The Degree of Permanent Pacemaker Dependence and Clinical Outcomes Following TAVI: Implications for Procedural Technique

Abstract

Conduction abnormalities necessitating permanent pacemaker (PPM) implantation remains the most frequent complication post-TAVI, yet reliance on PPM function varies. We evaluated the association of right-ventricular (RV)-stimulation rate post-TAVI with 1-year MACE (all-cause mortality and heart failure hospitalization). This retrospective cohort study of patients undergoing TAVI in 2 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 2 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. From 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 associated with a 2-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 correlates 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.