One-year pacing dependency after pacemaker implantation in patients undergoing transcatheter aortic valve implantation: Systematic review and meta-analysis

Effectiveness and Safety of Myval Versus Other Transcatheter Valves in Patients Undergoing TAVI: A Meta-Analysis

Transcatheter aortic valve implantation (TAVI) has changed the treatment of aortic stenosis. The Myval transcatheter heart valve (THV), a novel balloon-expandable THV, has shown promising outcomes. Our aim is to compare the comparative safety and effectiveness of Myval THV against established THVs, such as Sapien and Evolut. A systematic review and meta-analysis was conducted, comparing the Myval THV with other contemporary THVs. Primary endpoints were periprocedural, 30-day and 1-year all-cause mortality. Seven studies involving 3106 patients (1027 Myval; 2079 other THVs) were included. No significant differences were observed in the primary endpoints. Myval demonstrated higher procedural success (RR: 1.04, 95% CI: 1.01-1.07, I² = 29%) and lower rates of permanent pacemaker implantation (PPI) during the index hospitalization (RR: 0.57, 95% CI: 0.36-0.92, I² = 23%) and 30-days (RR: 0.60, 95% CI: 0.40-0.89, I² = 43%), compared to other THV. At 30-day, Myval was associated with lower rates of moderate or severe transvalvular aortic regurgitation (RR: 0.33, 95% CI: 0.11-0.98, I² = 57%) and minor vascular complications (RR: 0.45, 95% CI: 0.23-0.90, I² = 0%). When compared to self-expandable THV, Myval was associated with higher procedural and device success, higher early safety, lower risk for PPI, minor vascular complications and at least moderate transvalvular AR. When compared to Sapien, procedural success and risk for in-hospital PPI was borderline higher and lower in favor of Myval, respectively. The Myval THV demonstrates comparable safety and effectiveness to contemporary THVs, with advantages in procedural success, PPI, and vascular complications.

Early outcomes of the novel Myval THV series compared to SAPIEN THV series and Evolut THV series in individuals with severe aortic stenosis

BACKGROUND

There are limited head-to-head randomised trials comparing the performance of different transcatheter heart valves (THVs).

AIMS

We aimed to evaluate the non-inferiority of the balloon-expandable Myval THV series compared to the balloon-expandable SAPIEN THV series or the self-expanding Evolut THV series.

METHODS

The LANDMARK trial randomised 768 patients in a 1:1 ratio, (Myval THV series [n=384] vs contemporary series with 50% SAPIEN THV series [n=192] and 50% Evolut THV series [n=192]). The non-inferiority of Myval over the SAPIEN or Evolut THV series in terms of the 30-day primary composite safety and effectiveness endpoint as per the third Valve Academic Research Consortium (VARC-3) was tested in an intention-to-treat population with a predefined statistical power of 80% (1-sided alpha of 5%) for a non-inferiority margin of 10.44%.

RESULTS

The Myval THV series achieved non-inferiority for the primary composite endpoint over the SAPIEN THV series (24.7% vs 24.1%, risk difference [95% confidence interval {CI}]: 0.6% [not applicable {NA} to 8.0]; p=0.0033) and the Evolut THV series (24.7% vs 30.0%, risk difference [95% CI]: -5.3% [NA to 2.5]; p<0.0001). The incidences of pacemaker implantation were comparable (Myval THV series: 15.0%, SAPIEN THV series: 17.3%, Evolut THV series: 16.8%). At 30 days, the mean pressure gradient and effective orifice area were significantly better with the Myval THV series compared to the SAPIEN THV series (p<0.0001) and better with the Evolut THV series than with the Myval THV series (p<0.0001). At 30 days, the proportion of moderate to severe prosthetic valve regurgitation was numerically higher with the Evolut THV series compared to the Myval THV series (7.4% vs 3.4%; p=0.06), while not significantly different between the Myval THV series and the SAPIEN THV series (3.4% vs 1.6%; p=0.32).

CONCLUSIONS

The Myval THV series is non-inferior to the SAPIEN THV series and the Evolut THV series in terms of the primary composite endpoint at 30 days.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT04275726; EudraCT number 2020-000,137-40.

Prophylactic Permanent Pacemaker Implantation for Baseline Right Bundle Branch Block in Patients Undergoing Transcatheter Aortic Valve Replacement: Clinical Efficacy, Safety, and Long-Term Pacing Requirement

Background

Baseline right bundle branch block (RBBB) is an established predictor of permanent pacemaker (PPM) requirement after transcatheter aortic valve replacement (TAVR). There are limited data to support prophylactic PPM implantation in advance of TAVR. We aimed to evaluate the efficacy and safety of prophylactic PPM implantation in patients with RBBB prior to TAVR, and to identify the predictors of pacing dependence after TAVR.

Methods

This was a retrospective cohort study of patients undergoing prophylactic PPM implantation for baseline RBBB prior to TAVR at two high-volume UK centers between 2014 and 2022.

Results

Baseline RBBB was identified in 170/4580 (3.7%) patients undergoing TAVR during the study period. Of these, 106/170 (62.4%) underwent prophylactic PPM implantation. This group had a significantly shorter median length of hospital stay after TAVR compared to patients with RBBB undergoing TAVR without prophylactic PPM implantation (2 vs. 4 days, p = 0.028). Urgent PPM implantation after TAVR was required in 43/64 (67.2%) of patients with RBBB who underwent TAVR without a prophylactic PPM. Analysis of ventricular pacing over 12 months post-TAVR demonstrated a significant pacing requirement (ventricular pacing > 10%) in 50/79 (63%) of patients with a prophylactic PPM. Pacing requirement was independently predicted by baseline first-degree heart block (odds ratio 2.4, p = 0.03) and QRS duration >140 ​ms (odds ratio 4.3, p = 0.01).

Conclusions

In this retrospective two-center cohort study, prophylactic PPM implantation for patients with baseline RBBB was safe, effective, and reduced the length of hospital stay. First-degree atrioventricular block and broad RBBB (QRS > 140 ​ms) were independent baseline predictors of significant pacing requirements.

Comparison of Patient Outcomes Between Leadless vs Transvenous Pacemakers Following Transcatheter Aortic Valve Replacement

BACKGROUND

Evidence is limited regarding the effectiveness of leadless pacemaker implantation for conduction disturbance following transcatheter aortic valve replacement (TAVR).

OBJECTIVES

This study sought to examine the national trends in the use of leadless pacemaker implantation following TAVR and compare its performance with transvenous pacemakers.

METHODS

Medicare fee-for-service beneficiaries aged ≥65 years who underwent leadless or transvenous pacemakers following TAVR between 2017 and 2020 were included. Outcomes included in-hospital overall complications as well as midterm (up to 2 years) all-cause death, heart failure hospitalization, infective endocarditis, and device-related complications. Propensity score overlap weighting analysis was used.

RESULTS

A total of 10,338 patients (730 leadless vs 9,608 transvenous) were included. Between 2017 and 2020, there was a 3.5-fold increase in the proportion of leadless pacemakers implanted following TAVR. Leadless pacemaker recipients had more comorbidities, including atrial fibrillation and end-stage renal disease. After adjusting for potential confounders, patients with leadless pacemakers experienced a lower rate of in-hospital overall complications compared with patients who received transvenous pacemakers (7.2% vs 10.1%; P = 0.014). In the midterm, we found no significant differences in all-cause death (adjusted HR: 1.13; 95% CI: 0.96-1.32; P = 0.15), heart failure hospitalization (subdistribution HR: 0.89; 95% CI: 0.74-1.08; P = 0.24), or infective endocarditis (subdistribution HR: 0.98; 95% CI: 0.44-2.17; P = 0.95) between the 2 groups, but leadless pacemakers were associated with a lower risk of device-related complications (subdistribution HR: 0.37; 95% CI: 0.21-0.64; P < 0.001).

CONCLUSIONS

Leadless pacemakers are increasingly being used for conduction disturbance following TAVR and were associated with a lower rate of in-hospital complications and midterm device-related complications compared to transvenous pacemakers without a difference in midterm mortality.

Pacemaker dependency and conduction system recovery following transcatheter aortic valve implantation

BACKGROUND

Transcatheter aortic valve implantation (TAVI)-related conduction system disorders are dynamic and may resolve over time. The purpose of this study was to investigate predictive factors of PM dependency among patients receiving permanent PM implantation after TAVI.

METHODS

We included 37 consecutive patients who underwent PPM implantation within six days after TAVI and who completed a 12-month follow-up. Patients were divided into two groups according to PPM dependency at follow-up: PPM-dependent group and non-PPM-dependent group. Device follow-ups were performed at one, six and 12 months.

RESULTS

There were no significant differences in either baseline clinical characteristics or procedural data and results. Analysis of baseline ECGs showed a statistical difference in PR interval (200.1±17.2 ms in the PPM-dependent group vs. 175±23.3 ms in the non PPM-dependent group [P=0,003]) and in the presence of RBBB (four patients in the PPM-dependent group vs. no patients in the non PPM-dependent group [P=0.02]) as well as QRS duration (117.3±27.4 ms in the PPM-dependent group and 99±18.3 msec in the non PPM-dependent group [P=0.04]).

CONCLUSIONS

The rate of PPM dependency was significantly reduced at 12-month follow-up: from 62,2% at the time of implantation to 35,1%. PR interval and RBBB were the most important predictive factors for PPM dependency. Persistent AVB and alternating BBB were prevalent in the PPM-dependent group. In the absence of persistent AVB or alternating BBB, we suggest that patients without long PR interval and RBBB at baseline ECG be carefully evaluated before permanent PM implantation, as conduction system recovery is possible.

Ventricular pacing dependency after transcatheter aortic valve replacement: a prospective cohort

Background

Atrioventricular conduction disturbance occurs in a significant number of patients undergoing transcatheter aortic valve replacement (TAVR). However, not all cases are ventricular pacing-dependent. Thus, we aimed to study the incidence, predictors, and outcomes of new ventricular pacing dependency (VpDep) after TAVR.

Methods

We prospectively analyzed 130 consecutive transfemoral TAVR cases performed in Ramathibodi Hospital between 2015 and 2020. Three patients with prior ventricular pacing-dependent on cardiac implantable electronic devices (CIEDs) were excluded. The endpoints were VpDep at 1 month and all-cause mortality at the follow-up period end in 2021. The effects of variables on VpDep and all-cause mortality were evaluated using multivariate binary logistic regression and Cox regression analyses, respectively. First-degree atrioventricular block (AVB) was considered severe when the PR interval was >300 ms.

Results

Of the 127 patients [mean age, 81.8 years; 62.2% females; 67.7% balloon-expandable (BE) device], 7 patients (5.5%) had CIEDs implanted before TAVR that were not ventricular pacing-dependent. TAVR was successfully performed in 126 (99.2%) patients. Periprocedural stroke, cardiac tamponade, and major bleeding occurred in 2 (1.6%), 4 (3.1%), and 4 (3.1%) patients, respectively. The VpDep incidence at 1 month was 7.9% (n=10) among all patients and 34.5% among those with CIEDs (n=29). VpDep was more likely to occur in patients with pre-existing right bundle branch block (RBBB) [odds ratio (OR), 21.38; 95% confidence interval (CI): 3.28-139.33; P=0.001] and severe 1st degree or Mobitz I AVB (OR, 14.79; 95% CI: 1.65-132.74; P=0.016). After a mean follow-up of 25.8 months [standard deviation (SD), 21.2 months], death from any cause occurred in 18 patients (14.2%). However, VpDep was not associated with an increased mortality.

Conclusions

In this real-world cohort, pre-existing conduction abnormalities were significantly associated with a higher risk of VpDep. Mortality was similar between patients with and without VpDep.