Prognostic impact of permanent pacemaker implantation after transcatheter aortic valve replacement

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Permanent pacemaker implantation late after transcatheter aortic valve implantation

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Incidence of arrhythmias and impact of permanent pacemaker implantation in hospitalizations with transcatheter aortic valve replacement

Background

This study sought to analyze in‐hospital outcomes associated with preexisting and newly implanted permanent pacemaker (PPM) in patients who underwent transcatheter aortic valve replacement (TAVR). PPM implantation following the development of conduction abnormalities is a common adverse event following TAVR. Furthermore, PPM implantation rates are higher in TAVR hospitalizations compared with the surgical alternative, thus we have analyzed the predictors of pacing post‐TAVR.

Hypothesis

We hypothesize that incidence of arrhythmias are high post‐TAVR and have worse adverse outcomes after receiving PPM.

Methods

The study population was identified from the National Inpatient Sample database between 2012 and 2014. TAVR population was identified using ICD‐9‐CM procedure codes 35.05 and 35.06. Hospitalizations were divided into 3 group: (1) with preexisting PPM, (2) with newly implanted PPM, and (3) without any PPM.

Results

Overall, 0.8% of hospitalizations presented with preexisting PPM and 23.7% of hospitalizations received new PPM. The overall incidence of atrial fibrillation was 44.5%, left bundle branch block 8.9%, complete atrioventricular block 9.5%, and right bundle branch block 2.7%. In‐hospital mortality was higher in hospitalizations receiving PPM compared with those without (4.9% vs 4.0%; P = 0.05). Length of stay and cost were higher in the group receiving new PPM. Female sex, atrial fibrillation, left bundle branch block, and second‐degree and complete atrioventricular block were significant predictors for receiving PPM after TAVR.

Conclusions

A risk stratification for hospitalizations with conduction disorders is necessary to avoid longer hospital stays, added costs, and mortality. Further research is warranted to investigate additional predictors for PPM after TAVR.     

Conduction abnormalities after transcatheter aortic valve implantation

In the last few years, transcatheter aortic valve implantation (TAVI) has become an alternative procedure in patients with severe aortic stenosis and high risk for surgical aortic replacement. Due to the anatomic correlation between aortic valve structure and conduction system of the heart, one of the most common complications after TAVI is conduction system disturbances which including bundle branch block, complete heart block and need for permanent pacemaker implantation. Although these disturbances are usually not lethal, they may have a great influence on patients’ state and long term-survival. Several risk factors for conduction disturbances have been identified which including age, anatomy of the heart, periprocedural factors, type of implanted valve, preexisting abnormalities and comorbidities. As this technique becomes more familiar to physicians, patients should be carefully screened for risk factors for the development of conduction abnormalities after TAVI in order to provide effective prevention and proper treatment.     

Cardiac rehabilitation and mid-term follow-up after transcatheter aortic valve implantation

Background Evaluation of patient outcomes following transcatheter aortic valve implantation （TAVI） has usually been based on survival and clinical improvement. Studies on quality of life are limited, and data from comprehensive assessments after the procedure are lacking. Methods Sixty patients referred for cardiac rehabilitation after TAVI underwent in-hospital and after-discharge multidimensional assessments to evaluate clinical, functional, and nutritional statuses, degree of autonomy, cognitive impairment, depression and quality of life. Results On admission to rehabilitation, approximately half of the patients had severe functional impairment and dependence for basic activities of daily living. During their hospital stay, one-third of the patients suffered significant clinical complications and two had to be transferred to the implantation center. Despite this, the overall outcome was very good. All of the remaining patients were clinically stable at discharge and functional status, autonomy and quality of life were improved in most. During a mean follow-up of 540 days （range： 192-738 days）, five patients died from noncardiac causes, three were hospitalized for cardiac events, and nine for non cardiac reasons. Functional status and autonomy remained satisfactory in the majority of patients and most continued to live independently. Conclusions Patients referred for rehabilitation after TAVI are often very frail, with a high grade of functional impairment, dependence on others and high risk of clinical complications. During a rehabilitation programme, based on a multidimensional assessment and intervention, most patients showed significant improvement in functional status, quality of life, and autonomy, which remained stable in the majority of subjects during mid-term follow-up.     

Iatrogenic communications between aortic root and right ventricle/left atrium after transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) has emerged as an alternative, less invasive treatment option for patients with severe symptomatic aortic stenosis, who are high‐risk for conventional surgical aortic valve replacement, due to co‐morbidities. In addition to a 30‐day 10% mortality risk there is a recognized range of complications, which commonly relate to vascular access trauma, paravalvular aortic regurgitation, and cerebrovascular events. In the following case reports, we discuss two previously unreported complications of TAVR: (i) an iatrogenic communication between the aortic root and the right ventricle and (ii) an iatrogenic communication between the aortic root and the left atrium. Informed written consent was obtained from both paztients. © 2013 Wiley Periodicals, Inc.     

Prediction of permanent pacemaker implantation after transcatheter aortic valve replacement: The role of machine learning

BACKGROUND Atrioventricular block requiring permanent pacemaker(PPM) implantation is an important complication of transcatheter aortic valve replacement(TAVR).Application of machine learning could potentially be used to predict preprocedural risk for PPM.AIM To apply machine learning to be used to predict pre-procedural risk for PPM.METHODS A retrospective study of 1200 patients who underwent TAVR(January 2014-December 2017) was performed. 964 patients without prior PPM were included for a 30-d ...     

Acute kidney injury after transcatheter aortic valve implantation

Even though experience and techniques have constantly improved over the last years, peri- and postprocedural complications in high risk TAVI-collectives remain a major issue affecting outcome and survival. Acute kidney injury (AKI) is a frequent complication after transcatheter aortic valve implantation (TAVI) and effects outcome and survival. However, the definition of AKI in published studies dealing with the phenomenon of AKI after TAVI varies widely and lacks standardization. This Review aims to present an overview over the current literature concerning AKI after TAVI with regard to the definition of AKI, the impact of AKI on mortality and potential risk factors for renal impairment after TAVI.     

Ischemic colitis after transcatheter aortic valve implantation

Transcatheter aortic valve implantation is a novel therapeutic approach for high‐risk patients with severe symptomatic aortic stenosis. The success rate of this new procedure is high; however, it is associated with issues such as vascular access site complications and embolization related to the advancement of a large bore delivery catheter through the femoral and iliac arteries and aortic arch. Using the Edwards SAPIEN transcatheter heart valve, we describe a case of transfemoral catheter aortic valve implantation complicated by a mobile mass attached to the valve, probable due to atherosclerotic plaque from the aorta. Shortly thereafter, the patient presented with ischemic colitis and subsequently died. © 2012 Wiley Periodicals, Inc.     

Outcomes associated with pacemaker implantation following transcatheter aortic valve replacement: A nationwide cohort study

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Impact of severe left ventricular dysfunction on mid-term mortality in elderly patients undergoing transcatheter aortic valve implantation

Background Whether patients with reduced left ventricular function present worse outcome after transcatheter aortic valve implantation (TAVI) is controversial. The aim of this study was to assess the impact of baseline severe impairment of left ventricular ejection fraction (LVEF) on mortality after TAVI. Methods Six-hundred-forty-nine patients with aortic stenosis underwent TAVI with the CoreValve system (92.8%) or the Edwards SAPIEN valve system (7.2%). Baseline LVEF was measured by the echocardiographic Simpson method. The impact of LVEF ≤ 30% on mortality was assessed by Cox regression. Results Patients with LVEF ≤ 30% (n = 63), as compared to those with LVEF > 30% (n = 586), had a higher prevalence of NHYA class > 2 (P < 0.001) and presented with a higher Euroscore (P < 0.001). Procedural success was similar in both groups (98.4% vs. 97.2%, P = 1). After a median follow-up of 436 days (25th–75th percentile, 357–737 days), all-cause mortality [23.8% vs. 23.7%, P = 0.87, hazard ratios (HR): 0.96, 95% confidence intervals (CI): 0.56–1.63] and cardiac mortality (19.1% vs. 17.6%, P = 0.89, HR: 1.04, 95% CI: 0.57–1.90) were similar in patients with LVEF ≤ 30% as compared to those with LVEF > 30%. Thirty-day all-cause mortality was not significantly different between the two groups (11.1% vs. 6.3%, P = 0.14, HR: 1.81, 95% CI: 0.81–4.06). Patients with LVEF ≤ 30% had a trend toward higher risk of 30-day cardiac mortality (11.1% vs.5.3%; P = 0.06, HR: 2.16, 95% CI: 0.95–4.90), which disappeared after multivariable adjustment (P = 0.22). Conclusions Baseline severe impairment of LVEF is not a predictor of increased short-term and mid-term mortality after TAVI. Selected patients with severe impairment of left ventricular function should not be denied TAVI.     

Long-term outlook for transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) revolutionized the treatment of severe symptomatic aortic stenosis (AS). TAVR is increasingly offered for lower-risk patients. The role and place of TAVR in the future treatment of AS is not clear yet. In this review, we discuss the long-term outlook for TAVR, its challenges and its relationship to conventional surgical aortic valve replacement.