Association of Clinical and Economic Outcomes With Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement

Permanent Pacemaker Implantation and Long-Term Outcomes of Patients Undergoing Concomitant Mitral and Tricuspid Valve Surgery

BACKGROUND

Tricuspid valve annuloplasty (TA) during mitral valve repair (MVr) is associated with increased risk of permanent pacemaker (PPM) implantation, but the magnitude of risk and long-term clinical consequences have not been firmly established.

OBJECTIVES

This study assesses the incidence rates of PPM implantation after isolated MVr and following MVr with TA as well as the associated long-term clinical consequences of PPM implantation.

METHODS

State-mandated hospital discharge databases of New York and California were queried for patients undergoing MVr (isolated or with concomitant TA) between 2004 and 2019. Patients were stratified by whether or not they received a PPM within 90 days of index surgery. After weighting by propensity score, survival, heart failure hospitalizations (HFHs), endocarditis, stroke, and reoperation were compared between patients with or without PPM.

RESULTS

A total of 32,736 patients underwent isolated MVr (n = 28,003) or MVr + TA (n = 4,733). Annual MVr + TA volumes increased throughout the study period (P < 0.001, trend), and PPM rates decreased (P < 0.001, trend). The incidence of PPM implantation <90 days after surgery was 7.7% for MVr and 14.0% for MVr + TA. In 90-day conditional landmark-weighted analyses, PPMs were associated with reduced long-term survival among MVr (HR: 1.96; 95% CI: 1.75-2.19; P < 0.001) and MVr + TA recipients (HR: 1.65; 95% CI: 1.28-2.14; P < 0.001). In both surgical groups, PPMs were also associated with an increased risk of HFH (HR: 1.56; 95% CI: 1.27-1.90; P < 0.001) and endocarditis (HR: 1.95; 95% CI: 1.52-2.51; P < 0.001), but not with stroke or reoperation.

CONCLUSIONS

Compared to isolated MVr, adding TA to MVr was associated with a higher risk of 90-day PPM implantation. In both surgical groups, PPM implantation was associated with an increase in mortality, HFH, and endocarditis.

Predictors, clinical impact, and management strategies for conduction abnormalities after transcatheter aortic valve replacement: an updated review

Transcatheter aortic valve replacement (TAVR) has increasingly become a safe, feasible, and widely accepted alternative surgical treatment for patients with severe symptomatic aortic stenosis. However, the incidence of conduction abnormalities associated with TAVR, including left bundle branch block (LBBB) and high-degree atrioventricular block (HAVB), remains high and is often correlated with risk factors such as the severity of valvular calcification, preexisting conditions in patients, and procedural factors. The existing research results on the impact of post-TAVR conduction abnormalities and permanent pacemaker (PPM) requirements on prognosis, including all-cause mortality and rehospitalization, remain contradictory, with varied management strategies for post-TAVR conduction system diseases across different institutions. This review integrates the latest research in the field, offering a comprehensive discussion of the mechanisms, risk factors, consequences, and management of post-TAVR conduction abnormalities. This study provides insights into optimizing patient prognosis and explores the potential of novel strategies, such as conduction system pacing, to minimize the risk of adverse clinical outcomes.

Cusp overlap method for self-expanding transcatheter aortic valve replacement

BACKGROUND

Conduction disturbances and the need for permanent pacemaker (PPM) implantation remains a common complication for transcatheter aortic valve replacement (TAVR), particularly when self-expanding (SE) valves are used.

AIMS

We compared in-hospital and 30-day rates of new PPM implantation between patients undergoing TAVR with SE valves using the conventional three-cusp coplanar implantation technique and the cusp-overlap technique.

METHODS

We retrospectively compared patients without a pre-existing PPM who underwent a TAVR procedure with SE Evolut R or PRO valves using the cusp-overlap technique from July 2018 to September 2020 (n = 519) to patients who underwent TAVR using standard three-cusp technique from April 2016 to March 2017 (n = 128) in two high volume Canadian centers.

RESULTS

There was no significant difference in baseline RBBB between the groups (10.4% vs. 13.2; p = 0.35). The rate of in-hospital new complete heart block (9.4% vs. 23.4%; p ≤ 0.001) and PPM implantation (8% vs. 21%; p ≤ 0.001) were significantly reduced when using the cusp-overlap technique. The incidence of new LBBB (30.4% vs. 29%; p = 0.73) was similar. At 30 days, the rates of new complete heart block (11% vs. 23%; p ≤ 0.001) and PPM implantation (10% vs. 21%, p ≤ 0.001) remained significantly lower in the cusp-overlap group, while the rate of new LBBB (35% vs. 30%; p = 0.73) was similar.

CONCLUSION

Cusp-overlap approach offers several potential technical advantages compared to standard three-cusp view, and may result in lower PPM rates in TAVR with SE Evolut valve.

Incidence, Predictors, and Prognostic Impact of New Permanent Pacemaker Implantation After TAVR With Self-Expanding Valves

OBJECTIVES

The authors sought to evaluate the incidence, predictors, and outcomes of new permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR) with contemporary self-expanding valves (SEV).

BACKGROUND

Need for PPI is frequent post-TAVR, but conflicting data exist on new-generation SEV and on the prognostic impact of PPI.

METHODS

This study included 3,211 patients enrolled in the multicenter NEOPRO (A Multicenter Comparison of Acurate NEO Versus Evolut PRO Transcatheter Heart Valves) and NEOPRO-2 (A Multicenter Comparison of ACURATE NEO2 Versus Evolut PRO/PRO+ Transcatheter Heart Valves 2) registries (January 2012 to December 2021) who underwent transfemoral TAVR with SEV. Implanted transcatheter heart valves (THV) were Acurate neo (n = 1,090), Acurate neo2 (n = 665), Evolut PRO (n = 1,312), and Evolut PRO+ (n = 144). Incidence and predictors of new PPI and 1-year outcomes were evaluated.

RESULTS

New PPI was needed in 362 patients (11.3%) within 30 days after TAVR (8.8%, 7.7%, 15.2%, and 10.4%, respectively, after Acurate neo, Acurate neo2, Evolut PRO, and Evolut PRO+). Independent predictors of new PPI were Society of Thoracic Surgeons Predicted Risk of Mortality score, baseline right bundle branch block and depth of THV implantation, both in patients treated with Acurate neo/neo2 and in those treated with Evolut PRO/PRO+. Predischarge reduction in ejection fraction (EF) was more frequent in patients requiring PPI (P = 0.014). New PPI was associated with higher 1-year mortality (16.9% vs 10.8%; adjusted HR: 1.66; 95% CI: 1.13-2.43; P = 0.010), particularly in patients with baseline EF <40% (P for interaction = 0.049).

CONCLUSIONS

New PPI was frequently needed after TAVR with SEV (11.3%) and was associated with higher 1-year mortality, particularly in patients with EF <40%. Baseline right bundle branch block and depth of THV implantation independently predicted the need of PPI.

The Evolving Role of Surgical Aortic Valve Replacement in the Era of Transcatheter Valvular Procedures

Surgical aortic valve replacement (SAVR) has long been the standard treatment for severe symptomatic aortic stenosis (AS). However, transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative; it was initially intended for high-risk patients and has now expanded its use to patients of all risk groups. While TAVR has demonstrated promising outcomes in diverse patient populations, uncertainties persist regarding its long-term durability and potential complications, raising the issue of the ideal lifetime management strategy for patients with AS. Therefore, SAVR continues to play an important role in clinical practice, particularly in younger patients with longer life expectancies, those with complex aortic anatomy who are unsuitable for TAVR, and those requiring concomitant surgical procedures. The choice between TAVR and SAVR warrants personalized decision-making, considering patient characteristics, comorbidities, anatomical considerations, and overall life expectancy. A multidisciplinary approach involving an experienced heart team is crucial in the preoperative evaluation process. In this review, we aimed to explore the current role of surgical management in addressing aortic valve stenosis amidst the expanding utilization of less invasive transcatheter procedures.

Assessing the Novel Myval Balloon-Expandable Valve with the Evolut Valve: A Propensity-Matched Study

BACKGROUND

The Myval balloon-expandable (BE) valve has shown encouraging early clinical data in terms of safety and efficacy. Comparative data with other well-established contemporary valves are nonetheless still scarce. This study aims to compare the performance of the Myval BE valve with the Evolut self-expanding (SE) valve.

METHODS

In this retrospective single-center study, 223 patients with symptomatic severe aortic stenosis (AS) were included and treated with the Myval BE valve (n = 120) or with the Evolut SE valve (n = 103). Then, 91 pairs were compared after matching. Clinical outcomes were evaluated at 30 days and 1 year. Echocardiographic follow-up was performed at 30 days.

RESULTS

Procedural complications were rare in both groups. At the 30-day follow-up, no significant difference in cardiac death (Myval: 1% vs. Evolut: 2%, p = 0.56), stroke (2% vs. 4%, p = 0.41) and myocardial infarction (1% vs. 3%, p = 0.31) was observed. A permanent pacemaker implantation (PPI) was significantly less needed in the Myval group (4% vs. 15%, p = 0.01). At 1 year, cardiac death (2% vs. 4%, p = 0.41) and the stroke rate (7% vs. 5%, p = 0.76) were similar. Moderate-severe paravalvular leakage (PVL) was also comparable in both groups (1% vs. 4%, p = 0.17).

CONCLUSION

Safety and efficacy outcomes were comparable between the two valves, except for a higher PPI rate for the Evolut SE valve. Up to 1-year follow-up, clinical outcomes showed acceptable rates of stroke and cardiac death with both valves. Valve hemodynamics were excellent with a low rate of moderate-severe PVL in both groups.

Risk factors and mortality associated with permanent pacemaker after surgical or transcatheter aortic valve replacement: Early versus late implantation

INTRODUCTION

Inflation of transcatheter aortic valve replacement (TAVR) procedures compared to surgical aortic valve replacement (SAVR) has increased the number of patients requiring a postprocedure permanent pacemaker (PPM). We investigate the impact of PPM on mid-term mortality comparing SAVR versus TAVR procedures and risk factors for early and late (>14 days) need of PPM.

METHODS

We conducted a retrospective, single-center evaluation of 903 patients that underwent either SAVR or TAVR procedures at the Yale New Haven Hospital from 2012 to 2017. Patients were stratified into PPM and non-PPM groups. We performed Kaplan-Meier and Cox proportional hazard analysis to characterize mid-term mortality. Further subgroup analysis was performed to identify risk factors for early and late PPM implantation in the TAVR cohort.

RESULTS

There was no correlation between PPM implantation and mid-term mortality in both SAVR (hazard ratio [HR] = 0.69; confidence interval [CI] = 0.21-2.30; p = .56) and TAVR (HR = 0.70; CI = 0.42-1.17; p = .18) patients. The presence of the right bundle branch block (Odds ratio = 24.07; 95% CI = 2.34-247.64, p = .007) was associated with higher odds of early PPM requirement after TAVR procedures.

CONCLUSION

PPM placement after SAVR or TAVR procedures is not associated with increased mid-term mortality. In-depth characterization of risk factors for early and late PPM implantation will require further analysis in the growing TAVR patient population.

Invasive electrophysiological testing to predict and guide permanent pacemaker implantation after transcatheter aortic valve implantation: A meta-analysis

Background

Atrioventricular conduction abnormalities after transcatheter aortic valve implantation (TAVI) are common. The value of electrophysiological study (EPS) for risk stratification of high-grade atrioventricular block (HG-AVB) and guidance of permanent pacemaker (PPM) implantation is poorly defined.

Objective

The purpose of this study was to identify EPS parameters associated with HG-AVB and determine the value of EPS-guided PPM implantation after TAVI.

Methods

We performed a systematic review and meta-analysis of studies investigating the value of EPS parameters for risk stratification of TAVI-related HG-AVB and for guidance of PPM implantation among patients with equivocal PPM indications after TAVI.

Results

Eighteen studies (1230 patients) were eligible. In 7 studies, EPS was performed only after TAVI, whereas in 11 studies EPS was performed both before and after TAVI. Overall PPM implantation rate for HG-AVB was 16%. AV conduction intervals prolonged after TAVI, with the AH and HV intervals showing the largest magnitude of changes. Pre-TAVI HV >70 ms and the absolute value of the post-TAVI HV interval were associated with subsequent HG-AVB and PPM implantation with odds ratios of 2.53 (95% confidence interval [CI] 1.11-5.81; P = .04) and 1.10 (95% CI 1.03-1.17; P = .02; per 1-ms increase), respectively. In 10 studies, PPM was also implanted due to abnormal EPS findings in patients with equivocal PPM indications post-TAVI (typically new left bundle branch block or transient HG-AVB). Among them, the rate of long-term PPM dependency was 57%.

Conclusion

Selective EPS testing may assist in the risk stratification of post-TAVI HG-AVB and in the guidance of PPM implantation, especially in patients with equivocal PPM indications post-TAVI.

Prosthetic Valve Function after Aortic Valve Replacement for Severe Aortic Stenosis by Transcatheter Procedure versus Surgery

Background This study compared the clinical outcomes of transcatheter (TAVR) and surgical (SAVR) aortic valve replacements, focusing on postoperative valvular performance assessed by echocardiography. Method and Results A total of 425 patients who underwent TAVR (230 patients) or SAVR (195 patients) were included. Postoperative effective orifice area index (EOAI) was higher in the TAVR group (1.27 ± 0.35 cm2/m2) than in the SAVR group (1.06 ± 0.27 cm2/m2, p < 0.001), and patient−prosthesis mismatch (PPM) was more frequent in the SAVR group (22.6%) than in the TAVR group (8.7%, p < 0.001). Mild or greater paravalvular leakage (PVL) was more frequent in the TAVR group (21.3%) than in the SAVR group (0%, p < 0.001). Moreover, there was no difference in freedom from all-cause death, stroke, or rehospitalization between the groups. Patients with moderate or greater PPM (EOAI < 0.85 cm2/m2) had lower freedom from composite events than those without this PPM criterion (p = 0.008). Patients with mild or greater PVL also had lower freedom from composite events than those without this PVL criterion (p = 0.017). Conclusions Postoperative valvular performance of TAVR was superior to that of SAVR in terms of EOAI. This merit was counterbalanced by the significantly lower rates of PVL in patients who underwent SAVR. The overall clinical outcomes were similar between the study groups.

Validation of reliability and predictivity of membrane septum length measurements for pacemaker need after transcatheter aortic valve replacement

OBJECTIVES

To assess the inter methodological agreement of membrane septum (MS) length measurement and additive value for risk stratification of new pacemaker implantation (PMI) over the established predictors after transcatheter aortic valve replacement (TAVR).

BACKGROUND

Recent studies have suggested MS length and implantation depth (ID) as predictors for PMI after TAVR. However, the measurement of MS length is neither uniform nor validated in different cohort.

METHODS

We retrospectively analyzed patients who underwent TAVR at five centers. The MS length was measured by two previously proposed methods (coronal and annular view method). Predictive ability of risk factors, including MS length and ID, for new PMI within 30 days after TAVR were evaluated.

RESULTS

Among 754 patients of study population, 31 patients (4.1%) required new PMI within 30 days of TAVR. There was a weak correlation (ρ = 0.47) and a poor agreement between the two methods. The ID and the difference between MS length and ID (ΔMSID), were independent predictors for new PMI, whereas MS length alone was not. Further, for predicting new PMI after TAVR, discrimination performance was not significantly improved when MS length was added to the model with ID alone (integrated discrimination improvement = 0, p= 0.99; continuous net-reclassification improvement = 0.10, p= 0.62).

CONCLUSIONS

External validity and predictive accuracy of MS length for PMI after TAVR were not sufficient to provide better risk stratification over the established predictors in our cohort. Moreover, the ID and ΔMSID, but not MS length alone, are predictive of future PMI after TAVR.

Bicuspid Aortic Stenosis with and without Aortopathy: Considerations for Surgical Aortic Valve Replacement versus Transcatheter Aortic Valve Replacement

The treatment of aortic stenosis has evolved in recent years with the introduction of transcatheter aortic valve replacement (TAVR) as a complementary strategy to surgical aortic valve replacement (SAVR). The majority of clinical trials to date have included only tricuspid aortic stenosis and excluded bicuspid aortic valves (BAVs). BAVs are associated with unique challenges related to their anatomy, clinical presentation, and association with aortopathy. BAV has a spectrum of phenotypes and the classification is still evolving. There have been no definitive clinical guidelines on triaging BAV patients towards TAVR or SAVR. Given that TAVR is moving from high-risk to low-risk patients and becoming more widely used in the treatment of BAV, there are many factors that must be considered. The aim of this article is to review the literature and present considerations for heart teams to discuss in order to offer patients the best lifetime management strategy for BAV stenosis.

Atrioventricular conduction in PM recipients after transcatheter aortic valve implantation: Implications using Wenckebach point measurement

Background

Atrioventricular (AV) conduction disturbances requiring permanent pacemaker implantation (PPI) are a common complication after transcatheter aortic valve implantation (TAVI). However, a significant proportion of patients might recover AV conduction at follow-up.

Objectives

The aim of our study was to evaluate the recovery of AV conduction by determination through Wenckebach point in patients with PPI and therefore identify patients who could benefit from device reprogramming to avoid unnecessary RV pacing.

Methods

We enrolled 43 patients that underwent PM implantation after TAVI at our Department from January 2018 to January 2021. PM interrogation was performed at follow-up and patients with native spontaneous rhythm were further assessed for AV conduction through WP determination.

Results

A total of 43 patients requiring a PM represented the final study population, divided in patients with severely impaired AV conduction (no spontaneous valid rhythm or WP < 100; 26) and patients with valid AV conduction (WP ≥ 100; 17). In the first group patients had a significantly higher number of intraprocedural atrioventricular block (AVB) (20 vs. 1, p < 0.005), showed a significant higher implantation depth in LVOT (7.7 ± 2.2 vs. 4.4 ± 1.1, p < 0.05) and lower ΔMSID (−0.28 ± 3 vs. −3.94 ± 2, p < 0.05).

Conclusion

AV conduction may recover in a significant proportion of patients. In our study, valve implantation depth in the LVOT and intraprocedural AV block are associated with severely impaired AV conduction. Regular PM interrogation and reprogramming are required to avoid unnecessary permanent right ventricular stimulation in patients with AV conduction recovery.

Mid- to Long-Term Clinical and Echocardiographic Effects of Post-procedural Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Aims

To date, the prognostic effects of permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR) remain controversial. The purpose of this meta-analysis was to investigate the mid- (1 year) to long-term (> 1 year) clinical and echocardiographic effects of post-procedural PPI in patients after TAVR.

Methods

PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched from the establishment of databases up to 1 December 2021. Studies comparing clinical and echocardiographic outcomes between patients with and without post-TAVR PPI of ≥ 1-year follow-up were collected for further meta-analysis.

Results

A total of 39 studies comprising of 83,082 patients were included in this meta-analysis. At mid-term follow-up (1 year), the pooled results demonstrated a higher risk of all-cause mortality in patients with post-procedural PPI than those without following TAVR (relative risk (RR), 1.17; 95% CI, 1.10–1.24; P < 0.00001). No significant differences were observed in cardiovascular mortality (RR, 0.86; 95% CI, 0.71–1.03; P = 0.10) or heart failure rehospitalization (RR, 0.91; 95% CI, 0.58–1.44; P = 0.69) at 1-year follow-up. At long-term follow-up (> 1 year), post-TAVR PPI had negative effects on all-cause mortality (RR, 1.18; 95% CI, 1.09–1.28; P < 0.0001) and heart failure rehospitalization (RR, 1.42; 95% CI, 1.18–1.71; P = 0.0002). There was no difference in long-term cardiovascular mortality between the two groups (RR, 1.15; 95% CI, 0.97–1.36; P = 0.11). Left ventricular ejection fraction (LVEF) was not significantly different at baseline (mean difference, 1.40; 95% CI, –0.13–2.93; P = 0.07), but was significantly lower in the PPI group at 1-year follow-up (mean difference, –3.57; 95% CI, –4.88 to –2.26; P < 0.00001).

Conclusion

Our meta-analysis provides evidence that post-TAVR PPI has negative clinical and echocardiographic effects on patients at mid- to long-term follow-up. Further studies are urgently needed to explore the cause of these complications and optimize the treatment and management of patients requiring permanent pacing after TAVR.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289935], identifier [CRD42021289935].

Risk Factors for Hospital Readmission Post-Transcatheter Aortic Valve Implantation in the Contemporary Era: A Systematic Review

Background

Despite transcatheter aortic valve implantation (TAVI) becoming a widely accepted therapeutic option for the management of aortic stenosis, post-procedure readmission rates remain high. Rehospitalization is associated with negative patient outcomes, as well as increased healthcare costs, and has therefore been identified as an important target for quality improvement. Strategies to reduce the post-TAVI readmission rate are needed but require the identification of patients at high risk for rehospitalization. Our systematic review aims to identify predictors of post-procedure readmission in patients eligible for TAVI.

Methods

We conducted a comprehensive search of the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases for the time period from 2015 to the present for articles evaluating risk factors for rehospitalization post-TAVI with a follow-up period of at least 30 days in adults age ≥ 70 years with aortic stenosis. The quality of included studies was evaluated using the Newcastle-Ottawa Scale. We present the results as a qualitative narrative review.

Results

We identified 49 studies involving 828,528 patients. Post-TAVI readmission is frequent, and rates vary (14.9% to 54.3% at 1 year). The most-frequent predictors identified for both 30-day and 1-year post-TAVI readmission are atrial fibrillation, lung disease, renal disease, diabetes mellitus, in-hospital life-threatening bleeding, and non-femoral access.

Conclusions

This systematic review identifies the most-common predictors for 30-day and 1-year readmission post-TAVI, including comorbidities and potentially modifiable procedural approaches and complications. These predictors can be used to identify patients at high-risk for readmission who are most likely to benefit from increased support and follow-up post-TAVI.

Development of atrioventricular and intraventricular conduction disturbances in patients undergoing transcatheter aortic valve replacement with new generation self-expanding valves: A real world multicenter analysis

BACKGROUND

High degree cardiac conduction disturbances (HDCD) remain a major complication after transcatheter aortic valve replacement (TAVR), especially with self-expandable valves (SEV). Our aim was to investigate peri-procedural and in-hospital modification of atrioventricular and intracardiac conduction associated to new generation SEV implantation, and the development of new HDCD resulting in permanent pacemaker implantation (PPM) in patients undergoing TAVR.

METHODS AND RESULTS

Three-hundred forty-four consecutive patients with severe aortic stenosis who underwent TAVR with a new generation SEV [Evolut-R/Pro (n = 130), Acurate-neo (n = 79), Portico (n = 75) and Allegra (n = 60)] were included. An analysis of baseline, post-TAVR and pre-discharge ECG and procedural aspects were centrally performed. A significant increase in baseline PR interval (169.6 ± 28.2 ms) and QRS complex width (101.7 ± 25.9 ms) was noted immediately post-TAVR (188.04 ± 34.49; 129.55 ± 30.02 ms), with a partial in-hospital reversal (179.4 ± 30.1; 123.06 ± 30.94 ms), resulting in a net increase at hospital discharge of 12.6 ± 38.8 ms and 21.4 ± 31.6 ms (p < 0.001), respectively. The global incidence of new onset persistent HDCD at hospital discharge was 46.3%, with 17.7% of patients requiring PPM. Independent predictors of new onset HCDC at hospital discharge were valve recapture (OR: 2.8; 95% IC: 1.1-7.2, p = 0.033) and implantation depth ≥ 6 mm (OR: 1.9 05% IC 1.1-3.3, p = 0.015), while higher implantation (<3 mm (OR: 0.3, 95% IC 0.1-0.7, p = 0.014) and use of Acurate-Neo valve (OR: 0.4; 95% IC 0.2-0.8, p = 0.009) were protective factor.

CONCLUSIONS

New generation self-expanding aortic valves were associated with a significant increase in PR and QRS interval at hospital discharge leading to a very high rate of HDCD. While valve recapture and implantation depth were independent predictors for the occurrence of HDCD, use of Accurate-Neo valve was a protective factor.

A retrospective study on the trends in surgical aortic valve replacement outcomes in the post-transcatheter aortic valve replacement era

Background and Aims

Transcatheter aortic valve replacement (TAVR) is the mainstay of treatment of inoperable and severe high-risk aortic stenosis and is noninferior to surgical aortic valve replacement (SAVR) for low-risk and intermediate-risk patients as well. We aim to compare the valve size, area, and transaortic mean gradients in SAVR patients before and after the implementation of TAVR since being approved by the Food and Drug Administration  in 2011.

Methods

Patients who underwent a bioprosthetic SAVR placement were divided into two groups based on the date of procedure: the early pre-TAVR implementation group (years 2011-2012) and the contemporary post-TAVR group (years 2019-2020). The primary endpoint was the mean gradient across the aortic valve within 16 months of surgery. The secondary endpoints included the difference in valve size and various aortic valve echocardiographic variables.

Results

One hundred and thirty patients had their valves replaced in the years 2011-2012 and 134 in the years 2019-2020. The early group had a significantly higher mean gradient (median of 13 mmHg [interquartile range, IQR: 9.3-18] vs. 10 mmHg [IQR: 7.5-13.1], p = 0.001) and a smaller median effective orifice area index (0.8 cm2/m2 [IQR: 0.6-1] vs. 1.1 cm2/m2 [IQR: 0.8-1.3], p < 0.001). The median valve size was significantly smaller in the early group (median of 21 mm [IQR: 21-23] vs. 23 mm [IQR: 22.5-25], p < 0.001).

Conclusion

In the contemporary era, surgical patients receive larger valves which translates into lower mean gradients, larger valve area, and lower rates of patient-prosthesis mismatch than in previous years before the routine introduction of TAVR.

Financial Incentives for Transcatheter Aortic Valve Implantation in Ontario, Canada: A Cost-Utility Analysis

Background

Transcatheter aortic valve implantation (TAVI) is a minimally invasive therapy for patients with severe aortic stenosis, which has become standard of care. The objective of this study was to determine the maximum cost‐effective investment in TAVI care that should be made at a health system level to meet quality indicator goals.

Methods and Results

We performed a cost‐utility analysis using probabilistic patient‐level simulation of TAVI care from the Ontario, Canada, Ministry of Health perspective. Costs and health utilities were accrued over a 2‐year time horizon. We created 4 hypothetical strategies that represented TAVI care meeting ≥1 quality indicator targets, (1) reduced wait times, (2) reduced hospital length of stay, (3) reduced pacemaker use, and (4) combined strategy, and compared these with current TAVI care. Per‐person costs, quality‐adjusted life years, and clinical outcomes were estimated by the model. Using these, incremental net monetary benefits were calculated for each strategy at different cost‐effectiveness thresholds between $0 and $100 000 per quality‐adjusted life year. Clinical improvements over the current practice were estimated with all comparator strategies. In Ontario, achieving quality indicator benchmarks could avoid ≈26 wait‐list deaths and 200 wait‐list hospitalizations annually. Compared with current TAVI care, the incremental net monetary benefit for this strategy varied from $10 765 (±$8721) and $17 221 (±$8977). This would translate to an annual investment of between ≈$14 to ≈$22 million by the Ontario Ministry of Health to incentivize these performance measures being cost‐effective.

Conclusions

This study has quantified the modest annual investment required and substantial clinical benefit of meeting improvement goals in TAVI care.

Long-term clinical impact of permanent pacemaker implantation in patients undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis

Aims

The aims of this study is to assess by an updated meta-analysis the clinical outcomes related to permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) at long-term (≥12 months) follow-up (LTF).

Methods and results

A comprehensive literature research was performed on PubMed and EMBASE. The primary endpoint was all-cause death. Secondary endpoints were rehospitalization for heart failure, stroke, and myocardial infarction. A subgroup analysis was performed according to the Society of Thoracic Surgeon—Predicted Risk of Mortality (STS-PROM) score. This study is registered with PROSPERO (CRD42021243301). A total of 51 069 patients undergoing TAVI from 31 observational studies were included. The mean duration of follow-up was 22 months. At LTF, PPI post-TAVI was associated with a higher risk of all-cause death [risk ratio (RR) 1.18, 95% confidence interval (CI) 1.10–1.25; P < 0.001] and rehospitalization for heart failure (RR 1.32, 95% CI 1.13–1.52; P < 0.001). In contrast, the risks of stroke and myocardial infarction were not affected. Among the 20 studies that reported procedural risk, the association between PPI and all-cause death risk at LTF was statistically significant only in studies enrolling patients with high STS-PROM score (RR 1.25, 95% CI 1.12–1.40), although there was a similar tendency of the results in those at medium and low risk.

Conclusion

Patients necessitating PPI after TAVI have a higher long-term risk of all-cause death and rehospitalization for heart failure as compared to those who do not receive PPI.

The conjunction conundrum in Transcatheter Aortic Valve Implantation

A continuous discussion regarding the predictors for permanent pacemaker implantation (PPI) following transcatheter aortic valve implantation (TAVI) is ongoing, especially in the era of low and medium risk patients. The aim of this article is to review the data so far regarding the pathophysiology, risk factors, and the indications for permanent pacemaker implantation after TAVI. The factors that contribute to rhythm abnormalities post TAVI can be divided into pre-existing conduction abnormalities, patient-related anatomical factors, and peri-procedural technical factors. The latter components are potentially modifiable, and this is where attention should be directed, particularly now that in an era of TAVI expansion towards lower-risk patients.

Incidence, Predictors, and Implications of Permanent Pacemaker Requirement After Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is a safe and feasible alternative to surgery in patients with symptomatic severe aortic stenosis regardless of the surgical risk. Conduction abnormalities requiring permanent pacemaker (PPM) implantation remain a common finding after TAVR due to the close proximity of the atrioventricular conduction system to the aortic root. High-grade atrioventricular block and new onset left bundle branch block (LBBB) are the most commonly reported conduction abnormalities after TAVR. The overall rate of PPM implantation after TAVR varies and is related to pre-procedural and intraprocedural factors. The available literature regarding the impact of conduction abnormalities and PPM requirement on morbidity and mortality is still conflicting. Pre-procedural conduction abnormalities such as right bundle branch block and LBBB have been linked with increased PPM implantation and mortality after TAVR. When screening patients for TAVR, heart teams should be aware of various anatomical and pathophysiological conditions that make patients more susceptible to increased risk of conduction abnormalities and PPM requirement after the procedure. This is particularly important as TAVR has been recently approved for patients with low surgical risk. The purpose of this review is to discuss the incidence, predictors, impact, and management of the various conduction abnormalities requiring PPM implantation in patients undergoing TAVR.

Valve-in-Valve Transcatheter Aortic Valve Replacement Versus Redo Surgical Aortic Valve Replacement: An Updated Meta-Analysis

OBJECTIVES

The aim of this study was to evaluate early results of valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) versus redo surgical aortic valve replacement (SAVR) for structural valve degeneration (SVD).

BACKGROUND

ViV TAVR has been increasingly used for SVD, but it remains unknown whether it produces better or at least comparable results as redo SAVR.

METHODS

Observational studies comparing ViV TAVR and redo SAVR were identified in a systematic search of published research. Random-effects meta-analysis was performed, comparing clinical outcomes between the 2 groups.

RESULTS

Twelve publications including a total of 16,207 patients (ViV TAVR, n = 8,048; redo SAVR, n = 8,159) were included from studies published from 2015 to 2020. In the pooled analysis, ViV TAVR was associated with lower rates of 30-day mortality overall (odds ratio [OR]: 0.53; 95% confidence interval [CI]: 0.32 to 0.87; p = 0.017) and for matched populations (OR: 0.419; 95% CI: 0.278 to 0.632; p = 0.003), stroke (OR: 0.65; 95% CI: 0.55 to 0.76; p < 0.001), permanent pacemaker implantation (OR: 0.73; 95% CI: 0.22 to 2.43; p = 0.536), and major bleeding (OR: 0.49; 95% CI: 0.26 to 0.93; p = 0.034), as well as with shorter hospital stay (OR: -3.30; 95% CI: -4.52 to -2.08; p < 0.001). In contrast, ViV TAVR was associated with higher rates of myocardial infarction (OR: 1.50; 95% CI: 1.01 to 2.23; p = 0.045) and severe patient-prosthesis mismatch (OR: 4.63; 95% CI: 3.05 to 7.03; p < 0.001). The search revealed an important lack of comparative studies with long-term results.

CONCLUSIONS

ViV TAVR is a valuable option in the treatment of patients with SVD because of its lower incidence of post-operative complications and better early survival compared with redo SAVR. However, ViV TAVR is associated with higher rates of myocardial infarction and severe patient-prosthesis mismatch.

Evaluation and Management of Heart Block After Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) has developed substantially since its inception. Improvements in valve design, valve deployment technologies, preprocedural imaging and increased operator experience have led to a gradual decline in length of hospitalisation after TAVR. Despite these advances, the need for permanent pacemaker implantation for post-TAVR high-degree atrioventricular block (HAVB) has persisted and has well-established risk factors which can be used to identify patients who are at high risk and advise them accordingly. While most HAVB occurs within 48 hours of the procedure, there is a growing number of patients developing HAVB after initial hospitalisation for TAVR due to the trend for early discharge from hospital. Several observation and management strategies have been proposed. This article reviews major known risk factors for HAVB after TAVR, discusses trends in the timing of HAVB after TAVR and reviews some management strategies for observing transient HAVB after TAVR.

Permanent pacemaker implantation following mitral valve surgery: a retrospective cohort study of risk factors and long-term outcomes

OBJECTIVES

Conduction disturbances requiring permanent pacemaker (PPM) implantation remain a complication following valvular surgery. PPMs confer the risk of infection, tricuspid valve regurgitation and pacing-induced cardiomyopathy. Literature examining PPM placement in mitral valve surgery (MVS) is limited.

METHODS

Our institutional mitral valve (MV) database was retrospectively reviewed for adult patients undergoing surgery from 2011 to 2019. Patients with preoperative PPM were excluded. Patients were stratified by the receipt of PPM following their index operations. Multivariable logistic regression was performed to determine patient and operative risk factors for PPM. Subgroup analysis was performed on patients who underwent isolated MVS. Kaplan-Meier analysis and a multivariable Cox proportional hazards model were utilized to assess the association between PPM implantation and long-term survival.

RESULTS

A total of 3391 (2991 non-PPM and 400 PPM) patients met the study criteria. Significant predictors of PPM included increased decade of age (odds ratio: 1.23; 95% confidence interval: 1.12-1.35), concomitant aortic (1.44; 1.10-1.90) and tricuspid valve procedures (2.21; 1.64-2.97) and prior history of myocardial infarction (1.48; 1.07-1.86). In the isolated MV repair population, annuloplasty with ring prosthesis was associated with PPM (3.09; 1.19-8.02). Patients in the replacement population did not have significant identifiable risk factors. There was no survival difference found, and postoperative PPM placement was not found to be an independent predictor of mortality.

CONCLUSIONS

Our primary aim was to elucidate predictors for PPM implantation in MVS and found increasing age and concomitant procedures to be risk factors. Receipt of PPM is associated with worse long-term survival but does not independently predict survival. Among patients undergoing isolated MV repair, use of an annuloplasty ring confers a higher risk of PPM compared to an annuloplasty band.

Systemic corticosteroid exposure and atrioventricular conductance delays after transcatheter aortic valve implantation

BACKGROUND

Atrioventricular conduction delays (AVCD) are common after transcatheter aortic valve implantation (TAVI) and frequently require implantation of a permanent pacemaker (PPM). Autopsy studies demonstrated the role of ischemia, inflammation, and oedema in the pathogenesis of AVCD. Corticosteroids (CS) reduce inflammation and oedema and hence might lead to a lower rate of AVCD.

METHODS

Based on a prospective single-center registry, we performed a propensity score (PS) matched analysis of subjects treated with or without systemic CS (>2.5 mg prednisolone-equivalent per day) at the time of TAVI. The primary endpoint was a composite of PPM-implantation and new-onset left bundle branch block (LBBB) within 30 days after TAVI.

RESULTS

Among 2213 consecutive patients undergoing TAVI (51.5% female, mean age 82.1 ± 6.1 years) 89 patients were treated with systemic CS, of which 87 were included in the PS matched analysis. At 30 days, rates of the composite of PPM and LBBB were comparable between patients with versus without CS both in the overall cohort (33.7% versus 33.0%, p = 0.89) and the PS matched cohort (34.5% versus 40.2%, p = 0.443). There were no differences in a composite of major or minor vascular complications and major or life-threatening bleeding events between patients with versus without CS in the overall cohort (34.8% versus 26.6%, p = 0.088) or the PS matched cohort (33.3% versus 33.3%, p ≥ 0.999).

CONCLUSION

In this exploratory study, intake of systemic CS among patients undergoing TAVI was not associated with differences in rates of AVCD, vascular complications, or bleeding events after TAVI.

TAVI Beyond 3 Years: Durability and Predictors for Survival

The use of transcatheter aortic valve implantation (TAVI) has greatly increased over the past 2 decades and now has overtaken surgical aortic valve replacement. We have limited data regarding the long-term durability of TAVI and the predictors of survival. Calcification, inflammation, fibrous tissue deposition, and mechanical stress are important in the structural deterioration of surgical bioprosthetic valves and likely contribute to TAVI durability. However, TAVI has several differences to surgical valve replacement such as valve preparation, valve to native anatomy interaction, and valve sizing which all likely contribute to durability and long-term survival. Most procedures have been performed on older patients and therefore long-term follow-up studies have noted mortality of approximately 50% at 5 years and 75% by 7 years. Current data are limited by the high mortality of patients who have received TAVI often as a result of age, frailty, and other competing comorbidities. TAVI as compared with surgical valve replacement is associated with several differences including higher conduction abnormalities (i.e., need for pacemakers) and paravalvular leak, both of which may affect long-term morbidity and mortality. In this review, we discuss the current status of our knowledge and identify areas that require further investigation.

Minimising permanent pacemaker implantation (PPI) after TAVI

Increased demand for transcatheter aortic valve implantation (TAVI) procedures for patients with severe aortic stenosis has not been matched with a proportional increase in available resources in recent years. This article highlights the importance of developing integrated care pathways for TAVI, which incorporate standardised protocols for permanent pacemaker implantation (PPI) to ensure best practice, increase service efficiency and reduce rates of PPI post-TAVI.

Expansion of TAVR into Low-Risk Patients and Who to Consider for SAVR

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of severe aortic stenosis (AS) over the last decade. The results of the Placement of Aortic Transcatheter Valves (PARTNER) 3 and Evolut Low Risk trials demonstrated the safety and efficacy of TAVR in low-surgical-risk patients and led to the approval of TAVR for use across the risk spectrum. Heart teams around the world will now be faced with evaluating a deluge of younger, healthier patients with severe AS. Prior to the PARTNER 3 and Evolut Low Risk studies, this heterogenous patient population would have undergone surgical aortic valve replacement (SAVR). It is unlikely that TAVR will completely supplant SAVR for the treatment of severe AS in patients with a low surgical risk, as SAVR has excellent short- and long-term outcomes and years of durability data. In this review, we outline the critical role that SAVR will continue to play in the treatment of severe AS in the post-PARTNER 3/Evolut Low Risk era.

Severe aortic stenosis in the young, with or without bicuspid valve: is transcatheter aortic valve implantation the first choice?

During the last decade, transcatheter aortic valve implantation (TAVI) has represented a valid alternative to surgical aortic valve replacement in patients with aortic stenosis and elevated surgical risk. Recent randomized clinical trials reported excellent results also for patients at low surgical risk, but in clinical practice, the mean age of the patients treated remain over 75 years, and the presence of a bicuspid aortic valve still represents an important exclusion criteria. Today, aortic valve replacement with a mechanical prosthesis remains the treatment of choice for young adults with aortic stenosis, although the desire to avoid oral anticoagulants drives more patients younger than 65 years of age towards biological prostheses. Furthermore, despite the follow-up of patients after TAVI is still limited to a few years, the opportunity of a second percutaneous treatment (TAVI-in-TAVI), extends the scope of percutaneous strategy. In the next few years, TAVI has to face many challenges to become a valid alternative to surgery in the younger patients as well.

Transcatheter aortic valve replacement (TAVR): expanding indications to low-risk patients

Aortic stenosis (AS) is the most common cardiac valve disease in developed countries. Transcatheter aortic valve replacement (TAVR) for the treatment of severe symptomatic AS is an accepted therapy option for elderly patients with symptomatic severe AS. Nowadays, TAVR has revolutionized the treatment of AS with an exponential growth worldwide. Both the development of new generation valves and the experience of the operating teams have contributed significantly to decrease the complications rate after TAVR. Several randomized trials have reported similar short- and mid-term results, and even better than surgical aortic valve replacement (SAVR) in patients with high- or intermediate-risk. In addition, two comparison trials in low-risk patients have reported promising results. Therefore, in the future TAVR indications will expand, treating younger and younger patients, with less comorbidities and lower risk. However, the long-term durability of percutaneous prostheses is a matter of debate. The aim of this manuscript is to review available data that support to treat AS in low-risk patients and provide our perspective on the topic.

Temporal Trends in the Incidence and Outcomes of Pacemaker Implantation After Transcatheter Aortic Valve Replacement in the United States (2012-2017)

Background

Nationwide studies documenting temporal trends in permanent pacemaker implantation (PPMI) following transcatheter aortic valve replacement (TAVR) are limited.

Methods and Results

We selected patients who underwent TAVR between 2012 and 2017 in the National Readmission Database. The primary end point was the 6‐year trend in post‐TAVR PPMI at index hospitalization and at 30, 90, and 180 days after discharge. The secondary end point was the association between PPMI and in‐hospital mortality, stroke, cost, length of stay, and disposition. Among the 89 202 patients who underwent TAVR, 77 405 (86.8%) with no prior pacemaker or defibrillator were included. Patients who required PPMI had a higher prevalence of atrial fibrillation (43.6% versus 38.7%, P<0.001) and conduction abnormalities (28.4% versus 15.3%, P<0.001). The incidence of PPMI during index admission increased from 8.7% in 2012 to 13.2% in 2015, and then decreased to 9.6% in 2017. The incidence of inpatient PPMI within 30 days after discharge increased from 0.5% in 2012 to 1.25% in 2017 (P_trend<0.001). Inpatient PPMI beyond 30 days remained rare (<0.5%) during the study period. After risk adjustment, PPMI was not associated with in‐hospital mortality or stroke but was associated with increased nonhome discharge, longer hospitalization, and higher cost. The incremental expenditure associated with post‐TAVR PPMI during index admission increased from $9.6 million to $72.2 million between 2012 and 2017.

Conclusions

After an upward trend, rates of PPMI after TAVR in the United States stabilized at ~10% in 2016 to 2017, but there was a notable increase in PPMI within 30 days after the index admission. PPMI was not associated with increased in‐hospital morbidity or mortality but led to longer hospitalization, higher cost, and more nonhome discharges.

Predictors of conduction recovery after permanent pacemaker implantation following transcatheter aortic valve replacement

PURPOSE

Conduction disturbances after transcatheter aortic valve replacement (TAVR) requiring pacemaker (PPM) implantation are a known complication and may be reversible. Therefore, we sought to evaluate the incidence and predictors for atrioventricular (AV) conduction recovery after TAVR.

METHODS

A single-center, retrospective study of patients undergoing PPM implantation for conduction disorders after TAVR between June 2011 and March 2019. Conduction recovery was defined as ≤ 1% ventricular pacing (VP) on follow-up PPM interrogation.

RESULTS

A total of 110 patients (mean age 83.6 ± 6.6 years, 46.8% female) were included. At a median follow-up of 438 days (interquartile range [IQR] 111-760 days), 35 patients (32%) had conduction recovery, with 50% of these occurring within the first 6 months. On multivariate analysis, predictors of conduction recovery include female sex (hazard ratio [HR] 2.5, 95% confidence interval [CI] 1.01-6.4, p = 0.048), non-VP/non-complete heart block rhythm immediately post-TAVR (HR 5.2, 95% CI 1.5-18.1, p = 0.011), normal sinus rhythm 7 days post-TAVR (HR 3.9, 95% CI 1.7-9.2, p = 0.002), and smaller valve size (mm) (HR 0.81, 95% CI 0.7-0.996, p = 0.045). Significant narrowing of the QRS and resolution of new-onset left bundle branch block within 1 month post-TAVR occurred in those with conduction recovery on PPM interrogation.

CONCLUSIONS

One-third of patients receiving new PPM implantation have conduction recovery after TAVR, with 50% occurring within the first 6 months. Patient gender, valve size, and rhythm on serial ECGs after TAVR can help identify patients that may recover AV conduction. A conservative approach rather than immediate PPM implantation may be considered in these patients.

The cost-effectiveness of transcatheter aortic valve replacement in low surgical risk patients with severe aortic stenosis

Aims

The economic value of transcatheter aortic valve replacement (TAVR) in low surgical risk patients with severe, symptomatic aortic stenosis is not known. Our objective was to determine the cost-effectiveness of balloon-expandable TAVR and self-expandable TAVR relative to surgical aortic valve replacement (SAVR) in low-risk patients.

Methods and results

A fully probabilistic Markov cohort model was constructed to estimate differences in costs and effectiveness [quality-adjusted life years (QALYs)] over the patient’s life-time time from the third-party payer’s perspective. Clinical outcomes modelled were alive/well (no complications), permanent stroke, ≥moderate paravalvular leak, new pacemaker, rehospitalization, and death. A network meta-analysis of the PARTNER 3 and Evolut Low Risk trial was performed to compare balloon-expandable TAVR, self-expandable TAVR, and SAVR for the efficacy inputs. Incremental-cost effectiveness ratios (ICER) were calculated. The total life-time costs in the balloon-expandable TAVR, self-expandable-TAVR, and SAVR arms were $37  330 ± 4724, $39 660 ± 4862, and $34 583 ± 6731, respectively, and total life-time QALYs gained were 9.15 ± 3.23, 9.13 ± 3.23, and 9.05 ± 3.20, respectively. The ICERs for balloon-expandable TAVR and self-expandable TAVR against SAVR were $27 196/QALY and $59 641/QALY, respectively. Balloon-expandable TAVR was less costly and more effective than self-expandable TAVR. There was substantial uncertainty, with 53% and 58% of model iterations showing balloon-expandable TAVR to be the preferred option at willingness-to-pay thresholds of $50 000/QALY and $100  000/QALY, respectively.

Conclusion

Compared with SAVR, TAVR, particularly with balloon-expandable prostheses may be a cost-effective option for patients with severe aortic stenosis at low surgical risk.

Transcatheter aortic valve implantation in low-risk patients: is it too early?

The median age of patients treated by transcatheter aortic valve implantation (TAVI) is falling across Europe, and low-risk patients with severe aortic stenosis (AS) represent 80% of patients with severe AS undergoing surgical aortic valve replacement (SAVR). There are few data for TAVI in low-risk patients, but there are four ongoing randomised trials of SAVR versus TAVI. The key issues relate to pacemaker implantation rates and the associated potential longer term deleterious effects, and the need to minimise vascular complications and paravalvular leak. Valve leaflet thrombosis and paucity of data on valve durability remain a concern. Given the higher incidence of bicuspid aortic valves in younger patients, outcomes of TAVI in this setting need clarification and are discussed.

Aortic Valve Calcification as a Predictor of Post-Transcatheter Aortic Valve Replacement Pacemaker Dependence

Background

Atrioventricular block requiring permanent pacemaker (PPM) implantation is a common complication of transcatheter aortic valve replacement (TAVR). The mechanism of atrioventricular (AV) block during TAVR is not fully understood, but it may be due to the mechanical stress of TAVR deployment, resulting in possible injury to the nearby compact AV node. Aortic valve calcification (AVC) may worsen this condition and has been associated with an increased risk for post-TAVR PPM implantation. We performed a retrospective analysis to determine if AVC is predictive for long-term right ventricular (RV) pacing in post-TAVR pacemaker patients at 30 days.

Methods

A total of 262 consecutive patients who underwent TAVR with a balloon-expandable valve were analyzed. AVC data were derived from contrast-enhanced computed tomography and characterized by leaflet sector and region.

Results

A total of 25 patients (11.1%) required post-TAVR PPM implantation. Seventeen patients did not require RV pacing at 30 days. Nine of these 17 patients had no RV pacing requirement within 10 days. The presence of intra-procedural heart block (P = 0.004) was the only significant difference between patients who did not require PPM and those who required PPM but they were not RV pacing-dependent at 30 days. Non-coronary cusp (NCC) calcium volume was significantly higher in patients who were pacemaker-dependent at 30 days (P = 0.01) and a calcium volume of > 239.2 mm³ in the NCC was strongly predictive of pacemaker dependence at 30 days (area under the curve (AUC) = 0.813). Pre-existing right bundle branch block (RBBB) (odds ratio (OR) 105.4, P = 0.004), bifascicular block (OR 12.5, P = 0.02), QRS duration (OR 70.43, P = 0.007) and intra-procedural complete heart block (OR 12.83, P = 0.03) were also predictive of pacemaker dependence at 30 days.

Conclusions

In patients who required PPM after TAVR, quantification of AVC by non-coronary leaflet calcium volume was found to be a novel predictor for RV pacing dependence at 30 days. The association of NCC calcification and PPM dependence may be related to the proximity of the conduction bundle to the non-coronary leaflet. Further studies are necessary to improve risk prediction for long-term RV pacing requirements following TAVR.

The bicuspid aortic valve: Still a toothy problem

Transcatheter aortic valve replacement (TAVR) is an acceptable treatment alternative to surgical aortic valve replacement in selected patients with a bicuspid aortic valve. TAVR appears to have acceptable mid-term outcomes in patients with bicuspid aortic stenosis. A large-scale, randomized, clinical trial is necessary to better define the role of TAVR for patients with bicuspid aortic stenosis.

Remote Ambulatory Cardiac Monitoring Before and After Transcatheter Aortic Valve Replacement

Remote ambulatory cardiac monitoring (rACM) could identify high-grade atrioventricular block (AVB) before and after transcatheter aortic valve replacement (TAVR). Retrospective analysis of patients undergoing TAVR, with 14-day rACM before and after TAVR, was performed. Of 62 patients undergoing TAVR, 41 patients had rACM before TAVR. Three patients had asymptomatic AVB leading to planned pacemaker (PM) implant. After TAVR, 23 patients had rACM, with 1 patient requiring a PM implant for asymptomatic AVB. Five patients underwent unplanned PM after TAVR. Using rACM, almost half of PM implants in TAVR recipients were identified electively. High-grade AVB requiring PM was identified in nearly 10% of patients before TAVR.

The implications and requirements of transcatheter aortic valve replacement in low-risk patients

Transcatheter aortic valve replacement (TAVR) is a transformative technology that has changed the management of patients with severe, symptomatic aortic stenosis. The use of TAVR in intermediate- to high-risk patients has been validated in several rigorously performed, randomized clinical trials. Recent studies using newer generation devices have demonstrated the noninferiority of TAVR as compared with surgical aortic valve replacement in low-risk patients, supporting the increased utilization and expansion of TAVR. The use of TAVR in low-risk patients has important implications and requires a multifaceted approach that includes a highly functional multidisciplinary heart team for careful patient selection; a need to understand and help mitigate certain key complications, such as stroke, paravalvular regurgitation, and conduction disturbances; careful data collection for continual outcome assessment and improvement; and the necessary expertize and procedural volume to maintain excellent outcomes and ensure optimal clinical care pathways.

Episode Payments for Transcatheter and Surgical Aortic Valve Replacement

BACKGROUND

Aortic stenosis is the most common valvular heart disease in the United States. Transcatheter aortic valve replacement (TAVR) is increasingly being adopted as an alternative to surgical aortic valve replacement (SAVR). In an era of value-based payment reform, our objective was to better understand the economic impact of the use of TAVR and SAVR in the United States.

METHODS AND RESULTS

We performed a retrospective cohort study of Medicare beneficiaries who underwent TAVR or SAVR between 2012 and 2015. Using claims from a 20% sample of national fee-for-service Medicare beneficiaries, we calculated episode payments for patients who underwent aortic valve replacement from 90 days before aortic valve replacement through 90 days after hospital discharge. Among 18 804 eligible patients, 6455 underwent TAVR (34.3%), and 12 349 underwent SAVR (65.7%). After adjustment for patient characteristics, episode payments for TAVR were ≈7% lower than for SAVR (TAVR, $55 545 [95% CI, $54 643-56 446] versus $59 467 [95% CI, $58 723-60 211]; P<0.001). Patients with TAVR had higher preprocedural payments, but lower payments during and after the index hospitalization for the procedure. Episode payments increased with increasing comorbidity score for patients undergoing TAVR or SAVR (rate ratio, 1.16 [95% CI, 1.15-1.17]; P<0.001); however, this association was stronger for SAVR (rate ratio, 1.18 [95% CI, 1.17-1.19]) than for TAVR (rate ratio, 1.11 [95% CI, 1.11-1.12]; P<0.001 for interaction). Thus, differences in episode payments between TAVR and SAVR were greatest for the sickest patients but much less in healthier patients.

CONCLUSIONS

TAVR is associated with lower episode payments than SAVR. However, episode payments for TAVR are less influenced by patient comorbidity. Therefore, as TAVR is increasingly used in patients with better baseline health status, the economic advantages of TAVR relative to SAVR may diminish.

Conduction System Abnormalities After Transcatheter Aortic Valve Replacement: Mechanism, Prediction, and Management

Conduction disturbances following TAVR are a common occurrence given the proximity of the various conduction system tissues, including the AV node, His-bundle, and bundle branches to the left ventricular outflow tract and aortic root. Impairment of these conduction system abnormalities may necessitate permanent pacemaker implantation, which increases morbidity and mortality, as well as length of stay, for the patient. The incidence, mechanisms, and predictors of conduction abnormalities and treatment options are discussed in this up-to-date review of the topic.

Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement: A Cost Analysis

Background

Transcatheter aortic valve replacement (TAVR) can be complicated with a complete atrioventricular block requiring permanent pacemaker (PPM) implantation. The cost of index hospitalization for such patients is higher than usual. However, the magnitude of this increased cost is uncertain. We have looked at our five-year TAVR experience to analyze the detailed cost for PPM implantation in TAVR.

Methods

This study is a retrospective analysis of patients undergoing TAVR at our tertiary care center from December 2012 to April 2018. The initial sample size was 449. We excluded patients with prior PPM or an implantable cardioverter defibrillator (37). Patients who had their procedure aborted or required a cardiopulmonary bypass (16) and those with missing data variables (14) were excluded. The final sample size was 382. The cost for admission was calculated as the US dollars incurred by the hospital. Cohort costs were categorized as a direct cost, which is patient based, and an indirect cost, which represents overhead costs and is independent of patient volume. Patients were divided into two groups based on the placement of PPM after TAVR. Chi-square test, t-test, and logistic linear regression were used for the statistical analysis.

Results

Of 382 patients, 19 (4.9%) required PPM after TAVR. Baseline variables, including age, gender, and BMI, were not statistically significant. The PPM group had a significantly longer intensive care unit (ICU) stay (48.6 hours vs. 36.7 hours; p<0.001) and total stay in the hospital (4.2 days vs. 3.4 days; p=0.047). PPM implantation after TAVR increased cost on an average of $10,213 more than a typical TAVR admission (p=0.04). The direct cost was also significantly high for the PPM group ($7,087; p=0.02). On detailed analysis, almost all major cost categories showed a higher cost for pacemaker patients when compared with control.

Conclusions

PPM implantation adds a significant cost burden to TAVR admissions.