Post-TAVR pacemaker may increase repeat hospitalization, mortality

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 - electrophysiology, ICD, pacemaker

Pacemaker implantation after transcatheter aortic valve replacement (TAVR) may increase repeat hospitalization and mortality risks at 30 days and one year, according to a study published in the January issue of the Journal of the American College of Cardiology: Cardiovascular Interventions.

Secondary analysis of the PARTNER (Placement of AoRtic TraNscathetER Valves) trial revealed 8.8 percent of TAVR patients who previously did not have pacemakers ultimately needed them. Tamim M. Nazif, MD, of Columbia University Medical Center in New York City, and colleagues reviewed PARTNER to better understand rates of post-TAVR pacemaker implants and resulting patient outcomes. Qualifying pacemaker implantations occurred within the 30 days following TAVR; however, an additional 1.9 percent required a pacemaker within one year.

The mean time between TAVR and pacemaker implantations was 4.1 days; 97.1 percent occurred during the index hospitalization and 86.1 percent happened within seven days of TAVR. Independent predictors of pacemaker implantation following TAVR included baseline right bundle branch block, smaller left ventricular end-diastolic diameter, larger prosthesis-to-left-ventricular-outflow-tract diameter ratio and treatment in the continued access registry.

Following pacemaker implantation, 10.6 percent of patients were subsequently hospitalized in the first 30 days, as opposed to 5.9 percent of strictly TAVR patients. Mortality rates at 30 days for post-TAVR/pacemaker were 7.5 percent as opposed to 5.8 percent for strictly TAVR.

Repeat hospitalizations remained much higher post-TAVR/pacemaker at one year (23.9 vs. 18.2 percent). At one year, mortality or repeat hospitalization as a combined endpoint was 42 and 32.6 percent, for post-TAVR/pacemaker and post-TAVR, respectively. They found no significant difference between groups at one year in change in left ventricular ejection fraction.

An editorial written by Marina Urena, MD, and Josep Rodés-Cabau, MD, from the Quebec Heart & Lung Institute at Laval University, noted that while the study “provides new insight into the potential consequences of PPM [permanent pacemaker] implantation after TAVR,” they wanted further confirmation of the findings over a longer span.

They cited that effects of right ventricular pacing, including heart failure, aren’t as apparent until after three years while “the longest reported follow-up for TAVR patients in studies assessing the effect of PPM implantation is <2 years, probably not long enough to see such clinical consequences.”

“The current analysis, representing the largest reported experience, showed no clear association of PPM after TAVR with 1-year mortality, but did demonstrate an association of new PPM with increased duration of hospitalization and increased rehospitalization and hospitalization or mortality after TAVR. The economic effect of the additional procedure, longer hospitalization, and rehospitalization must be considered given the current health care environment,” Nazif et al wrote.