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No Increase in Adverse Clinical Outcomes with New Permanent Pacemaker After TAVR

Summary and Comment |
March 28, 2014

No Increase in Adverse Clinical Outcomes with New Permanent Pacemaker After TAVR

  1. Howard C. Herrmann, MD

Rates of long-term mortality or hospitalization for heart failure did not differ significantly between patients who required PPM implantation after transcatheter aortic valve replacement and those who did not.

  1. Howard C. Herrmann, MD

The frequent need for a new permanent pacemaker (PPM) after either surgical or transcatheter aortic valve replacement (TAVR) is well described, but the effect of PPM implantation on late outcomes is less clear. In light of strong evidence that right ventricular apical pacing has adverse consequences in patients with heart failure (HF), investigators conducted a large multicenter study of long-term outcomes in 1556 patients undergoing TAVR without a preexisting PPM.

The rate of new PPM implantation within 30 days after TAVR was 15% overall, 26% in recipients of a self-expanding prosthesis, and 7% in recipients of a balloon-expandable prosthesis. Thirty-day rates of death (about 7%) and stroke (3%–4%) were similar in new PPM recipients and nonrecipients. At a mean follow-up of 22 months, 34% of patients had died or required hospitalization for HF; this rate was similar between PPM recipients and nonrecipients. The rate of sudden or unknown death was lower in PPM recipients than in nonrecipients (hazard ratio, 0.31; 95% confidence interval, 0.11–0.85; P=0.023). Subgroup analyses in patients with low versus preserved left ventricular ejection fraction and based on prosthesis type yielded similar findings. About one third of patients who received a PPM did not exhibit pacing activity on follow-up electrocardiograms.

Comment

The frequent need for a new permanent pacemaker after transcatheter aortic valve replacement adds cost and morbidity to the procedure and is a point of differentiation between the two main TAVR systems. Contrary to findings from broader studies of pacing in heart-failure patients, the current results failed to show that PPM implantation after TAVR increases long-term mortality or HF risk, even in recipients with preexisting left ventricular dysfunction. This may reflect a lack of need for pacing in many patients late after TAVR or the relatively old age of this population. Nevertheless, the findings should be reassuring to TAVR patients and implanters, particularly those utilizing the self-expanding device.

  • Disclosures for Howard C. Herrmann, MD at time of publication Consultant / Advisory board Gerson Lehrman Group; Siemens; St. Jude Medical Speaker's bureau American College of Cardiology Foundation; Cardiovascular Institute; Cardiovascular Research Foundation; Christiana Medical Center; Coastal Cardiovascular Society; Crozer-Chester Hospital; Mayo Clinic; New York Cardiology Society Equity Micro-Interventional Devices, Inc. Grant / research support Abbott Vascular; Edwards Lifesciences; Gore; Medtronic; St. Jude Medical Editorial boards Catheterization and Cardiovascular Interventions; Circulation-Cardiovascular Interventions; Journal of Interventional Cardiology; Journal of Invasive Cardiology

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