Risk Factors For Permanent Pacemaker After Minimally Invasive Replacement With Rapid Deployment Valve
Joshua Gustafson, Elaine Tseng.
San Francisco Veteran's Administration Medical Center, San Francisco, CA, USA.
Backrground- Surgical and transcatheter aortic valve replacement (AVR) differ in their risk of permanent pacemaker (PPM) implantation. The EDWARDS INTUITY Elite aortic valve (Edwards Lifesciences, Irvine, CA) is a hybrid between the surgical PERIMOUNT MagnaEase (Edwards Lifesciences) pericardial valve, using 3 annular sutures but with annular fixation using stent features similar to SAPIEN transcatheter valve system (Edwards Lifesciences). Prior studies have suggested PPM higher than surgical but lower than transcatheter valves. Our objective was to determine incidence and risk factors of PPM in the veteran population. Methods- We performed a retrospective review of rapid deployment minimally invasive AVR starting from October 2016 to October 2019 at a Veterans Affairs medical center. 75 rapid-deployment AVRs were performed as an isolated or concomitant procedure. Four patients who underwent a concurrent MAZE procedure were excluded from analysis. PPM implantation was implanted based on electrophysiology consensus. Patient characteristics and electrocardiograms were used to gather data from all patients. Statistical analysis determined risk factors for PPM implantation. Results- Rapid-deployment valves (n=75) were surgically implanted, 63 via mini-sternotomy. Eight pacemakers (10.6%) were implanted within 30 days of surgery. In patients requiring PPM implantation, baseline conduction abnormalities were present in 50% versus 22% in patients without PPM (OR 4.4, CI 0.99-19.62). New-onset ventricular conduction abnormalities, including left bundle branch block, right bundle branch block and intraventricular conduction delay had an increased risk of PPM (OR 2.58, CI 0.49-13.73). QRS widening immediately postoperatively from baseline QRS length in patients requiring PPM versus those that did not averaged 50.8ms versus 19.1ms (p=0.003). No statistical difference was found in any other ECG interval. No patient descriptive variable was found to be a risk factor. Conclusions- Our data on rapid-deployment valves in veterans showed a lower risk of permanent pacemaker implantation than the original studies showed, 10.6% vs 13.6%. Risk factors for PPM implantation included pre-existing baseline conduction abnormalities, new-onset ventricular conduction abnormalities, and QRS widening from baseline greater than 50ms.
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