Chronic pacing and adverse outcomes after transcatheter aortic valve implantation.
OBJECTIVE
Many patients undergoing transcatheter aortic valve implantation (TAVI) have a pre-existing, permanent pacemaker (PPM) or receive one as a consequence of the procedure. We hypothesised that chronic pacing may have adverse effects on TAVI outcomes.


RESULTS
Four groups of patients undergoing TAVI in the Placement of Aortic Transcatheter Valves (PARTNER) trial and registries were compared: prior PPM (n=586), new PPM (n=173), no PPM (n=1612), and left bundle branch block (LBBB)/no PPM (n=160). At 1 year, prior PPM, new PPM and LBBB/no PPM had higher all-cause mortality than no PPM (27.4%, 26.3%, 27.7% and 20.0%, p<0.05), and prior PPM or new PPM had higher rehospitalisation or mortality/rehospitalisation (p<0.04). By Cox regression analysis, new PPM (HR 1.38, 1.00 to 1.89, p=0.05) and prior PPM (HR 1.31, 1.08 to 1.60, p=0.006) were independently associated with 1-year mortality. Surviving prior PPM, new PPM and LBBB/no PPM patients had lower LVEF at 1 year relative to no PPM (50.5%, 55.4%, 48.9% and 57.6%, p<0.01). Prior PPM had worsened recovery of LVEF after TAVI (Δ=10.0 prior vs 19.7% no PPM for baseline LVEF <35%, p<0.0001; Δ=4.1 prior vs 7.4% no PPM for baseline LVEF 35-50%, p=0.006). Paced ECGs displayed a high prevalence of RV pacing (>88%).


CONCLUSIONS
In the PARTNER trial, prior PPM, along with new PPM and chronic LBBB patients, had worsened clinical and echocardiographic outcomes relative to no PPM patients, and the presence of a PPM was independently associated with 1-year mortality. Ventricular dyssynchrony due to chronic RV pacing may be mechanistically responsible for these findings.


BACKGROUND
(ClinicalTrials.gov NCT00530894).
Department of Medicine, Columbia University, New York, New York, USA Cardiovascular Research Foundation, New York, New York, USA.
Jose' M
JM
Dizon
Department of Medicine, Columbia University, New York, New York, USA Cardiovascular Research Foundation, New York, New York, USA.
Tamim M
TM
Nazif
Department of Medicine, Duke University, Durham, North Carolina, USA.
Paul L
PL
Hess
Department of Medicine, Columbia University, New York, New York, USA Cardiovascular Research Foundation, New York, New York, USA.
Angelo
A
Biviano
Department of Medicine, Columbia University, New York, New York, USA.
Hasan
H
Garan
Department of Medicine, Duke University, Durham, North Carolina, USA.
Pamela S
PS
Douglas
Cleveland Clinic, Cleveland, Ohio, USA.
Samir
S
Kapadia
Emory University School of Medicine, Atlanta, Georgia, USA.
Vasilis
V
Babaliaros
Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Howard C
HC
Herrmann
Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Wilson Y
WY
Szeto
Cedars-Sinai Medical Center, Los Angeles, California, USA.
Hasan
H
Jilaihawi
Stanford University, Stanford, California, USA.
William F
WF
Fearon
Cleveland Clinic, Cleveland, Ohio, USA.
E Murat
EM
Tuzcu
Medstar Washington Hospital Center, Washington DC, USA.
Augusto D
AD
Pichard
Cedars-Sinai Medical Center, Los Angeles, California, USA.
Raj
R
Makkar
NYU Langone Medical Center, New York, New York, USA.
Mathew
M
Williams
Department of Medicine, Columbia University, New York, New York, USA Cardiovascular Research Foundation, New York, New York, USA.
Rebecca T
RT
Hahn
Cardiovascular Research Foundation, New York, New York, USA.
Ke
K
Xu
Department of Medicine, Columbia University, New York, New York, USA Cardiovascular Research Foundation, New York, New York, USA.
Craig R
CR
Smith
Department of Medicine, Columbia University, New York, New York, USA Cardiovascular Research Foundation, New York, New York, USA.
Martin B
MB
Leon
Department of Medicine, Columbia University, New York, New York, USA Cardiovascular Research Foundation, New York, New York, USA.
Susheel K
SK
Kodali
D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000150:complications / Q000401:mortality / Q000601:surgery*; D002037:Bundle-Branch Block / Q000150:complications / Q000401:mortality / Q000628:therapy*; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D010138:Pacemaker, Artificial / Q000009:adverse effects*; D011379:Prognosis; D015996:Survival Rate / Q000639:trends; D065467:Transcatheter Aortic Valve Replacement; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology