Bates Matthew G D, Matthews Iain G, Fazal Iftikhar A, Turley Andrew J
Institute for Ageing and Health, Newcastle University, and Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne NE2 4HH, UK.
Interact Cardiovasc Thorac Surg. 2011 Feb;12(2):243-53. doi: 10.1510/icvts.2010.256578. Epub 2010 Nov 23.
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.
根据结构化方案撰写了一篇最佳证据主题。问题是确定因症状性钙化性主动脉瓣狭窄接受经导管主动脉瓣植入术（TAVI）的患者术后永久性起搏器（PPM）植入的发生率及预测因素，并将其与外科主动脉瓣置换术（AVR）后该并发症的已知风险进行比较。使用报告的检索方法共识别出3071篇文章，其中94篇与TAVI手术相关，14篇被视为代表最佳证据。所有14项研究，包括多中心注册研究和含≥30例患者的单中心回顾性病例系列，均报告了术后PPM植入的发生率。其中5项研究还评估了术后PPM植入需求的预测因素。将这些研究的作者、期刊、发表日期和国家、研究类型、证据水平、患者组、结局和结果制成表格。我们得出结论，目前可得的最佳证据表明，TAVI后PPM植入的平均发生率为14.2%（范围0 - 34%，中位数9.7%），不过使用CoreValve瓣膜假体时这一发生率似乎更高（5项研究，平均20.8%，范围9.3 - 30.0%），高于使用Edwards - Sapien瓣膜假体时（6项研究，平均5.4%，范围0 - 10.1%）。总体及使用CoreValve瓣膜假体时PPM植入的平均发生率高于传统AVR后的平均发生率7.0%（范围3 - 11.8%，中位数7.2%），这可能是由于所涉及的患者组和实施的手术存在明显差异所致。TAVI后PPM植入的指征似乎在术后早期出现，且几乎没有证据表明房室传导阻滞（AVB）后会恢复。TAVI后新发持续性左束支传导阻滞很常见，但意义及所需随访尚不清楚。TAVI后PPM需求的独立预测因素包括使用CoreValve瓣膜假体以及传导系统功能障碍的证据，即术前存在右束支传导阻滞或TAVI时存在AVB情况。应让所有患者知晓TAVI后PPM植入的高风险。
