Introduction In patients undergoing transcatheter aortic valve implantation (TAVI), right bundle branch block (RBBB) is a strong predictor of the development of high-grade AV block (AVB). We assessed mortality and length of hospital stay in patients with RBBB undergoing TAVI according to whether they had had pre-procedural permanent pacemaker implantation.
Methods and Results Consecutive patients undergoing TAVI for severe aortic stenosis at a single centre between 2009 – 2021 were screened for the presence of RBBB and formed the study cohort. The endpoints were mortality at 30 days and 5 years, and in-hospital length of stay. 1684 patients (median age 83 [79 – 87] years; 32% female) were screened, of whom 121 (7.2%) had RBBB. 41 (33.9%) patients received a prophylactic PPM by clinical preference. Of the remaining 80, 45 (56%) patients received a PPM after TAVI. Baseline demographic and procedural characteristics were similar. Among those patients in sinus rhythm who had a prophylactic PPM, the PR interval was longer than in those who did not receive a prophylactic pacemaker (200 ms [170 – 228] vs. 175 ms [158 – 196]; p=0.05). Similarly, the QRS duration was longer (140 ms [126 – 156] vs. 131 ms [120 – 142]; p=0.01). There was numerically but not statistically more left anterior hemi-block (24 [62%] vs. 29 [45%]; p=0.10). All-cause mortality was similar at 5 years with death in 17 patients (41.4%) in the prophylactic PPM group vs. 27 (33.8%) in the no prophylactic PPM group; hazard ratio 1.27 (95% CI 0.69 to 2.33; p=0.44; Figure 1). In the no prophylactic PPM group 16 (35.6%) deaths occurred in those receiving PPM after TAVI and 11 (31.4%) in those not receiving PPM; hazard ratio 0.95 (95% CI 0.43 to 2.09; p=0.90). 30-day all-cause mortality was also similar with 2 deaths (5.3%) occurring in the prophylactic group vs. 5 deaths (6%) in those without a prophylactic PPM, 3 (8.6%) of which were in those not receiving PPM and 2 (4.4%) receiving PPM after TAVI. There was a trend to a reduced hospital length of stay in those receiving prophylactic PPM compared to those who either received a post TAVI PPM or who were discharged without PPM (2.5 (1.6) days vs. 4.0 (4.8) days, respectively; p = 0.08). When comparing the prophylactic PPM group to those who received PPM after TAVI, there was a statistically significant reduction in length of stay (2.5 [1.6] vs. 4.3 [4.5] days, respectively; p=0.02; Figure 2). Two patients in the prophylactic PPM group developed a pocket haematoma managed non-operatively.
Conclusions Over half of patients with RBBB undergoing TAVI require a pacemaker after their valve implant for high-grade AV block. A prophylactic pacing strategy in this high-risk cohort is safe and reduces length of hospital stay.
Conflict of Interest None
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