Tick Tock timing of permanent pacemaker implantation after transcatheter aortic valve replacement. A single center review

FUNDING ACKNOWLEDGEMENTS: Type of funding sources: None. BACKGROUND: Permanent pacemaker implantation (PPI) for high degree atrio-ventricular block (AVB) is common in patients after transcatheter aortic valve replacement (TAVR). There is still no clear recommendation regarding the optimal timing of PPI and programming of the pacemakers (PM) in these patients. METHODS: Data of all 1363 patients who underwent TAVR in our center between July 2019 and September 2022 was included in this retrospective study. In patients with high degree AVB a PPI was performed either in the same procedure or at least within 24 h after TAVR. All patients underwent a PM-interrogation before discharge. RESULTS: A permanent PM was implanted in 122 of 1363 (9%) patients with a mean age of 82 years. AVB that required PPI occurred in 9.2% (100/1087) of the patients with a self-expandable (SE) valve and in 8% (22/276) of the patients with a balloon expandable (BE) valve. In 34 patients PPI was performed in the same TAVR procedure, and 88 patients were treated in an average of 3.5 days after TAVR. Right-sided PM was implanted in 27 out of the 34 (79.4%) intra-procedural cases and in 3 of the 88 (3.4%) post-procedural cases. No major complications were reported. Two revision procedures were performed due to lead dislodgements in both groups respectively [(2/34 (5.9%); 2/88 (2.3%)]. Two pneumothoraces (2/88, 2.3%) were reported in the post-procedural PPI patients. The overall complication rate was 4.9 % (6/122). The AV-conduction showed recovery in 37 Patients (37/122, 30%) during the first interrogation in an average of 2.1 days after TAVR [(9/34(26.5%); 28/88 (31.8%)]. The AV-hysteresis was programmed in 48 out of the 94 implanted dual chamber pacemakers during the first interrogation. The average length of stay in hospital in patients with intra-procedural PPI and in those who underwent PPI in a second procedure was 13.7 and 14 days respectively with no significant difference between both groups (p>0.05). CONCLUSION: Intra-procedural PPI was not associated with significant reduction of in hospital stay. The percentage of AV-conduction recovery after TAVR was high, even in short term follow up. Patients could benefit from a longer monitoring to avoid PPI and programming of AV-hysteresis during the first interrogation in these population should be recommended. Randomized and long-term follow up data are needed.