Section of Interventional Cardiology, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Section of Interventional Cardiology, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
JACC Cardiovasc Interv. 2020 May 11;13(9):1046-1054. doi: 10.1016/j.jcin.2020.01.215. Epub 2020 Apr 15.
The aim of this study was to determine the utility of rapid atrial pacing immediately after transcatheter aortic valve replacement (TAVR) to predict the need for permanent pacemaker implantation (PPI).
Risk stratification for patients without high-grade atrioventricular block (AVB) after TAVR is imprecise and based on anatomic considerations, electrocardiographic characteristics, and clinical suspicion. A more reliable assessment is necessary to minimize inpatient rhythm monitoring and/or reduce unnecessary PPI.
Consecutive patients undergoing TAVR at 2 centers were included. After valve implantation in patients without pacemakers who did not have complete heart block or atrial fibrillation, the temporary pacemaker was withdrawn from the right ventricle and placed in the right atrium. Rapid atrial pacing was performed from 70 to 120 beats/min, and patients were assessed for the development of Wenckebach AVB. Patients were then followed for clinical outcomes, including PPI.
A total of 284 patients were included. Of these, 130 (45.8%) developed Wenckebach AVB. There was a higher rate of PPI within 30 days of TAVR among the patients who developed Wenckebach AVB (13.1% vs. 1.3%; p < 0.001), with a negative predictive value for PPI in the group without Wenckebach AVB of 98.7%. A greater percentage of patients receiving self-expanding valves required PPI than those receiving a balloon-expandable valves (15.9% vs. 3.7%; p = 0.001), though these rates were still relatively low among patients who did not develop Wenckebach AVB (2.9% and 0.8%).
Atrial pacing post-TAVR is easily performed and can help identify patients who may benefit from extended rhythm monitoring. Patients who did not develop pacing-induced Wenckebach AVB demonstrated an extremely low likelihood of PPI.
本研究旨在确定经导管主动脉瓣置换术（TAVR）后即刻行快速心房起搏预测是否需要植入永久性起搏器（PPI）的效用。
TAVR 后无高度房室传导阻滞（AVB）的患者的风险分层不精确，主要基于解剖考虑、心电图特征和临床怀疑。需要更可靠的评估以减少住院期间的节律监测和/或减少不必要的 PPI。
连续纳入在 2 个中心接受 TAVR 的患者。在未植入起搏器且无完全性心脏阻滞或心房颤动的患者中，将临时起搏器从右心室取出并放置在右心房。以 70-120 次/分的速度进行快速心房起搏，并评估患者出现 Wenckebach AVB 的情况。然后对患者进行临床结局随访，包括 PPI。
共纳入 284 例患者，其中 130 例（45.8%）出现 Wenckebach AVB。发生 Wenckebach AVB 的患者 TAVR 后 30 天内 PPI 发生率更高（13.1% vs. 1.3%；p < 0.001），而在未发生 Wenckebach AVB 的患者中，PPI 的阴性预测值为 98.7%。接受自膨式瓣膜的患者需要 PPI 的比例高于接受球囊扩张式瓣膜的患者（15.9% vs. 3.7%；p = 0.001），但在未发生 Wenckebach AVB 的患者中，这些比例仍然相对较低（2.9%和 0.8%）。
TAVR 后行心房起搏易于操作，并可帮助识别可能受益于延长节律监测的患者。未发生起搏诱导性 Wenckebach AVB 的患者植入 PPI 的可能性极低。
