Prophylactic Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement.

BACKGROUND

The management of patients developing new conduction disturbances after transcatheter aortic valve replacement (TAVR) remains largely debated.

OBJECTIVES

The purpose of this study was to evaluate the incidence and clinical impact of prophylactic permanent pacemaker implantation (PPI) after TAVR.

METHODS

This was a prespecified subanalysis of the PROMOTE (PRospective Application of a Pre-Specified Scientific Expert Panel AlgOrithm for the Management of COnduction Disturbances Following Transcatheter Aortic Valve Replacement) trial, a prospective multicenter study including 2,110 consecutive patients without prior pacemaker undergoing TAVR. Prophylactic PPI was considered in case of enlarged QRS with active electrocardiogram changes (daily PR or QRS interval increase ≥20 ms during 2 consecutive days), or new-onset persistent with either QRS>150 ms or PR >240 ms.

RESULTS

A total of 329 patients with PPI post-TAVR were included, 80 (24.3%) of which had a prophylactic indication. The main indication (90%) of prophylactic PPI was new-onset persistent left bundle branch block with QRS >150 ms and/or PR >240 ms. The 30-day clinical outcomes were similar in prophylactic and nonprophylactic PPI patients, but the median rate of ventricular pacing percentage was significantly lower in the prophylactic PPI group (2% vs 73%; P < 0.001), with a higher rate of patients with ventricular pacing percentage <1% (42.6% vs 14.5%; P < 0.001). Prophylactic PPI after a positive electrophysiological study (His-Ventricle interval ≥70 ms) did not seem to impact the pacing burden at follow-up (median: 2.0% vs 1.9% in no electrophysiological study patients; P = 0.585).

CONCLUSIONS

About one fourth of patients receiving PPI after TAVR had a prophylactic indication. Despite similar clinical outcomes, prophylactic PPI patients exhibited a very low pacing burden at 30 days. These findings would question the systematic use of prophylactic PPI after TAVR. (PRospective Application of a Pre-Specified Scientific Expert Panel AlgOrithm for the Management of COnducton Disturbances Following Transcatheter Aortic Valve Replacement [PROMOTE]; NCT04139616).