 22 patients (22%) underwent PPM implantation. The indication for implantation of PPM for all patients was complete heart block. Clinical characteristics which shows statistical significance for PPM implantation are preprocedural left ventricular dysfunction (p=0.015), right bundle branch block (RBBB) p&lt;0.001, and left anterior hemiblock (p&lt;0.001) noted on ECG and post-deployment valve area post-procedure (p&lt;0.001). Multivariate analysis showed that pre-procedure RBBB and large post-deployment valve area are independent predictors for PPM implantation in Post TAVI patients. Conclusion: The incidence of PPM implantation in patients who underwent TAVI at NICVD is 22%. Preprocedural left ventricular dysfunction, RBBB, and post-procedure large post-deployment valve area were noted to be significant predictors for PPM implantation.

Outcomes of Patients With Hypertrophic Obstructive Cardiomyopathy and Pacemaker Implanted After AlcoholSeptal Ablation.

Atrioventricular block is a frequent major complication after alcohol septal ablation (ASA). The aim of this study was to evaluate the outcomes of patients with implanted permanent pacemaker (PPM) related to a high-grade atrioventricular block after ASA for hypertrophic obstructive cardiomyopathy. We used a multinational registry (the Euro-ASA registry) to evaluate the outcome of patients with PPM after ASA. A total of 1,814 patients were enrolled and followed up for 5.0 ± 4.3 years (median=4.0 years). A total of 170 (9.4%) patients underwent PPM implantation during the first 30days after ASA. Using propensity score matching, 139 pairs (n = 278) constituted the matched PPM and non-PPM groups. Between the matched groups, there were no long-term differences in New York Heart Association functional class (1.5 ± 0.7 vs 1.5 ± 0.9, P = 0.99) and survival (log-rank P = 0.47). Patients in the matched PPM group had lower long-term left ventricular (LV) outflow gradient (12±12 mm Hg vs 17 ± 19mmHg, P< 0.01), more pronounced LV outflow gradient decrease (81% ± 17% vs 72%±35%, P< 0.01), and lower LV ejection fraction (64% ± 8% vs 66% ± 8%, P = 0.02) and were less likely to undergo reintervention (re-ASA or myectomy) (log-rank P = 0.02). Patients with hypertrophic obstructive cardiomyopathy treated with ASA have a 9% probability of PPM implantation within 30days after ASA. In long-term follow-up, patients with PPM had similar long-term survival and New York Heart Association functional class but lower LV outflow gradient, a more pronounced LV outflow gradient decrease, a lower LV ejection fraction, and a lower likelihood of reintervention compared with patients without PPM.

Sinus Node Dysfunction after Successful Atrial Flutter Ablation during Follow-Up: Clinical Characteristics and Predictors

Identification of sinus node dysfunction (SND) before termination of persistent AFL by catheter ablation (CA) is challenging. This study aimed to investigate the characteristics and predictors of acute and delayed SND after AFL ablation. We retrospectively enrolled 221 patients undergoing CA of persistent AFL in a tertiary referral center. Patients with SND who required a temporary pacemaker (TPM) after termination of AFL or a permanent pacemaker (PPM) during follow-up were identified. Acute SND requiring a TPM was found in 14 of 221 (6.3%) patients following successful termination of AFL. A total of 10 of the 14 patients (71.4%) recovered from acute SND. An additional 11 (5%) patients presenting with delayed SND required a PPM during follow-up, including 4 patients recovering from acute SND. Of these, 9 of these 11 patients (81.8%) underwent PPM implantation within 1 year after the ablation. In multivariable analysis, female gender and a history of hypothyroidism were associated with the requirement for a TPM following termination of persistent AFL, while older age and a history of hypothyroidism predicted PPM implantation. This study concluded that the majority of patients with acute SND still require a PPM implantation despite the initial improvement. Therefore, it is reasonable to monitor the patients closely for at least one year after AFL ablation.

Optimal timing of pacemaker implantation after cardiac surgery: should we wait 12 days? A 5-year observational study from a UK tertiary centre

Abstract Funding Acknowledgements Type of funding sources: None. Background and Purpose Post-operative bradycardia is common but intrinsic rhythm often recovers. There is little consensus on the optimum time to wait between cardiac surgery and the implantation of a permanent pacemaker (PPM). Earlier device implantation may facilitate shorter length of stay. However, it may expose some patients who have no long-term pacing requirement to the risks associated with device therapy. This study aimed to understand how the number of days between cardiac surgery and PPM implantation is associated with pacing dependence and recovery of intrinsic conduction by 30 days. Methods We examined healthcare records of consecutive patients who underwent cardiac surgery at our centre between 01/01/2015 to 01/01/2021. The primary outcome measures were pacing dependence (PD) at 30 days and recovery of intrinsic conduction at 30 days. Recovery was defined as showing evidence of intrinsic rhythm at the 30 day check after being pacing dependent at the time of implant. Patient demographics, baseline ECG characteristics and surgical procedure were recorded. Time to pacemaker implantation and pacing indication were identified. Pacing checks at 30 days post implant were reviewed and PD defined as no intrinsic rhythm seen over a 30 second period with base rate set at 40bpm. Univariate analysis and binary logistic regression were used to determine factors significantly associated with the primary outcome measures. Subsequent receiver-operator characteristic (ROC) analysis was used to determine the optimal timing of pacemaker implantation as defined by the Youden Index. This aims to maximise sensitivity and specificity of days to implant in predicting PD and conduction recovery at 30 days. Results Following 5849 operations, 103 (1.8%) patients underwent PPM implantation for a new bradycardic indication. The baseline characteristics of those paced are summarised in table 1. Numerous factors were associated with pacing dependence at 30 days on univariate analysis (table 2). However, multivariate analysis showed that only PD at implant and days to implant (DTI) were significant predictors of PD at 30 days. The only significant association with conduction recovery was DTI. ROC analysis showed that the optimal DTI is 12 days for a variety of analyses: 1.) Predicting PD at 30 days for all patients (AUC 0.620, SE 0.056, p=0.031, 95% CI 0.511-0.730) 2.) Predicting PD in patients whose PPM indication was AV nodal dysfunction (AUC 0.706, p=0.001, Youden Index (YI) 1.34). 3.) Predicting recovery of intrinsic rhythm in patients who were pacing dependent at implant (AUC 0.80, p= 0.000, YI 1.515). Conclusions The number of days between surgery and pacemaker implantation is the only factor significantly associated with both pacing dependence and recovery of intrinsic conduction at 30 days. The optimum time to wait is 12 days to allow time for intrinsic conduction to recover.

Permanent pacemaker implantation late after transcatheter aortic valve implantation.

Impairment of atrioventricular (AV) conduction may occur late after transcatheter aortic valve implantation (TAVI), and progression to complete AV block is a matter of concern. The purpose of this study was to describe the incidence of permanent pacemaker (PPM) implantation late after TAVI. In a prospective TAVI registry, we retrospectively identified patients with PPM implantation after hospital discharge for TAVI and analyzed serial electrocardiograms for AV conduction impairment before PPM implantation. Among 1059 patients discharged after TAVI without PPM between January 2012 and December 2017, 62 patients (5.9%) underwent PPM implantation at a median of 305 days after discharge for TAVI. Indications for PPM implantation late after TAVI were AVconduction impairment in 46 patients (74.2%); sick sinus syndrome in 10 (16.1%); cardiac resynchronization or implantable cardioverter-defibrillator indication in 2 (3.2%); and a pace and ablate strategy in 4 (6.5%). Clinical symptoms leading to PPM implantation late after TAVI included syncope in 19 patients (30.7%), presyncope in 7 (11.3%), and dyspnea in 8 (12.9%). First-degree AV block and new left bundle branch block (LBBB) after TAVI as well as valve-in-valve procedure during follow-up were independent predictors of PPM implantation late after TAVI due to AV conduction impairment. PPM implantation late after TAVI is infrequent and is associated with clinical symptoms in half of patients. Impairment of AV conduction was the indication in three-quarters of patients. First-degree AV block and new LBBB after TAVI as well as valve-in-valve procedure during follow-up emerged as independent predictors.

High-degree atrioventricular block after valve-in-valve transcatheter aortic valve implantation: incidence and predictors

Abstract Background High-degree atrioventricular (AV) block and permanent pacemaker (PPM) implantation represent major complications after transcatheter aortic valve implantation (TAVI). Data on the incidence of AV block for patients undergoing valve-in-valve (ViV) TAVI are scarce. We examined the incidence and predictors of periinterventional AV conduction disturbances in a cohort of subjects undergoing ViV TAVI compared to subjects undergoing TAVI of native aortic valves. Methods In 50 consecutive patients who underwent ViV TAVI, clinical characteristics, incidence and predictors for AV conduction disturbances as well as intrahospital outcome were assessed. Applying a matched pair approach for age, gender, type and size of transcatheter valve, these subjects were compared to 50 patients undergoing TAVI of native tricuspid aortic valves. Results Mean age in both groups was 80±6 years and 50% of subjects were male. In the ViV group, 22 patients (44%) had a stented bioprosthesis, 10 patients (20%) a stentless bioprosthesis and 18 patients (36%) a previous TAVI prosthesis (balloon-expandable: n=15, self-expandable n=3). The majority of subjects (92% in each group) were treated using balloon-expandable valves (ViV group: Sapien XT, n=20 or Sapien 3, n=26, control group: Sapien XT, n=19 or Sapien 3, n=27). Periinterventional, non-reversible 3rd degree AV-block occurred in 6 patients within each group (12%), and all of the affected patients underwent PPM implantation. Among the 32 patients who underwent ViV-TAVI of a surgically placed bioprosthesis, only 2 (6%) developed a high-degree AV block (1/22 with a stented bioprosthesis and 1/10 with a stentless bioprosthesis). In contrast, high-degree AV block occurred in 4/18 patients (22%) who underwent ViV TAVI of a prior TAVI prosthesis. There was a significant difference in the occurrence of total high-degree AV blocks requiring postinterventional PPM implantation (p=0.033) between subjects who received TAVI of stented bioprostheses and those who received re-TAVI. In logistic regression analysis, pre-existing RBBB represented a significant predictor for periinterventional 3rd degree AV block across the whole cohort (p=0.001, Exp(B)=10.667), both in ViV subjects (p=0.016, Exp(B)=12.0) and in the control group (p=0.018, Exp(B)=10.0). Conclusion Periinterventional AV block occurs infrequently in subjects undergoing ViV TAVI for treatment of degenerated surgical bioprostheses. However, patients undergoing ViV TAVI for degenerated transcatheter prostheses as well as subjects with pre-existing RBBB are at substantial risk for the occurence of AV block and require close peri-interventional monitoring. Funding Acknowledgement Type of funding sources: None.

Left Ventricular Global Longitudinal Strain Is Associated With Cardiovascular Outcomes in Patients Who Underwent Permanent Pacemaker Implantation.

Background: Patients who underwent permanent pacemaker (PM) implantation have a potential risk of left ventricular (LV) systolic dysfunction. However, assessment of LV ejection fraction (LVEF) shows a limited role in identifying subclinical LV systolic dysfunction and predicting cardiovascular (CV) outcomes.Methods: We reviewed 1,103 patients who underwent permanent PM implantation between January 2007 and December 2017. After excluding patients who did not undergo echocardiograms before or after PM implantation and those with LV ejection fraction (LVEF) <50%, significant valve dysfunction, and history of cardiac surgery before PM implantation, 300 (67 ± 13 years, 119 men) were finally analyzed. LV mechanical function was assessed with LV global longitudinal strain (LV-GLS) using 2-dimensional speckle-tracking echocardiography. CV outcomes were defined as a composite of CV death and hospitalization for heart failure.Results: At 44 ± 28 months after post-PM echocardiogram, 23 patients (7.7%) had experienced CV outcomes. Patients with CV outcomes were older and had more comorbidities and a lower baseline |LV-GLS| than those without CV outcomes. LV mechanical function worsened after PM implantation in patients with CV outcomes. The cut-off value of 11.2% in |LV-GLS| on post-PM echocardiogram had a better predictive value for CV outcomes (AUC; 0.784 vs. 0.647, p = 0.012). CV outcome in patients with |LV-GLS| <11.2% was worse than that in those with |LV-GLS| ≥ 11.2% (log-rank p < 0.001). Multivariate Cox model revealed that reduced |LV-GLS| was independently associated with CV outcomes.Conclusions: Pacing deteriorates LV mechanical function. Impaired LV-GLS is associated with poor CV outcomes in patients who underwent PM implantation.

The association of multimorbidity to mortality in older adults after permanent pacemaker placement.

In the United States 2018 bradycardia guideline, the current class III recommendation that patients with permanent pacemaker (PPM) indications and high multimorbidity burden may not have meaningful clinical benefit from PPM therapy is based on limited data. Observational study (January 1, 2008-December 31, 2015) of adults ≥65 years (N=16,678) who underwent PPM implantation. Exposure variable: Elixhauser comorbidity number (ECN, 29 well-validated conditions). ≤1-year mortality; secondary outcome:>1-year mortality. Those who died ≤1-year were older, had a lower body mass index (BMI), and higher ECN (p<.001). Cumulative survival at 1-year was 92.3% (95% confidence interval [CI]: 91.9-92.7). One-year survival decreased by increasing ECN-with a difference at 1-year between lowest and highest ECN category of 17.3% (ECN 0-1: 97.1% [95% CI: 96.3-97.7]; ECN ≥8: 79.8% [95% CI: 77.9-81.5]). For those who survived the first year, cumulative survival at 8-years was 51.2% (95% CI=49.8-52.6) with a difference between ECN 0-1 and ≥8 of 43.4%. Increasing ECN was associated equally with ≤1-year (HR 1.28 [95% CI: 1.25-1.30]) and>1-year (HR 1.19 [95% CI: 1.17-1.20]) mortality. A predictive model including age, sex, BMI, PPM type, race, and ECN had greater discriminative ability (p<.0001) than a bedside model (age, sex) for the primary outcome. Across the heterogeneity of indications for PPM placement, multimorbidity is increasingly common. The association of multimorbidity to mortality (≤1-year,>1-year) should be routinely discussed during the shared decision-making process as an important prognostic geriatric domain variable.