The Conundrum of Permanent Pacemaker Implantation After Transcatheter Aortic Valve Implantation
This article requires a subscription to view the full text. If you have a subscription you may use the login form below to view the article. Access to this article can also be purchased.
Transcatheter aortic valve implantation (TAVI) has matured into the preferred treatment modality for patients with severe aortic stenosis at extreme or high risk for conventional surgery and a valuable alternative for those at intermediate risk in view of similar or superior clinical outcomes and decreased rates of periprocedural adverse events.1–3 In this context, it remains unclear whether other procedure-related events—including atrioventricular conduction disturbances that require permanent pacemaker (PPM) implantation—are of prognostic relevance.
See Article by Mohananey et al
In the natural history of aortic stenosis, variable degrees of heart block may occur with calcium deposits expanding progressively from the left ventricular outflow tract to the atrioventricular conduction system. As matter of fact, a PPM is already present in ≈10% to ≈20% of patients with severe aortic stenosis at the time of transcatheter or surgical intervention.4 Because of its proximity to the aortic root, iatrogenic injury to the atrioventricular conduction system also occurs after surgical bioprosthesis implantation, with comparable PPM rates for TAVI and surgery reported in the PARTNER trials (Placement of Aortic Transcatheter Valves).2,5 Several patient- and procedure-related factors have been associated with PPM implantation after TAVI and include advanced age, male gender, atrial fibrillation, calcification of aortic and mitral annulus, small left ventricular outflow tract, pre-procedural or intraprocedural conduction disorders, balloon pre-dilation, and depth of prosthesis implantation.6,7 In addition, the type of transcatheter bioprosthesis plays an important role with rates of PPM implantation progressively increasing from balloon-expandable prostheses over self-expanding prostheses to mechanically deployed prostheses.8 Along this line, outer skirts and adaptive seals surrounding the inflow portion, designed to reduce paravalvular leaks, as well as features that allow for repositionability of the device within the aortic annulus, may modify the risk of atrioventricular conduction disturbances after TAVI.