Cardiologie clinique et expérimentale
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An Approach for the Management of Risk Factors for Permanent Pacemaker Implantation Following Transcather Aortic Valve Replacement in Severe Aortic Stenosis Patients

Wesley R. Pedersen*, Christopher W. Pedersen, Irvin F. Goldenberg

Clinical Practice Guidelines have not yet been developed for the evaluation and management of risk factors associated with Permanent Pacemaker (PPM) implantation following Transcatheter Aortic Valve Replacement (TAVR) in patients with severe Aortic Stenosis (AS). Sufficient gaps in adequate data have resulted in a variety of valve center biases, small retrospective studies and consensus documents. TAVR is now more common in the US than Surgical Aortic Valve Replacement (SAVR) and the importance of establishing guideline therapy for this persistent major complication in FDA approved TAVR therapies is substantial. The thirty day PPM rate was 10.9% during the period of 2011-2013 and 10.8% in 2019 was highlighted in a recent publication tracking TAVR outcomes using FDA approved devices. Continued improvements in TAVR technology and technique along with the increasing experience in TAVR operators and valve team members have not changed this paradigm. We have gained some improvement in our understanding of Atrial Ventricular (AV) conduction abnormalities as it relates to segmental cardiac anatomy and procedural variables. Our approach to the management of post-TAVR patients at risk for PPM implantation nevertheless remains heterogenous. This review offers a proposed template for the evaluation and management of risk factors for PPM implantation following TAVR. Relevant risk factors are generally conduction defects that include High Grade AV Block or Complete Heart Block (HAVB/CHB). Risk factors for PPM implantation can be categorized into pre, intra or post-procedural findings and generally detected as conduction defects on pre or post TAVR ElectroCardiogram (ECG), telemetry, Ambulatory ECG Monitoring (AEM), ElectroPhysiologic Studies (EPS) post-TAVR, anatomic characteristics by cardiac computerized tomography screening of the para aortic valve region and procedural characteristics. A more homogenous approach needs to be driven by more definitive prospectively randomized data and less reliant on retrospective studies and anecdotal experiences. In the interim professional societies have suggested management pathways for patients at risk for post-TAVR PPM. Nevertheless in the absence of these data and formal Clinical Guidelines, the authors offer a tailored strategy described in this manuscript