Pacemaker Implantation Before, After TAVR Tied to Increased Risk of Death

NEW YORK (Reuters Health) – Pacemaker implantation before or soon after transcatheter aortic-valve replacement (TAVR) is associated with an increased risk of death and hospitalization for heart failure (HF), a French study has found.

Patients with conduction abnormalities after TAVR often need a pacemaker, but few studies have evaluated mortality and hospitalization outcomes in this population.

Dr. Nicolas Clementy of Centre Hospitalier Regional Universitaire de Tours and colleagues analyzed data on more than 49,000 patients who were treated for TAVR in France between 2010 and 2019. Using an administrative hospital-discharge database, they looked at the incidence of all-cause death and HR-related hospitalization rates, all within the first 30 days after TAVR.

The median follow-up period was 1.7 years, the researchers report in Heart Rhythm. At baseline, 22% of patients already had an implanted permanent pacemaker. Another 22% underwent permanent pacemaker implantation within the first 30 days after TAVR.

Patients with previous pacemaker implantation and patients who were implanted within 30 days of TAVR had significantly higher adjusted combined risk for all-cause death and hospitalization for HF compared with patients without a pacemaker (adjusted hazard ratio, 1.12 and 1.11, respectively).

Dr. Sreekanth Vemulapalli of Duke University School of Medicine, in Durham, North Carolina, told Reuters Health by email that the optimal implantation techniques and device choices to reduce the need for pacemaker implantation following TAVR are only now beginning to come into focus.

Meanwhile, he noted, the data in the study were collected during a period when implantation techniques underwent significant changes. Additionally, the high number of patients in the study who already had a pacemaker prior to TAVR suggests the cohort was sicker than the average patient, indicating the findings may be limited in their generalizability.

In spite of these limitations, Dr. Vemulapalli, who was not involved in the study, said it “re-emphasizes the need to solidify optimal device design and implantation techniques to lower the risk of pacemaker placement after TAVR.”

Dr. Ibrahim Sultan, director of the UPMC Center for Thoracic Aortic Disease, said the study serves as a reminder “that pacemakers after TAVR are not benign and are likely to have consequences with respect to survival and HF.”

Dr. Sultan, who also did not participate in the study, told Reuters Health by email that the findings are particularly important as TAVR continues to expand to younger patients who are otherwise considered at low risk for surgery.

He said recent advances in the field have improved his center’s implantation technique for TAVR valves. As a result, the rate of patients needing a new pacemaker after TAVR at his institution is now as low as 6% to 8%. The data from the French study are “humbling and are important to keep in mind when discussing the natural history of patients requiring pacemakers after TAVR,” he added.

“While the need for pacemakers after TAVR has decreased over time and outcomes after TAVR have improved significantly, we still have room to improve as we strive to provide the best outcomes for our patients,” Dr. Sultan said.

SOURCE: Heart Rhythm, online June 16, 2021.

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