Postoperative permanent pacemaker implantation in patients undergoing trans-catheter aortic valve implantation: what is the incidence and are there any predicting factors?

A best evidence topic was written according to a structured protocol. The issue was to determine the incidence and predictors of postoperative permanent pacemaker (PPM) implantation in patients undergoing trans-catheter aortic valve implantation (TAVI) for symptomatic calcific aortic stenosis and to compare this to the known risks of this complication following surgical aortic valve replacement (AVR). Using the reported search method 3071 articles were identified, of which 94 were relevant to the procedure of TAVI and 14 were deemed to represent the best evidence. All 14 studies, including both multi-centre registries and single-centre retrospective case series containing ≥30 patients, reported incidence of postoperative PPM implantation. Five of these studies also assessed predictors of the need for postoperative PPM implantation. The author, journal, date and country of publication, study type, level of evidence, patient group, outcomes and results were tabulated for these studies. We conclude that the current best available evidence suggests that the mean incidence of PPM implantation following TAVI is 14.2% (range 0-34%, median 9.7%), although this appears higher with the CoreValve prosthesis (five studies, mean 20.8%, range 9.3-30.0%) than with the Edwards-Sapien prosthesis (six studies, mean 5.4%, range 0-10.1%). The mean incidences of PPM implantation overall and when using the CoreValve prosthesis are higher than the mean incidence of 7.0% (range 3-11.8%, median 7.2%) following conventional AVR and may be explained by distinct differences between the patient groups involved and the procedure performed. Indications for PPM implantation appear to occur early in the postoperative period following TAVI and there is little evidence of recovery following atrioventricular block (AVB). New onset persistent left bundle branch block is common following TAVI but the significance and follow-up required is unclear. Independent predictors of PPM requirement following TAVI include use of the CoreValve prosthesis and evidence of conduction system dysfunction, either pre-existing right bundle branch block or AVB at the time of TAVI. All patients should be made aware of the high risk of PPM implantation with TAVI.