The aim of this study was to determine the utility of rapid atrial pacing immediately after transcatheter aortic valve replacement (TAVR) to predict the need for permanent pacemaker implantation ...(PPI).
Risk stratification for patients without high-grade atrioventricular block (AVB) after TAVR is imprecise and based on anatomic considerations, electrocardiographic characteristics, and clinical suspicion. A more reliable assessment is necessary to minimize inpatient rhythm monitoring and/or reduce unnecessary PPI.
Consecutive patients undergoing TAVR at 2 centers were included. After valve implantation in patients without pacemakers who did not have complete heart block or atrial fibrillation, the temporary pacemaker was withdrawn from the right ventricle and placed in the right atrium. Rapid atrial pacing was performed from 70 to 120 beats/min, and patients were assessed for the development of Wenckebach AVB. Patients were then followed for clinical outcomes, including PPI.
A total of 284 patients were included. Of these, 130 (45.8%) developed Wenckebach AVB. There was a higher rate of PPI within 30 days of TAVR among the patients who developed Wenckebach AVB (13.1% vs. 1.3%; p < 0.001), with a negative predictive value for PPI in the group without Wenckebach AVB of 98.7%. A greater percentage of patients receiving self-expanding valves required PPI than those receiving a balloon-expandable valves (15.9% vs. 3.7%; p = 0.001), though these rates were still relatively low among patients who did not develop Wenckebach AVB (2.9% and 0.8%).
Atrial pacing post-TAVR is easily performed and can help identify patients who may benefit from extended rhythm monitoring. Patients who did not develop pacing-induced Wenckebach AVB demonstrated an extremely low likelihood of PPI.
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In case of pacemaker implantation, axillary vein puncture remains a less common technique in both domestic and foreign institutions. In our article, we present the implementation of this method in a ...center where there was no prior experience with it. During our study, dividing the patients into two groups, we retrospectively compared the success and complication rates of subclavian and axillary punctures. Based on our results, introducing the electrode through the axillary vein is equally effective and safer than subclavian puncture. It can be easily mastered even without specific training by an electrophysiologist experienced in subclavian vein cannulation.
The use of RDV in SAVR is associated with risk of conduction abnormality requiring PPM implantation, when compared to conventional bioprosthetic valves. We aimed to evaluate the outcome after ...selective placement of annular compression sutures during surgical aortic valve replacement (SAVR) using Intuity rapid deployment valve (RDV).
This is a retrospective study of prospectively enrolled patients receiving SAVR using Intuity RDV. Selective placement of commissural compression suture was assessed for all patients based on their annular morphology. Outcomes including operative mortality, rate of pacemaker rate, paravalvular leak and change in trans-valvular pressure gradient were analyzed.
56 consecutive patients underwent SAVR with the INTUITY RDV at our institution from January 2020 to November 2021. The Mean age of our cohort was 69.9 ± 10.6 years with a EuroSCORE II of 3.4 ± 2.4%. 28.6% (16/56) of patients had notable conduction abnormalities pre-operatively, which included atrial fibrillation and left/right bundle branch block. Compression sutures were selectively applied in 19/56 (33.9%) patients. Of which, 13 were bicuspid aortic valve. Post-operatively, we observed no conduction abnormality requiring PPM implantation. In addition, only 3 of the 56 (5.4%) had any degree of paravalvular leak on post-operative echocardiography (all ≤ mild). The mean reduction in trans-valvular gradient was 29.9 mmHg and the mean pressure gradient at 1 month and 1 year follow-up were 9.3 ± 3.6 mmHg and 10.2 ± 4.1 mmHg, respectively.
Selective placement of compression suture helps to avoid unnecessary oversizing, which may reduce the risk of paravalvular leak and post-operative PPM implantation.
The aims of this study is to assess by an updated meta-analysis the clinical outcomes related to permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) at ...long-term (≥12 months) follow-up (LTF).
A comprehensive literature research was performed on PubMed and EMBASE. The primary endpoint was all-cause death. Secondary endpoints were rehospitalization for heart failure, stroke, and myocardial infarction. A subgroup analysis was performed according to the Society of Thoracic Surgeon-Predicted Risk of Mortality (STS-PROM) score. This study is registered with PROSPERO (CRD42021243301). A total of 51 069 patients undergoing TAVI from 31 observational studies were included. The mean duration of follow-up was 22 months. At LTF, PPI post-TAVI was associated with a higher risk of all-cause death risk ratio (RR) 1.18, 95% confidence interval (CI) 1.10-1.25; P < 0.001 and rehospitalization for heart failure (RR 1.32, 95% CI 1.13-1.52; P < 0.001). In contrast, the risks of stroke and myocardial infarction were not affected. Among the 20 studies that reported procedural risk, the association between PPI and all-cause death risk at LTF was statistically significant only in studies enrolling patients with high STS-PROM score (RR 1.25, 95% CI 1.12-1.40), although there was a similar tendency of the results in those at medium and low risk.
Patients necessitating PPI after TAVI have a higher long-term risk of all-cause death and rehospitalization for heart failure as compared to those who do not receive PPI.
Local anesthetics are commonly deployed for a variety of medical procedures across many disciplines. Systemic toxicity is rarely seen in clinical practice, and quick recognition and how to manage ...this syndrome are crucial. The development of systemic toxicity is influenced by the site of administration, the type of anesthetic used, and the total dose administered. Local anesthetic systemic toxicity (LAST) syndrome is used as a diagnosis to encompass the cardiovascular and pulmonary adverse effects associated with the intradermal and subcutaneous use of local anesthetics-in our case, lidocaine. We present a case of a 37-year-old man who experienced dysarthria, bilateral arm shaking, and sinus tachycardia following the administration of 70 mL of lidocaine 2% during surgery for dual-chamber pacemaker placement. While some form of allergic reaction remained a possibility, the strongest clinical correlation and diagnosis were attributed to LAST.
Abstract
Aims
Atrioventricular block (AVB) of unknown aetiology is rare in the young, and outcome in these patients is unknown. We aimed to assess long-term morbidity and mortality in young patients ...with AVB of unknown aetiology.
Methods and results
We identified all Danish patients younger than 50 years receiving a first pacemaker due to AVB between January 1996 and December 2015. By reviewing medical records, we included patients with AVB of unknown aetiology. A matched control cohort was established. Follow-up was performed using national registries. The primary outcome was a composite endpoint consisting of death, heart failure hospitalization, ventricular tachyarrhythmia, and cardiac arrest with successful resuscitation. We included 517 patients, and 5170 controls. Median age at first pacemaker implantation was 41.3 years interquartile range (IQR) 32.7–46.2 years. After a median follow-up of 9.8 years (IQR 5.7–14.5 years), the primary endpoint had occurred in 14.9% of patients and 3.2% of controls hazard ratio (HR) 3.8; 95% confidence interval (CI) 2.9–5.1; P < 0.001. Patients with persistent AVB at time of diagnosis had a higher risk of the primary endpoint (HR 10.6; 95% CI 5.7–20.0; P < 0.001), and risk was highest early in the follow-up period (HR 6.8; 95% CI 4.6–10.0; P < 0.001, during 0–5 years of follow-up).
Conclusion
Atrioventricular block of unknown aetiology presenting before the age of 50 years and treated with pacemaker implantation was associated with a three- to four-fold higher rate of the composite endpoint of death or hospitalization for heart failure, ventricular tachyarrhythmia, or cardiac arrest with successful resuscitation. Patients with persistent AVB were at higher risk. These findings warrant improved follow-up strategies for young patients with AVB of unknown aetiology.
Graphical Abstract
Atrioventricular block of unknown aetiology presenting before the age of 50 years and treated with pacemaker implantation was associated with a three- to four-fold higher rate of the composite endpoint of death or hospitalization for heart failure, ventricular tachyarrhythmia, or cardiac arrest with successful resuscitation. CI, confidence interval.
Objective: Tricuspid annuloplasty is associated with increased risk of atrioventricular block and subsequent implantation of a permanent pacemaker. However, the exact incidence of permanent ...pacemaker, associated risk factors, and outcomes in this frame remain debated. The aim of the study was to report permanent pacemaker incidence, risk factors, and outcomes after tricuspid annuloplasty from nationwide databases. Methods: By using data from multiple Swedish mandatory national registries, all patients (n = 1502) who underwent tricuspid annuloplasty in Sweden from 2006 to 2020 were identified. Patients who needed permanent pacemaker within 30 days from surgery were compared with those who did not. The cumulative incidence of permanent pacemaker implantation was estimated. A multivariable logistic regression model was fit to identify risk factors of 30-day permanent pacemaker implantation. The association between permanent pacemaker implantation and long-term survival was evaluated with multivariable Cox regression. Results: The 30-day permanent pacemaker rate was 14.2% (214/1502). Patients with permanent pacemakers were older (69.8 ± 10.3 years vs 67.5 ± 12.4 years, P = .012). Independent risk factors of permanent pacemaker implantation were concomitant mitral valve surgery (odds ratio, 2.07; 95% CI, 1.34-3.27), ablation surgery (odds ratio, 1.59; 95% CI, 1.12-2.23), and surgery performed in a low-volume center (odds ratio, 1.85; 95% CI, 1.17-2.83). Permanent pacemaker implantation was not associated with increased long-term mortality risk (adjusted hazard ratio, 0.74; 95% CI, 0.53-1.03). Conclusions: This nationwide study demonstrated a high risk of permanent pacemaker implantation within 30 days of tricuspid annuloplasty. However, patients who needed a permanent pacemaker did not have worse long-term survival, and the cumulative incidence of heart failure and major adverse cardiovascular events was similar to patients who did not receive a permanent pacemaker.
The implantation of rapid-deployment aortic valves may interfere with the conduction system of the heart. This study evaluates the occurrence and predictive factors of conduction anomalies in ...patients undergoing surgical aortic valve replacement (SAVR) with a rapid-deployment balloon-expandable bioprosthesis in a single-center, real-world experience.
Between May 2010 and April 2019, 700 consecutive patients were included in a prospective, ongoing database with a longitudinal follow-up preoperatively, at discharge, and at 3 months, 1 year, 3 years, and 5 years postoperatively. Thirty-seven patients (5.3%) had a permanent pacemaker at baseline and were excluded from further analysis, leaving 663 patients for analysis. Assessment of conduction anomalies was performed by electrocardiography (ECG) monitoring and repeated 12-lead ECG during the hospital stay and at postoperative follow-ups.
Preoperatively, 126 patients (19.0%) presented with different conduction disturbances. New permanent pacemaker implantation (PPI) occurred in 61 patients during the first 14 days (cumulative incidence, 9.4%). The indication for PPI was complete atrioventricular block in 47 cases (77%). Preoperative conduction anomalies, such as right bundle branch block, as well as operative characteristics (concomitant procedures) were found to be independent predictors for new PPI. One-year survival was 98% in patients with new early PPI and 96% in those without new early PPI (P = .60).
The PPI rate was in the range of previous reports for rapid-deployment prostheses. PPI did not have a significant influence on short- to intermediate-term survival. Case selection with exclusion of patients presenting with baseline conduction disturbances may decrease the rate of new PPIs after SAVR with rapid-deployment balloon-expandable bioprostheses.
Conduction disturbances after rapid-deployment aortic valve replacement: incidence and anatomic considerations. The expansion of the subannular stent within the left ventricular outflow tract in the proximity of the left bundle branch (black arrows) may exert compression to the conduction system and influence the occurrence of postoperative conduction disturbances. SA, sinoatrial; AV, atrioventricular; PPI, permanent pacemaker implantation; LBBB, left bundle branch block; RBBB, right bundle branch block, AVB, I, first-degree atrioventricular block; AVB II, second-degree atrioventricular block. Display omitted
Background
The need for new permanent pacemaker implantation (PPI) after Transcatheter Aortic Valve Implantation (TAVI) remains a critical issue. Membranous Septum (MS) length is associated with PPI ...after TAVI. The aim of this study was to identify different MS thresholds for the contemporary THV-platforms.
Methods
This retrospective, case-control study enrolled all patients who underwent a successful TAVI procedure with contemporary THV-platforms in the Erasmus University Medical Center between January 2016 and March 2020. The follow-up period for new PPI was 30 days. MS-length was determined by Computed Tomography.
Results
The study consisted 653 TAVI patients with median age 80.6 years (IQR 74.7–84.8). New PPI occurred in 120 patients (18.4%). Patients with new PPI had a shorter MS-length (2.9 mm (IQR 2.3–4.3) vs. 4.2 mm (IQR 2.9–5.7), p < 0.001). MS-length < 3 mm identified a high-risk phenotype with 30.3% PPI-rate (OR 6.5 95%CI 2.9–14.9), MS-length 3–6 mm an intermediate-risk phenotype with 15.4% PPI-rate (OR 2.7 95%CI 1.2–6.2) and MS > 6 mm a low-risk phenotype with a 6.3% PPI-rate (reference). For the Lotus valve, there was no significant difference in PPI-rates between the high-risk (45.8%, OR 3.5 95%CI 0.8–15.1) and low-risk group (20%).
By multivariate analysis MS-length, Agatston-score, use of Lotus valve, and ECG with first-degree AV block, RBBB or bifascular block were independent predictors for new PPI.
Conclusion
MS-length was an independent predictor for new PPI post-TAVI. Three phenotypes were found based on MS-length. MS < 3 mm was universally associated with a high risk for new PPI (>30%). MS > 6 mm represented a low-risk phenotype with PPI-rate < 10%. PPI-rate varied per THV type in the intermediate phenotype. PPI-rate with Lotus was high regardless of MS-length.
•The length of the membranous interventricular septum is an independent predictor for pacemaker implantation post-TAVI.•MS length is an argument to choose between the different valve platforms to minimize the risk for new pacemaker post-TAVI.•MS length < 3 mm gives a high risk for pacemaker (>30%) regardless of the valve platform.•The pacemaker-rate varied per valve platform by a MS length > 3 mm.
Pacemaker (PPM) implantation is indicated for conduction abnormalities which can develop post-transcatheter aortic valve replacement (TAVR). However, whether post-TAVR PPM risk is associated with the ...geographical location of the hospital and socioeconomic status of the patient is not well established. Our goal was to explore geographical and socioeconomic disparities in post-TAVR PPM implantation.
A retrospective cohort analysis was conducted using the National Inpatient Sample 2016–2020 with respective ICD-10 codes for TAVR and PPM implantation. A weighted multivariate logistic regression model was used to analyze prognostic outcomes.
The number of patients hospitalized for undergoing TAVR was 296,740, out of which 28,265 patients had PPM implantation (prevalence 9.5 %). Patients' demographics including sex, ethnicity, household income, and insurance were not associated with risk of post-TAVR PPM except age (OR 1.01, CI 1.07–12.5, p < 0.001). Compared to rural hospitals, urban non-teaching hospitals were associated with a higher risk of post-TAVR PPM (OR 2.09, 1.3–3.43, p = 0.003). Compared to New England hospitals (ME, NH, VT, MA, RI, CT), middle Atlantic hospitals (NY, NJ, PA) were associated with highest post-TAVR PPM risk (OR 1.54, CI 1.2–1.98, p < 0.001), followed by Pacific (AK, WA, OR, CA, HI), mountain (ID, MT, WY, NV, UT, CO, AZ, NM) and east north central US.
Patients' demographics including sex, ethnicity, household income, and insurance were not associated with the risk of post-TAVR PPM except for age. Compared to New England hospitals, Middle Atlantic hospitals were associated with the highest post-TAVR PPM risk followed by Pacific, Mountain, and East North Central US. Prospective studies with data on TAVR wait times, expertise of the interventional staff, and post-TAVR management and discharge planning are required to further explore the observed regional distribution of TAVR outcomes.
•Patient’s demographics and socioeconomic status are not associated with the risk of post-TAVR pacemaker except for age.•Compared to New England hospitals, Middle Atlantic hospitals are associated with the highest post-TAVR PPM risk.•Pacific, Mountain, and East North Central US hospitals are also associated with higher post-TAVR PPM risk than New England.
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