Identifying Predictive Risk Factors for Pacemaker Need in Patients Undergoing Transcatheter Aortic Valve Replacement

by Miranda Lees, Jeffrey MacLeod, Zlatko Pozeg, Brent McGrath, Vernon Paddock, Robert Teskey, Darren Ferguson, Brian Archer, Heather Leblanc, Jean-Francois Légaré

Abstract: Transcatheter aortic valve replacement (TAVR) has become an established treatment for patients suffering with aortic stenosis. However, uncertainty remains on associated risk factors and post-procedure conduction disturbances requiring permanent pacemaker insertion (PPI). This study aimed to identify risk factors for post-TAVR pacemaker need and examine the effect of PPI on long-term outcomes. A retrospective study was performed on all patients who underwent TAVR at the Saint John Regional Hospital between 2010-2018, excluding those with an existing pacemaker. Risk factors predictive of post-procedure PPI were identified using two-tailed t-test, χ-square test, and hierarchical logistic regression model. Kaplan-Meier survival analysis was performed to compare all-cause mortality between patients with or without PPI. 377 patients with no previous pacemaker were included in the study, 42 requiring PPI post-TAVR. Univariate analysis suggested valves >29cm (p=0.05), renal insufficiency (p=0.03), and ECG abnormalities (p<0.0001) including right bundle branch block (p<0.0001), QRS duration >200ms (p=0.0003), and heart rate <50bpm (p=0.01) were associated with increased PPI. After multivariable analysis, only ECG abnormalities as a combined outcome (OR 5.19, CI 2.52-11.04, p<0.0001) was independently predictive of PPI. Kaplan-Meier survival analysis demonstrated PPI had no significant impact on all-cause mortality. Our study identifies several ECG abnormalities as the most robust predictors of PPI post-TAVR, however, that post-TAVR PPI is not associated with all-cause mortality after discharge. As TAVR becomes a treatment option for lower surgical risk patients, considerations for post-procedural PPI may affect clinical decision making and warrant screening for conduction abnormalities in patients undergoing TAVR. 

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