Pacemaker implantation after TAVI: predictors of AV block persistence

Approximately every fifth patient undergoing transcatheter aortic valve implantation (TAVI) requires a permanent pacemaker (PPM) after the procedure. The aim of this study was to analyse predictors of atrioventricular block III° (AVBIII) persistence with concurrent PPM dependency after TAVI.

Between 2010 and 2015 a total of 1198 patients underwent TAVI at the Kerckhoff Heart and Thorax Center, Germany. After exclusion of patients with prior PPM (n = 173) 14.7% (n = 176) of the patients underwent PPM implantation after the procedure. Independent predictors of PPM implantation were pre-existing right bundle branch block (RBBB, p < 0.001) and implantation of a CoreValve prosthesis (p < 0.001). A subgroup of patients with a newly implanted PPM (n = 102) were followed-up for a median of 73 (IQR 62-85) days. The leading indication for PPM implantation was AVBIII in 74.5% (76/102). Of these patients only 22.4% (17/76) had persistent AVBIII at follow-up. Predictors of AVBIII persistence were prior RBBB (p = 0.04), postdilatation (p = 0.006) and higher mean aortic valve gradient prior to implantation (p = 0.013). PPMs were implanted earlier in patients with persisting AVBIII [1 day (IQR0-2.5) vs. 4 days (IQR2-7); p < 0.001]. Early PPM implantation after TAVI was the only independent predictor of persistent AVBIII [OR 1.36 (95% 1.05-1.75); p = 0.02].

The long-term persistence of AVBIII is generally low after TAVI. Therefore, it may be wise to postpone the indication for PPM implantation for a couple of days. The only predictors of a lack of recovery of the AVB are prior RBBB, higher mean aortic valve gradients and postdilatation of the prosthesis.