Schernthaner Christiana, Kraus Johannes, Danmayr Franz, Hammerer Matthias, Schneider Jens, Hoppe Uta C, Strohmer Bernhard
Department of Cardiology, Paracelsus Medical University, Salzburger Landeskliniken, Muellner Hauptstrasse 48, 5020, Salzburg, Austria.
Department of Cardiac Surgery, Paracelsus Medical University, Salzburger Landeskliniken, Muellner Hauptstrasse 48, 5020, Salzburg, Austria.
Wien Klin Wochenschr. 2016 Mar;128(5-6):198-203. doi: 10.1007/s00508-015-0906-4. Epub 2016 Jan 8.
Transcatheter aortic valve implantation (TAVI) is a less invasive technique for the treatment of severe aortic stenosis in high-risk patients. Occurrence of conduction disturbances requiring permanent pacemaker (PPM) implantation after TAVI is frequently observed.
The retrospective analysis comprised 153 patients (96 women, aged from 65 to 97 years) who underwent TAVI due to high-grade aortic stenosis. The aim was to evaluate the incidence of high-grade atrioventricular (AV) block after TAVI and the percentage of ventricular pacing and pacemaker (PM)-dependency at the first follow-up 6-8 weeks after implantation.
Out of the 153 patients (age 81 ± 6 years) who underwent TAVI, 144 (94 %) had a transfemoral and 9 (6 %) patients a transapical approach. A PPM was implanted in 31 (20 %) patients, 24 (16 %) were implanted with the Medtronic CoreValve® and 7 (5 %) with the Edwards Sapien® valve (p = n.s.). Complete AV block was the indication in 21 patients (68 %), second-degree AV block in 1 patient (3 %), slow atrial fibrillation in 3 patients (10 %), new left bundle branch block (LBBB) plus sustained ventricular tachycardia (VT) in 1 patient (3 %), sick sinus syndrome in 2 patients (7 %), whereas in 3 patients (10 %) a PPM was inserted for safety reasons because of new LBBB and first-grade AV block. All of the nine patients (6 %) with a preexisting bundle branch block developed total AV block after TAVI. At follow-up PM-dependency (intrinsic rhythm < 30 bpm) occurred in 11/30 patients (37 %), whereas an intrinsic rhythm > 50 bpm was seen in 17 patients (57 %). At nominal device programming the percentage of ventricular stimulation (VP) during the short-term observation period was 60 ± 44 % in dual-chamber devices (N = 18), and 70 ± 36 % in single-chamber PPM (N = 5).
The PPM implantation rate of about 20 % after TAVI is comparable to previously published data. The need for permanent pacing is linked to the valve type and preexistence of a right bundle branch block. At short-term more than half of the patients implanted with a device were not strictly PM-dependent, but presented an underlying intrinsic rhythm, indicating that temporary AV conduction disturbances may recover over time. This might justify a more conservative approach in some patients under watchful waiting. From another point of view, ventricular pacing at a regular or sensor-modulated rate may provide rhythm stability and chronotropy during the short-term period post-TAVI.
经导管主动脉瓣植入术（TAVI）是一种用于治疗高危患者严重主动脉瓣狭窄的侵入性较小的技术。TAVI术后经常观察到需要植入永久起搏器（PPM）的传导障碍的发生。
回顾性分析包括153例（96名女性，年龄65至97岁）因重度主动脉瓣狭窄接受TAVI的患者。目的是评估TAVI术后高度房室（AV）阻滞的发生率以及植入后6 - 8周首次随访时心室起搏和起搏器（PM）依赖的百分比。
在153例接受TAVI的患者（年龄81±6岁）中，144例（94%）采用经股动脉途径，9例（6%）采用经心尖途径。31例（20%）患者植入了PPM，24例（16%）植入了美敦力CoreValve®，7例（5%）植入了爱德华兹Sapien®瓣膜（p = 无显著差异）。21例患者（68%）的植入指征为完全性AV阻滞，1例患者（3%）为二度AV阻滞，3例患者（10%）为缓慢型心房颤动，1例患者（3%）为新发左束支传导阻滞（LBBB）加持续性室性心动过速（VT），2例患者（7%）为病态窦房结综合征，而3例患者（10%）因新发LBBB和一度AV阻滞出于安全原因植入了PPM。所有9例（6%）术前存在束支传导阻滞的患者在TAVI术后均发生了完全性AV阻滞。随访时，11/30例患者（37%）出现PM依赖（固有心律<30次/分），而17例患者（57%）固有心律>50次/分。在名义设备编程时，双腔设备（N = 18）在短期观察期内心室刺激（VP）的百分比为60±44%，单腔PPM（N = 5）为70±36%。
TAVI术后约20%的PPM植入率与先前发表的数据相当。永久起搏的需求与瓣膜类型和右束支传导阻滞的术前存在有关。在短期内，超过一半植入设备的患者并非严格依赖PM，而是存在潜在的固有心律，这表明暂时性AV传导障碍可能会随时间恢复。这可能证明在一些密切观察的患者中采取更保守的方法是合理的。从另一个角度来看，以规则或传感器调制的速率进行心室起搏可能在TAVI术后短期内提供节律稳定性和变时性。
