Invasive electrophysiological testing to predict and guide permanent pacemaker implantation after transcatheter aortic valve implantation: A meta-analysis

Konstantinos C Siontis; Abdalla Kara Balla; Yong-Mei Cha; Thomas Pilgrim; Romy Sweda; Laurent Roten; Tobias Reichlin; Paul A Friedman; Stephan Windecker; George C M Siontis

doi:10.1016/j.hroo.2022.10.007

Invasive electrophysiological testing to predict and guide permanent pacemaker implantation after transcatheter aortic valve implantation: A meta-analysis

Heart Rhythm O2. 2022 Oct 22;4(1):24-33. doi: 10.1016/j.hroo.2022.10.007. eCollection 2023 Jan.

Affiliations

¹ Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
² Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland.

Abstract

Background: Atrioventricular conduction abnormalities after transcatheter aortic valve implantation (TAVI) are common. The value of electrophysiological study (EPS) for risk stratification of high-grade atrioventricular block (HG-AVB) and guidance of permanent pacemaker (PPM) implantation is poorly defined.

Objective: The purpose of this study was to identify EPS parameters associated with HG-AVB and determine the value of EPS-guided PPM implantation after TAVI.

Methods: We performed a systematic review and meta-analysis of studies investigating the value of EPS parameters for risk stratification of TAVI-related HG-AVB and for guidance of PPM implantation among patients with equivocal PPM indications after TAVI.

Results: Eighteen studies (1230 patients) were eligible. In 7 studies, EPS was performed only after TAVI, whereas in 11 studies EPS was performed both before and after TAVI. Overall PPM implantation rate for HG-AVB was 16%. AV conduction intervals prolonged after TAVI, with the AH and HV intervals showing the largest magnitude of changes. Pre-TAVI HV >70 ms and the absolute value of the post-TAVI HV interval were associated with subsequent HG-AVB and PPM implantation with odds ratios of 2.53 (95% confidence interval [CI] 1.11-5.81; P = .04) and 1.10 (95% CI 1.03-1.17; P = .02; per 1-ms increase), respectively. In 10 studies, PPM was also implanted due to abnormal EPS findings in patients with equivocal PPM indications post-TAVI (typically new left bundle branch block or transient HG-AVB). Among them, the rate of long-term PPM dependency was 57%.

Conclusion: Selective EPS testing may assist in the risk stratification of post-TAVI HG-AVB and in the guidance of PPM implantation, especially in patients with equivocal PPM indications post-TAVI.

Keywords: Aortic stenosis; Electrophysiological study; Permanent pacemaker; Risk stratification; Transcatheter aortic valve implantation.