Permanent Pacing After Transcatheter Aortic Valve Implantation: Incidence, Predictors and Evolution of Left Ventricular Function

Abstract Background: Transcatheter aortic valve implantation (TAVI) is a well-established procedure; however, atrioventricular block requiring permanent pacemaker implantation (PPI) is a common complication. Objectives: To determine the incidence, predictors and clinical outcomes of PPI after TAVI, focusing on how PPI affects left ventricular ejection fraction (LVEF) after TAVI. Methods: The Brazilian Multicenter TAVI Registry included 819 patients submitted to TAVI due to severe aortic stenosis from 22 centers from January/2008 to January/2015. After exclusions, the predictors of PPI were assessed in 670 patients by use of multivariate regression. Analysis of the ROC curve was used to measure the ability of the predictors; p 50 mm Hg (OR, 1.86; 1.08-3.2; p = 0.025) were predictors of PPI. The estimated risk of PPI ranged from 4%, when none of those predictors was present, to 63%, in the presence of all of them. The model showed good ability to predict the need for PPI: 0.69 (95%CI: 0.64 - 0.74) in the ROC curve. The substudy of 287 echocardiograms during the 1-year follow-up showed worse LVEF course in patients submitted to PPI (p = 0.01). Conclusion: BRD prévio, gradiente aórtico médio > 50 mmHg e CoreValve® são preditores independentes de implante de MPD pós-TAVI. Ocorreu implante de MPD em aproximadamente 20% dos casos de TAVI, o que prolongou a internação hospitalar, mas não afetou a mortalidade. O implante de MPD afetou negativamente a FEVE pós-TAVI.

研究背景：经导管主动脉瓣植入术（Transcatheter Aortic Valve Implantation, TAVI）是一项已广泛应用的成熟术式，但术后并发需行永久起搏器植入（Permanent Pacemaker Implantation, PPI）的房室传导阻滞是其常见并发症。研究目的：明确TAVI术后需行永久起搏器植入的发生率、预测因素及临床结局，重点探讨PPI对TAVI术后左心室射血分数（Left Ventricular Ejection Fraction, LVEF）的影响。研究方法：巴西多中心TAVI注册研究纳入2008年1月至2015年1月期间，来自22个医学中心的819例因重度主动脉瓣狭窄接受TAVI治疗的患者。经排除不符合入组标准的病例后，最终纳入670例患者，采用多因素回归分析评估PPI的独立预测因素，并通过受试者工作特征（Receiver Operating Characteristic, ROC）曲线评估各预测因素的预测效能。结果显示，术前束支传导阻滞、平均主动脉梯度>50mmHg（优势比（Odds Ratio, OR）=1.86，95%置信区间（Confidence Interval, CI）：1.08~3.2，P=0.025）为PPI的独立预测因素。PPI的发生风险可从无上述任一预测因素时的4%，升至存在全部三项预测因素时的63%。该预测模型的受试者工作特征曲线下面积为0.69（95%CI：0.64~0.74），提示其具备较好的PPI预测效能。针对287例患者术后1年随访的超声心动图亚组分析显示，接受PPI治疗的患者术后LVEF变化轨迹更差（P=0.01）。研究结论：术前束支传导阻滞、平均主动脉梯度>50mmHg及CoreValve®瓣膜为TAVI术后永久起搏器植入的独立预测因素。约20%的TAVI患者术后需行永久起搏器植入，该操作可延长患者住院时长，但对患者总体死亡率无显著影响；而永久起搏器植入会对TAVI术后左心室射血分数产生负面影响。