Author + information
- Rachel Kaplan1,
- Ajay Yadlapati2,
- Rod Passman2,
- Bradley Knight2,
- Ranya Sweis3,
- Mark Ricciardi1,
- Duc Thinh Pham1,
- S. Malaisrie4,
- Charles Davidson1 and
- James Flaherty2
Transcatheter aortic valve replacement (TAVR) is increasingly used to treat severe aortic stenosis. A frequent complication of TAVR is atrioventricular (AV) block requiring a permanent pacemaker (PPM). The long-term dependency of pacing after TAVR is unknown. Post-balloon dilation (PBD) immediately after implantation is frequently done. Its long-term influence on AV block is unknown.
Of 409 consecutive patients without prior PPM, undergoing TAVR (77% balloon-expandable, 23% self-expandable valve), 48 (11.7%) received a new PPM. Patients receiving a late PPM (>10 days after TAVR, n=5), a biventricular device (n=3), or who died within 30 days (n=1) were excluded. PPM dependency was defined as AV block with a ventricular escape rate ≤ 40 bpm. Patient and procedural characteristics were examined according to PPM dependency status.
Nineteen of the 39 patients (48.8%) in the study group who received a PPM following TAVR were dependent at 30-days. There was no significant difference in age (80.1 ± 9.3 vs. 82.8 ± 6.7) or gender (47.4% and 55.0% female) between dependent and non-dependent groups. PPM dependency was more common after a self-expanding valve (47.4% vs. 15.0%, p = 0.03). PBD was performed in 25% of all TAVRs. Among patients without a pre-existing PPM, PBD was associated with a higher rate of new PPM (17.5% vs. 9.8%, p=0.04). Patients who underwent PBD also had a higher rate of PPM dependency (73.7% vs. 20.0%, p < 0.01). PPM dependent patients received the device earlier in the hospitalization (1 ± 1.6 days vs. 4 ± 2.6 days post-TAVR, p < 0.01) (Table 1).
|Variable||Non-dependent (N = 20)||Dependent (N = 19)||P value|
|Median Valve Size (mm)||26||26|
|Balloon expandable Valve Type||17 (85.0%)||10 (52.6%)||0.03|
|Self-expanding Valve Type||3 (15.0%)||9 (47.4%)||0.03|
|Pre-op PR (msec)||183.7 ± 41.9*||176.9 ± 26.6∧||0.55|
|Pre-op QRS (msec)||111.1 ± 36.5||119.3 ± 25.3||0.42|
|Days post-TAVR when PPM was placed||4 ± 2.6||1 ± 1.6||< 0.01|
|Post-balloon dilation by valve type (%)|
|- Balloon expandable||23.5||90.0||< 0.01|
Half of patients who receive a new PPM following TAVR are not clearly pacemaker dependent at follow-up. PBD is associated with a markedly increased risk of PPM dependency.