Original title: Reduction of pacemaker implantation rates alter CoreValve implantation by moderate predilatation 
Reference: Philipp Lange, et al. EuroIntervention 2014;9:1151-1159

Aortic valve implantation has been proven a valid strategy to treat high risk patients. The CoreValve self-expanding transcatheter aortic valve is associated with a relatively high rate of permanent pacemaker implantation and, until now, no efforts have been made to reduce this rate.

This study included 269 consecutive patients undergoing TAVI with the CoreValve prosthesis; 32 with previously implanted permanent pacemaker were excluded and 237 patients were included in the final analysis. All patients presented severe aortic stenosis and had high surgical risk. Implantation success rate was 99.3% (236) and no patients turned to surgery. The most frequent conduction complication was complete left bundle branch block (42%).

Globally, 50 patients required permanent pacemakers (21.1%); the rate was higher in patients that received a # 29 valve (18.5% vs. 25%).  All patients received balloon valvuloplasty previous to implantation, 114 with 25 mm balloons and 123 with 23 mm balloons, where the PP implantation rate decreased (27.1% vs. 15.4% respectively; p=0.042). 

The analysis was performed according to implanted VB size (26 or 29 mm) and both groups showed lower PP rates the smaller the predilation balloon. PP requirement predictors were preexisting complete left bundle branch block, complete right bundle branch block, first degree AV block, valve high positioning and inter ventricular septal diameter.

Conclusion:

Moderate balloon predilation previous to transcatheter valve implantation with CoreValve reduces the need for permanent pacemaker without affecting procedural success.

Comment

The need for a permanent pacemaker after TAVI is now between 16% and 40%, depending on prosthesis size, and does not represent a complication that will modify prognosis, though it does affect procedural costs.

Balloon predilation may fracture calcified lesions, with the risk of stroke. We should measure the risk/benefit ratio for each patient when evaluating our strategy.

Courtesy of Dr. Carlos Fava.
Interventional Cardiologist
Favaloro Foundation – Buenos Aires

Dr. Carlos Fava para SOLACI.ORG