Timing of Conduction Abnormalities Leading to Permanent Pacemaker Insertion After Transcatheter Aortic Valve...

Transcatheter aortic valve implantation (TAVI) is the preferred alternative to traditional surgical aortic valve replacement; however, it remains expensive. One potential driver of cost is the need for postprocedural monitoring for conduction abnormalities after TAVI. Given the paucity of literature on the optimal length of monitoring, we aimed to determine when clinically significant conduction abnormalities leading to permanent pacemaker (PPM) insertion after TAVI were first identified.

We identified all patients in the Sunnybrook Health Sciences Centre TAVI registry (Toronto, Canada) who underwent TAVI between 2009 and 2016, excluding those with pre-existing PPMs or those who underwent emergency open heart surgery. Through dedicated chart review, the timing and type of conduction abnormalities leading to PPM were recorded. Patients were divided according to the timing of conduction abnormality: during the procedure vs after the procedure.

The overall PPM insertion rate was 15.6% (80 of 512 cases), with all but 1 patient receiving a PPM for class I indications. PPMs were inserted for complete heart block/high-grade atrioventricular block (91.3%), severe sinus node dysfunction (3.8%), and alternating bundle branch block (3.8%). Of these conduction abnormalities, 55.0% occurred during the procedure (intraprocedure; n = 44 patients). The mean time to the development of a conduction abnormality necessitating PPM was 1.2 days (interquartile range, 0-2 days), with 88.8% occurring within 72 hours of the procedure (n = 71 patients). In the entire TAVI cohort, < 3% had conduction abnormalities beyond 48 hours after the procedure leading to PPM.

The majority of conduction abnormalities leading to PPM insertion after TAVI occur in the very early periprocedural period, suggesting that early mobilization and discharge will be safe from a conduction standpoint.