New Guidance Available on Rates, Risks and Effects of Post-TAVR Permanent Pacemaker Requirement

The emergence of transcatheter aortic valve replacement (TAVR) as an alternative to surgery for patients with severe aortic stenosis has been universally welcomed, but it doesn’t come without caveats. A leading one is the heightened post-procedural risk of advanced conduction abnormalities, most notably new-onset left bundle branch block (LBBB) and high-grade atrioventricular block (AVB) requiring implantation of a permanent pacemaker (PPM).

The fast-evolving landscape around PPM requirements in TAVR patients is the focus of a helpful new “State-of-the-Art Review” in JACC: Cardiovascular Interventions (2021;14:115-134) by a group of authors predominantly from Cleveland Clinic.

“Despite ongoing improvements in TAVR safety and efficacy, conduction abnormalities that require PPM placement remain a common development following TAVR because of the proximity of the atrioventricular conduction system to the aortic root,” explains the review’s senior and corresponding author, Samir Kapadia, MD, Chair of Cardiovascular Medicine at Cleveland Clinic. “As TAVR use expands in the wake of its August 2019 FDA approval for patients at low surgical risk, there is increased need to understand the impact of both PPM implantation and post-TAVR conduction abnormalities on mortality and other outcomes.”

To promote that understanding, Dr. Kapadia and colleagues performed a systematic literature search through mid-2020 for comprehensive data on the following:

• The incidence of conduction deficits and PPM implantation in TAVR patients
• Predictors of conduction abnormalities and PPM requirement in TAVR patients
• Post-procedural risk factors for PPM implantation
• Long-term outcomes following new-onset LBBB and PPM placement in TAVR patients
• Management of conduction abnormalities in the wake of TAVR

Their resulting review outlines and interprets current evidence on these issues, presenting data across a number of reader-friendly tables, figures and illustrations. The latter include a central illustration presenting Cleveland Clinic’s algorithm for managing conduction disturbances and assessing need for PPM placement after TAVR. “We offer our rationale for atrial pacing in the immediate post-TAVR environment to further risk-stratify patients in terms of PPM requirement,” Dr. Kapadia explains.

Across the course of the review, the authors share a number of conclusions, including the following:

• The rate of PPM placement after TAVR varies considerably among published reports and is influenced by numerous pre- and intraprocedural factors.
• Despite lack of consensus about the optimal duration of post-TAVR telemetry monitoring and the precise indications for PPM implantation, the most common indications in this setting are high-grade AVB and new-onset LBBB.
• Both PPM implantation and new-onset LBBB appear to adversely impact morbidity and mortality following TAVR. The long-term effects of pacing in younger TAVR patients are not well defined.
• Immediate post-TAVR testing of atrioventricular conduction is a reasonable option to gauge potential need for a PPM.

“We also urge heart teams to carefully consider specific anatomic, electrical and clinical risk factors when evaluating candidates for TAVR,” Dr. Kapadia notes. “Moreover, clinicians’ choice of valve and implantation technique should be made with an aim to minimize the risk of post-procedural conduction abnormalities. The duration and need for post-procedural monitoring of heart rhythm prior to committing the patient to a permanent pacemaker is something that needs further investigation.”

The full State-of-the-Art Review is available here.