Impact of postprocedural permanent pacemaker implantation on clinical outcomes after transcatheter aortic valve replacement: a systematic review and meta-analysis

Abstract

Background: The incidence of conduction disturbances requiring permanent pacemaker (PPM) implantation following transcatheter aortic valve replacement (TAVR) have remained a common concern. The purpose of this study was to evaluate the impact of postprocedural PPM implantation following TAVR on clinical outcomes.

Methods: We performed a systematic search in PubMed and EMBASE databases for studies that reported raw data on clinical outcomes of patients with and without PPM implantation after TAVR and followed up patients for 10 months or longer. The primary endpoint was all-cause death. The secondary endpoints were cardiovascular death, heart failure and a composite of stroke and myocardial infarction (MI).

Results: Data from 20 studies with a total of 21,666 patients undergoing TAVR, of whom 12.5% required PPM implantation after intervention, were analysed and the mean duration follow-up was 16.9 months. The rate of PPM ranged from 6.2% to 32.8% among different studies. A total of 6,753 (31.2%) patients underwent TAVR with self-expandable prosthesis and 14,913 (68.8%) with balloon-expandable prosthesis. The incidence of postprocedural PPM implantation was higher with the self-expandable prosthesis (n=1,717, 25.4%) compared with the balloon-expandable prosthesis (n=996, 6.7%). PPM after TAVR was associated with a higher risk of all-cause death (RR: 1.13; 95% CI: 1.01-1.25; P=0.03) but not incidence of stroke and MI (RR: 0.85; 95% CI: 0.64-1.13; P=0.27).

Conclusions: In patients undergoing TAVR, the PPM implantation after intervention was associated higher all-cause mortality but not cardiovascular mortality, heart failure and stroke or MI, which remain an unsolved issue of TAVR.

Keywords: Permanent pacemaker (PPM); conduction disturbances; transcatheter aortic valve replacement (TAVR).

Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

2019 Journal of Thoracic Disease. All rights reserved.

Figures

Figure 1

Flow diagram of selected studies based on the Preferred Reported Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.

Figure 2

Risk of all-cause death in patients with new permanent pacemaker (PPM) implantation after transcatheter aortic valve replacement (TAVR).

Figure 3

Incidence of permanent pacemaker (PPM) implantation after transcatheter aortic valve replacement (TAVR) with each valve type.

Figure S1

Risk of cardiovascular death in patients with new permanent pacemaker (PPM) implantation after transcatheter aortic valve replacement (TAVR).

Figure S2

Risk of heart failure in patients with new permanent pacemaker (PPM) implantation after transcatheter aortic valve replacement (TAVR).

Figure S3

Risk of myocardial infarction (MI) and stroke in patients with new permanent pacemaker (PPM) implantation after transcatheter aortic valve replacement (TAVR).