Conduction disturbances after TAVR: rates of pacemaker implantation, burden of ventricular pacing and prognostic significance

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND The occurrence of conduction disturbances remains frequent after TAVR. However, the effect of PM on mortality is controversial and many patients may recover spontaneous AV conduction during follow-up. PURPOSE To evaluate the incidence of PM implantation after TAVR, PM dependency and burden of ventricular pacing during follow-up and their influence on mortality. METHODS AND RESULTS We performed a retrospective analysis of all consecutive 293 patients who underwent TAVR from 2015 to 2019 at our hospital, regional hub for this procedure. Patients were classified into 3 groups: patients without PM (no-PM), patients with a PM implanted prior to TAVR (pre-PM) and patients requiring a PM following TAVR (post-PM) and their clinical and procedural characteristics are listed in Table 1. The rate of PM implantation after TAVR was 20,8%, at a median of 3.6 days after the procedure. The most common indication was complete AV block. A VVIR pacemaker was implanted in 28 patients, a DDD/DDDR PM in 27 patients and 2 patients received a CRT device. Among post-PPM patients, only 16% were PM-dependent at 2-month and 1-year follow-up. All of them received a PM for complete AV block (AVB). At 1-year follow-up, RV pacing burden was 60% among AVB patients and 23% in patients with a PM implanted for other reasons. PM implantation after TAVR was not associated with a mortality difference at 30-day, 1-year and long-term follow-up. Pre-PPM patients showed a higher mortality rate at long-term follow-up although not statistically significant. CONCLUSIONS Our data suggest that a single chamber device should be preferred in patients implanted for reasons other than complete AVB; in patients with AVB, the use of dual chamber device with an algorithm to minimize RV pacing should be the most suitable choice. Overall (293)No PPM (216)Pre-PPM (19)Post-PPM (57)p-valueAge, median(IQR)82(80-86)82(80-86)82(79-87)82(80-86)0,53Female, n(%)160(55)129(59)6(32)25(44)0,40NYHA III-IV, n(%)191(65)147(68)15(79)29(51)0,06Logistic Euroscore, mean (IQR)7,53(3,5-8,3)7(3,5-8)9,83(3,6-12)6(3,5-7,4)0,51Right bundle-branch block, n(%)21(7)13(6)na8(14)0,04AVA, mean ± SD0,69 ± 0,190,7 ± 0,190,7 ± 0,160,66 ± 0,180,23Self-expandable valve, n(%)181(62)123(57)12(63)46(81)0,001Balloon-expandable valve, n(%)102(35)86(40)7(37)8(14)0,0003Implant depth, mean ± SD6,87 ± 2,96,32 ± 2,65,71 ± 39,12 ± 30,0001Abstract Figure. Kaplan-Meier survival curve

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6118Mid- and long-term percentage of ventricular pacing in patients implanted with a pacemaker after a transcatheter aortic valve replacement procedure: potential clinical implications

European Heart Journal ◽

10.1093/eurheartj/ehz746.0144 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

E Baldi ◽

A Demarchi ◽

S Mauri ◽

C Di Giacomo ◽

M Ferrario Ormezzano ◽

...

Keyword(s):

Aortic Valve ◽

Transcatheter Aortic Valve Replacement ◽

Av Block ◽

Ventricular Pacing ◽

Conduction Disturbance ◽

Conduction Disturbances ◽

Transcatheter Aortic Valve ◽

Long Term Follow Up

Abstract Background Cardiac conduction disturbances frequently occur following transcatheter aortic valve replacement (TAVR). As this procedure is getting more and more common, more research efforts should focus on post procedural rhythm disturbances and their evolution over time Purpose To evaluate the percentage of pacing in patients who underwent a TAVR procedure and developed a conduction disturbance requiring a transvenous pacemaker (PM) implantation Methods We considered all the patients who underwent a TAVR procedure between march 2009 and november 2018 in our centre. Patients implanted with a PM or an ICD before the TAVR procedure or 30 days after the TAVR were not considered eligible for our analysis, because likely not related to TAVR. The percentage of effective right ventricular pacing was assessed both at mid- and long-term follow-up Results 265 patients underwent TAVR in the study period (45% males, 81±6 years). 20 patients already had a PM and were excluded. 39 of the 245 patients (16%) were implanted with a PM after TAVR, 26 of them were implanted within 30 days (median time TAVR-PM implant: 8±7 days). The rate of PM implant within 30 days after TAVR was 8% (20/246) for patients implanted with an Edward Sapien valve, 25% (4/16) for patients with an Evolute Pro valve and 66% (2/3) in patients with a Lotus Edge valve. The indication for PM implant was a permanent 3rd degree A-V block in 12 patients, a paroxysmal A-V block in 4, a bifascicular A-V block with an infra-hisian disease in 5, a II degree Mobitz II A-V block in 2, an atrial fibrillation with slow A-V conduction in 2 and a 2:1 A-V block with infra-hisian disease in 1. The first follow-up after the PM implantation was available in 24 patients (mean 78±87 days after PM implant) and the second in 15 patients (372±267 days after PM implant). The patients were divided into two groups based on the presence/absence of permanent 3rd degree AV block at the time of implantation. At the first follow-up the percentage of pacing was significantly higher in patients implanted with vs. without a permanent 3rd degree AV block (98.5% vs 11%, p<0.001). Notably, in none of the patients without a permanent 3rd AV block at baseline conduction disturbances progressed toward a permanent AV block during long-term follow-up. Accordingly, at the second follow-up patients without permanent 3rd AV block at baseline showed a significantly lower percentage of pacing (1% vs 100%; p<0.01) Conclusion Patients implanted with a PM after TAVR in the absence of a permanent 3rd AV block have a very low likelihood of progression to a permanent AV conduction disturbance and show a negligible percentage of pacing during follow-up. Our results may impact the choice of the correct timing of PM implantation after TAVR and the potential indication for a leadless PM.

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Abstract 16099: Predictors of Cardiovascular Implantable Electronic Device-dependence at Long-term Follow-up After Alcohol Septal Ablation in Hypertrophic Cardiomyopathy Patients

Circulation ◽

10.1161/circ.142.suppl_3.16099 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Weeranun D Bode ◽

Michael F Bode ◽

Megan Zhao ◽

Rahul Sakhuja ◽

Michael A Fifer ◽

...

Keyword(s):

Hypertrophic Cardiomyopathy ◽

Electronic Device ◽

Av Block ◽

Ventricular Pacing ◽

Alcohol Septal Ablation ◽

Long Term Follow Up ◽

Baseline Characteristics ◽

Cardiovascular Implantable Electronic Device

Introduction: The most common complication of alcohol septal ablation (ASA) is periprocedural high grade AV block (HGAVB). No long-term follow-up of cardiovascular implantable electronic device (CIED) utilization after ASA has been reported. Hypothesis: Pacemaker dependence on long-term follow up can be predicted by ECG or procedural characteristics. Methods: We analyzed all patients with hypertrophic cardiomyopathy who underwent ASA from December 1998 to December 2019 at our institution and received their first CIED within 30 days after ASA for HGAVB. All available follow-up interrogations were reviewed. CIED dependence was defined as ventricular pacing of ≥5%. CIED programming was determined by the patients’ cardiologists' discretion. Results: A total of 103 patients with hypertrophic cardiomyopathy underwent ASA. The average follow up duration was 10.1 years. Within 30 days after ASA, a total 25 patients received a CIED for HGAVB. On long term follow-up 16 patients (64%) were found to be CIED-dependent. Baseline characteristics, including pre and post-ASA ECG, were not significantly different between dependent and non-dependent patients (Table). The only predictor for CIED dependence was >1 ml of alcohol injected during ASA (OR 6.0, p<0.046). Conclusions: CIED implantation after ASA is common. Almost two thirds of patients who received CIED for postprocedural HGAVB were CIED-dependent on long term follow up. CIED dependence can be predicted by amount of injected alcohol >1 ml during ASA.

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Long-term impact of transient atrioventricular block during atrioventricular nodal re-entrant tachycardia ablation

EP Europace ◽

10.1093/europace/euab116.303 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

I Marco Clement ◽

M Cossiani Martinez ◽

S Castrejon Castrejon ◽

C Alvarez Ortega ◽

L Martin Polo ◽

...

Keyword(s):

Pacemaker Implantation ◽

Cardiac Pacing ◽

Safe Procedure ◽

Av Block ◽

Energy Delivery ◽

Funding Sources ◽

Long Term Follow Up ◽

Long Term Impact

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Ablation of atrioventricular nodal re-entrant tachycardia (AVNRT) is an extremely safe procedure, being complete atrioventricular (AV) block the most feared complication. Transient AV or ventriculoatrial (VA) block during ablation is considered a risk marker of immediate AV permanent block. Purpose To study whether TB (transient block) during AVNRT ablation is associated with a higher risk of AV permanent block and pacemaker implantation during long term follow-up. Methods Retrospective analysis of all patients who underwent ablation for AVNRT in our center and had a minimum five years follow-up. Patients carrying a cardiac pacing device were excluded. Data was extracted from electronic medical records and follow-up was performed by telephone contact. TB was defined as AV or VA loss of conduction of at least 1 beat during energy delivery. Results We included 689 patients who underwent AVNRT ablation from March 1995 to December 2015: mean age 52.6 ± 18.6 years; 240 (34.8%) male; 677 radiofrequency and 12 cryotherapy ablations. TB was observed in 106 (15,4%) patients. Baseline characteristics are described in Table 1. Within the TB group, 44 (41.5%) patients presented with AV block, 60 (56.6%) with VA block, and 2 patients presented with both. TB concerned more than one beat in 65 (61.9%) cases and persisted after cessation of energy delivery in 15 (14.2%) cases. Two patients did not recover AV conduction, requiring pacemaker implantation before discharge. During a median 12.5 years follow-up (IQR 9.5-16.6), 3 of the remaining 104 TB patients required pacemaker implantation due to AV block. All 3 had presented AV TB and had undergone radiofrequency ablation; they were not significantly older (67.0 ± 9.3 vs 48.8 ± 19.8, p = 0.12) but presented longer basal PR (237.0 ± 115.2 vs 152.6 ± 26.5, p < 0.001) and HV (57.3 ± 6.7 vs 44.2 ± 7.6, p = 0.004) intervals. When compared to the non-TB group, there were no differences in pacemaker implantation due to AV block during follow-up (7 (1.2%) p = 0.19). However, median time to pacemaker implantation was shorter in TB patients than in non-TB: 0.7 [0.1-1.4] vs 13.7 [5.2-22.0], p = 0.02. Conclusion Long term incidence of permanent AV block did not differ between TB and non-TB groups, however AV block occurred significantly earlier in TB patients. Non-TB group(n = 583) TB group(n = 106) p Age (mean ± SD) 53.2 ± 18.3 49.3 ± 19.8 0.05 PR (mean ± SD) 153.0 ± 28.4 155.0 ± 33.8 0.54 AH (mean ± SD) 83.3 ± 23.6 82.1 ± 22.2 0.64 HV (mean ± SD) 44.4 ± 7.8 44.6 ± 7.9 0.76

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The feasibility and safety of left bundle branch pacing vs. right ventricular pacing after mid-long-term follow-up: a single-centre experience

EP Europace ◽

10.1093/europace/euaa294 ◽

2020 ◽

Vol 22 (Supplement_2) ◽

pp. ii36-ii44

Author(s):

Xueying Chen ◽

Qinchun Jin ◽

Jin Bai ◽

Wei Wang ◽

Shengmei Qin ◽

...

Keyword(s):

Right Ventricular ◽

Pacemaker Implantation ◽

Ventricular Pacing ◽

Right Ventricular Pacing ◽

Cardiac Outcomes ◽

Post Procedure ◽

Long Term Follow Up ◽

Qrs Duration

Abstract Aims The aim of this study is to prospectively assess the feasibility and safety of left bundle branch pacing (LBBP) when compared with right ventricular pacing (RVP) during mid-long-term follow-up in a large cohort. Methods and results Patients (n = 554) indicated for pacemaker implantation were prospectively and consecutively enrolled and were non-randomized divided into LBBP group and RVP group. The levels of cTnT and N-terminal pro-B type natriuretic peptide were measured and compared within 2 days post-procedure between two groups. Implant characteristics, procedure-related complications, and clinical outcomes were also compared. Pacing thresholds, sensing, and impedance were assessed during procedure and follow-up. Left bundle branch pacing was feasible with a success rate of 94.8% with high incidence of LBB potential (89.9%), selective LBBP (57.8%), and left deviation of paced QRS axis (79.7%) with mean Sti-LVAT of 65.07 ± 8.58 ms. Paced QRS duration was significantly narrower in LBBP when compared with RVP (132.02 ± 7.93 vs. 177.68 ± 15.58 ms, P < 0.0001) and the pacing parameters remained stable in two groups during 18 months follow-up. cTnT elevation was more significant in LBBP when compared with RVP within 2 days post-procedure (baseline: 0.03 ± 0.03 vs. 0.02 ± 0.03 ng/mL, P = 0.002; 1 day post-procedure: 0.13 ± 0.09 vs. 0.04 ± 0.03 ng/mL, P < 0.001; 2 days post-procedure: 0.10 ± 0.08 vs. 0.03 ± 0.08 ng/mL, P < 0.001). The complications and cardiac outcomes were not significantly different between two groups. Conclusion Left bundle branch pacing was feasible in bradycardia patients associated with stable pacing parameters during 18 months follow-up. Paced QRS duration was significantly narrower than that of RVP. Though cTnT elevation was more significant in LBBP within 2 days post-procedure, the complications, and cardiac outcomes were not significantly different between two groups.

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Single-Chamber Cardiac Pacemaker Implantation in a Donkey with Complete AV Block: A Long-Term Follow-Up

Animals ◽

10.3390/ani11030746 ◽

2021 ◽

Vol 11 (3) ◽

pp. 746

Author(s):

Markéta Sedlinská ◽

Radovan Kabeš ◽

Miroslav Novák ◽

Filip Kološ ◽

Pavlína Melková

Keyword(s):

Heart Function ◽

Pacemaker Implantation ◽

Exercise Intolerance ◽

Av Block ◽

Long Term Outcome ◽

Single Chamber ◽

Ventricular Lead ◽

Complete Av Block

A five-month-old African jenny was presented with a history of exercise intolerance and syncopal episodes. Severe bradycardic arrhythmia due to a high-grade second-degree atrioventricular (AV) block with progression to complete AV block was diagnosed. The jenny underwent a transvenous single-chamber pacemaker implantation. The implantation procedure was performed in a lateral recumbency and the ventricular lead was inserted through the jugular vein. Positioning of the lead was guided by echocardiography. The pacemaker was programmed to VVI mode with a minimal ventricular rate of 40 pulses per minute, a pulse amplitude of 2.4 V, a pulse width of 0.5 ms and sensing amplitude of 2.5 mV. Short-term complications associated with the procedure included lead dislodgement and pacemaker pocket infection. The long-term outcome was satisfactory; the jenny showed improvement in heart function and quality of life after pacemaker implantation. The pulse generator replacement was performed twice (at nine-year intervals) and the intervention was always associated with a local inflammatory reaction around the pacing device. Cardiac examination 18 years after pacemaker implantation revealed no morphological changes in the heart; the electrode lead was still in the correct position and successful pacing and sensing of the ventricle were obtained. Regular follow-up checks are important to evaluate pacemaker function.

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Diffuse PRAME Expression Is Highly Specific for Thin Melanomas in the Distinction from Severely Dysplastic Nevi but Does Not Distinguish Metastasizing from Non-Metastasizing Thin Melanomas

Cancers ◽

10.3390/cancers13153864 ◽

2021 ◽

Vol 13 (15) ◽

pp. 3864

Author(s):

Maximilian Gassenmaier ◽

Matthias Hahn ◽

Gisela Metzler ◽

Jürgen Bauer ◽

Amir Sadegh Yazdi ◽

...

Keyword(s):

Prognostic Significance ◽

Diagnostic Interpretation ◽

Dysplastic Nevi ◽

Melanocytic Tumors ◽

Invasive Component ◽

Uncertain Significance ◽

Long Term Follow Up

Background: PReferentially expressed Antigen in MElanoma (PRAME) immunohistochemistry is increasingly used as diagnostic adjunct in the evaluation of melanocytic tumors. The expression and prognostic significance of PRAME in melanomas ≤1.0 mm and its diagnostic utility in the distinction from severely dysplastic compound nevi (SDN) have not been studied. Methods: We investigated and compared the immunohistochemical PRAME expression in 70 matched thin metastasizing and non-metastasizing melanomas and 45 nevi from patients with long-term follow-up (35 SDN and 10 unequivocally benign compound nevi). Results: Diffuse PRAME staining in >75% of lesional epidermal and dermal melanocytes identified 58.6% of thin melanomas but did not distinguish metastasizing from non-metastasizing melanomas (p = 0.81). A superficial atypical melanocytic proliferation of uncertain significance, in which the final diagnostic interpretation favored a SDN was the only nevus with diffuse PRAME expression (1/45). Melanomas and SDN with PRAME immunoreactivity exhibited different staining patterns. Most melanomas (67.6%) showed uniform PRAME expression in the in situ and invasive component, whereas most SDN (81.0%) showed a decreasing gradient with depth. Conclusion: Diffuse intraepidermal and dermal PRAME staining is highly specific for melanomas in the distinction from SDN. PRAME expression is not a prognostic biomarker in melanomas ≤1.0 mm.

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