Exploring the value of same-day permanent pacemaker implantation after TAVR
Same-day permanent pacemaker implantation (PPMI) after transcatheter aortic valve replacement (TAVR) may be a safe, effective treatment strategy when patients develop persistent complete or high-degree atrio-ventricular block (CHB/HAVB).
That is the primary takeaway from a new study published in JACC: Cardiovascular Interventions, an American College of Cardiology journal.[1]
“TAVR has become a standard treatment for treating severe symptomatic aortic stenosis, regardless of surgical risk,” wrote first author Quentin Fischer, MD, a researcher with the Quebec Heart and Lung Institute at Laval University in Canada, and colleagues. “Also, a minimalist approach including early discharge has been implemented in a high proportion of TAVR centers in recent years. However, the occurrence of conduction disturbances during the TAVR procedure, many of them leading to PPMI, still represents a major limitation of the procedure. Indeed, recent improvements in transcatheter heart valve design have not translated into a substantial decrease in the rate of PPMI, which remains at ∼10%.”
Fischer et al. noted that most guidelines currently recommend the use of a temporary pacemaker for at least 24 hours before considering a permanent device. A high number of those patients end up ultimately requiring a PPMI, however, making the group wonder if skipping the temporary pacemaker may be a more reasonable option in terms of healthcare costs, hospital volumes and patient satisfaction.
The group reviewed data from more than 5,000 TAVR patients, focusing on 584 with persistent CHB/HAVB after treatment. The mean patient age of this group was 81 years old, 50.2% were women and the mean Society of Thoracic Surgeons score was 5%.
While 26.8% of patients received their permanent pacemaker on the same day that they underwent TAVR, the remaining patients underwent temporary pacing and observation for at least 24 hours before PPMI. There were no significant differences other than a higher rate of pre-existing first-degree atrio-ventricular block (35.2% vs. 19.9%) in the same-day PPMI group.
Overall, 30-day clinical outcomes were comparable between these groups. Approximately 88% of patients who underwent temporary pacing and observation first still ended up receiving a permanent pacemaker. Periprocedural complications were also comparable between the groups, and the same-day PPMI group was linked to a median length of stay that was significantly shorter (5 days vs. 8 days).
A majority of patients received a dual-chamber permanent pacemaker, the authors noted. Pacemaker interrogation was available in 82.2% of patients, and 64% of patients exhibited a ventricular pacing burden of more than 40%.
“The percentage of ventricular pacing, complete CHB/HAVB recovery, and pacemaker dependency were similar in both groups,” the authors wrote.
After one year, the group added, there were no differences in the rates of mortality, heart failure hospitalization or infective endocarditis for these two groups.
“Our data on the timing for PPMI in TAVR patients with procedural persistent CHB/HAVB would partially challenge current guideline recommendations,” Fischer and colleagues wrote. “In a real-world scenario, a thoughtful evaluation of each case would be important, considering the factors associated with potential recovery, and the potential negative effects of watchful waiting strategy. After this careful evaluation, we consider that a same-day PPMI may be a good option in a significant proportion of patients.”
The authors also warned that it is crucial not too implant permanent pacemakers when they are not clinically necessary.
“PPI is not exempt from potential complications affecting patients’ wellbeing and increasing costs,” they wrote. “Indeed, the risks of neglecting a potentially fatal CD and those associated with pacing must be balanced to avoid the misidentification of patients requiring PPMI but also to avoid unnecessary PPMI.”
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Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.