Courtesy of Dr. Carlos Fava.

Transcatheter aortic valve replacement (TAVR) has shown ample benefit in different groups, but one of its drawbacks continues to be the need for permanent pacemaker (PPM), which ranges between 5 and 30%. Its long term impact in terms of mortality is still controversial, since some studies associate it with ventricular dysfunction.

1062 patients were analyzed: 783 (73.7%) did not require PPM, 164 (15.4%) required new post-TAVR PPM, and 115 (10.8%) already had one prior TAVR.

Those with prior PPM were more often men, with more peripheral heart disease, kidney deterioration and higher EuroSCORE. In addition, ejection fraction (EF) and transvalvular gradient were lower.

The need for PPM was more frequent in those receiving the self-expandable CoreValve.

At 30 days, there were no differences in implantation success or paravalvular aortic regurgitation, but those receiving a new PPM saw longer inhospital stay.

Global and cardiac mortality were higher in those presenting prior PPM, with no differences between the groups.

At two year follow up, there were no differences in overall mortality and cardiac mortality between the groups with PPM (HR 1.11, CI 95% 0.74-1.67; p=0.26), though there was higher mortality when comparing prior PPM patients vs. no PPM patients.

The presence of new PPM and paravalvular aortic regurgitation ≥1 was associated with higher risk of death and no EF improvement (p<0.0001).

EF significantly improved in the no PPM group, and slightly improved in the new PPM group.

Conclusion

In patients receiving transcatheter aortic valve replacement, the presence of prior definite pacemaker had a negative effect in the long term, vs. new PPM after TAVR. However, the combination of a new permanent pacemaker with paravalvular aortic regurgitation had a negative impact in survival and ventricular function recovery.

Editorial Comment

This analyzis changes our view of post TAVR PPM implantation, since it has a negative impact when associated to paravalvular regurgitation.

One of the greatest challenges of the new valves is to reduce the need of PPM, because it requires additional monitoring and therefore increases healthcare cost.

This is important, because the technique is advancing into lower risk, younger, populations.

Courtesy of Dr. Carlos Fava. Favaloro Foundation, Buenos Aires, Argentina.

Original Title: Impact of permanet pacemarker on mortality after trancatheter aortic valve implantation: the PRAGMATIC (Pooled Roterdam-Milan-Toulose in Collaboration) Pacemaker substudy.

Reference: Gennaro Giustino. EuroIntervention 2016;12:1185-1193.

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