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 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.
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
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.
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.
One of the challenges of left bundle branch (LBB) pacing is placing the pacing lead deep enough in the septum to reach the LBB area, yet not too deep to avoid perforation.
The purpose of this study ...was to investigate whether the occurrence of the ectopic beats with qR/rsR' morphology in lead V
(fixation beats) during lead fixation would predict whether the desired intraseptal lead depth had been reached, whereas the lack of fixation beats would indicate a too-shallow position and the need for more lead rotations.
Consecutive patients during LBB pacing device implantation were analyzed retrospectively and then prospectively with respect to the occurrence of fixation beats during each episode of lead rotation. We compared the presence of fixation beats during the lead rotation event directly before the LBB area depth was reached vs during the events before intermediate/unsuccessful positions.
A total of 339 patients and 1278 lead rotation events were analyzed. In the retrospective phase, fixation beats were observed in 327 of 339 final lead positions and in 9 of 939 intermediate lead positions (P <.001). Sensitivity, specificity, and positive and negative predictive values of the fixation beats as a marker for reaching the LBB area were 96.4%, 97.3%, 97.3%, and 96.5%, respectively. In the prospective, fixation beats-guided implantation phase, fixation beats were observed in all patients and only at the LBB capture depth.
Monitoring fixation beats during deep septal lead deployment can facilitate the procedure and possibly increase the safety of lead implantation.
Background: It is not uncommon for patients who undergo TAVI to experience conduction abnormalities that require the placement of a new permanent pacemaker PPM. However, using a comprehensive ...multi-slice computed tomography MSCT analysis can aid in predicting and planning the procedure for optimal results.Aim of the work: Our objective was to examine the MSCT predictors of conduction disturbances that necessitate PPM after TAVI.Patients and Methods: We enrolled patients who had undergone TAVI with the Evolut platform. A comprehensive MSCT analysis was conducted, which included measuring the length of the membranous septum MS, semi-quantitative analysis of the aortic leaflets, and assessment of mitral annulus calcification.Results: Among 100 patients age, 81.8±5.1 years; 32% female, median EuroSCORE II 2.81.8, 4.4, 1010% required PPM at discharge. Compared with patients who did not require a new PPM, those who did have shorter membranous septum MS length and more frequent ≥moderate mitral annular calcification.Conclusion: The length of the membranous septum and the severity of mitral annular calcification have been determined to be important factors in predicting the need for a permanent pacemaker implantation following transcatheter aortic valve implantation.
Background:This study aimed to evaluate the early outcomes of Perceval sutureless valves in the Korean population and to introduce a modified technique of guiding suture placement during valve ...deployment.Methods and Results:From December 2014 to April 2019, 121 patients (mean age: 74.7±6.2 years; 53.7% female) received a Perceval sutureless aortic valve replacement. To prevent conduction system injury, the depth of guiding suture placement (1 mm below the nadir of the annulus) was modified. All patients underwent echocardiographic evaluation at discharge and 6–12 months postoperatively, with a mean follow up of 13.7±11.2 months. Concomitant surgeries, such as coronary artery bypass grafting, and other valvular surgeries, were performed in 45.5% of cases. The mean aortic cross-clamp times for isolated and minimal procedures were 32.8±7.9, and 41.2±8.0 min, respectively. The overall transvalvular mean gradients were 13.1±3.8 mmHg at discharge and 11.5±4.7 mmHg at the last follow up. After modifying the guiding suture placement, permanent pacemaker implantation risk decreased from 9.9% to 2.5%. Cardiac-related mortality was 0.8%, with no patient developing valvular or paravalvular aortic regurgitation, valve thrombosis, or endocarditis.Conclusions:Perceval valve implantation provided a significant cardiac-related survival benefit with excellent early hemodynamic and clinical outcomes. Further research is needed to determine whether adjusting the implantation depth, such as modification of the guiding suture technique, can reduce the risk of permanent pacemaker implantation.
Abstract
Aims
High and unstable capture thresholds affect the success rate of permanent His-bundle pacing (HBP). We aimed to introduce the modified techniques during different periods and the ...corresponding success rate of HBP implantation.
Methods and results
Patients from a single centre who had intrinsic QRS < 120 ms and HBP attempts were included in the study. The success rate and pacing parameters were described for three periods based on procedural modifications, i.e. Stage 1 using the conventional HBP procedure (August 2012 to May 2013), Stage 2 with addition of the dual-lead method (June 2013 to October 2014), and Stage 3 with the further addition of stability assessment during fixation (November 2014 to October 2016). The patients with successful permanent HBP were followed. A total of 310 patients were included with the average age of 70.3 ± 10.7 years. The success rate of acute HBP was 84.85%, 98.3%, and 99.20% during Stages 1–3, respectively (P < 0.001). The permanent HBP implantation rates increased from 77.3% during Stage 1 to 85.7% during Stage 2 and 89.6% during Stage 3 (P = 0.07). The acute His-bundle capture threshold reduced from 1.30 ± 0.7 V/0.5 ms during Stage 1 to 1.11 ± 0.6 V/0.5 ms during Stage 2 and further to 0.85 ± 0.51 V/0.5 ms during Stage 3 (P < 0.001). At the 12-month follow-up, the mean change in the HBP threshold decreased from 0.60 ± 0.59 V/0.5 ms during Stage 1 to 0.33 ± 0.39 V/0.5 ms during Stage 3 (P = 0.002).
Conclusion
The HBP implantation success rate, pacing threshold, and its stability during follow-up were improved by using the dual-lead method and stability assessment techniques.
PDF
