Predictors of right ventricular pacing and pacemaker dependence in transcatheter aortic valve replacement patients

Transcatheter aortic valve replacement (TAVR) is an increasingly prevalent therapy in patients with severe symptomatic aortic stenosis. Conduction disturbances requiring permanent pacemaker (PPM) implantation are a known complication of TAVR. This study investigated the progression of cardiac conduction disease in the post-TAVR pacemaker population and identified predictors of post-TAVR right ventricular (RV) pacing dependence.

Prospectively collected echocardiographic, ECG, and PPM interrogation data of 262 consecutive patients who underwent TAVR with placement of a balloon-expandable valve at one institution from March 2012 to October 2016 were analyzed.

A total of 25 patients (11.1%) required post-TAVR PPM implantation. Seventeen patients who received PPMs did not require RV pacing at 30 days. Nine of these 17 patients had no RV pacing requirement within 10 days. Pre-existing right bundle branch block (RBBB) (OR 105.4, 4.52-2458.5, p = 0.0002), bifascicular block (OR 12.50, 1.60-97.65, p = 0.02), intra-procedural complete heart block (OR 12.83, 1.26-130.52, p = 0.03), and QRS duration > 120 ms (OR 70.43, 3.23-1535.22, p = 0.0002) on pre-TAVR ECG were associated with RV pacing dependence at 30 days.

Sixty-eight percent of patients meeting post-procedural guideline indications for PPM did not require RV pacing at 30 days. Fifty-two percent of these patients demonstrated recovery of sinus node function or AV conduction within 10 days post-implant. RBBB, intra-procedural complete heart block, bifascicular block, and QRS duration > 120 ms were associated with RV pacing dependence at 30 days. These findings suggest that post-TAVR conduction disturbances may be acutely reversible in a significant proportion of patients receiving PPM within 10-30 days of implant.