Delaying pacemaker implantation to 14 days after ASA reduced unnecessary PMI in periprocedural CAVB cases from 20.3% to 1.7% (p=0.003) without adverse events.
Does a delayed strategy for pacemaker implantation (postoperative day 14) reduce unnecessary pacemaker implantations compared to a conventional strategy (postoperative day 7) in patients with complete atrioventricular block after alcohol septal ablation?
Extending the observation period to 14 days before pacemaker implantation in patients with complete AV block after alcohol septal ablation significantly reduces unnecessary pacemaker placements without increasing adverse events.
Absolute Event Rate: 0% vs 0%
Abstract Background Complete atrioventricular block (CAVB) is a common complication following alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM). CAVB occurs because the proximal septal branch, the target artery in ASA, supplies a critical part of the interventricular conduction system. As a result, 10%–15% of patients undergoing ASA require pacemaker implantation (PMI). Although PMI is generally performed when CAVB persists for 7 days following ASA, atrioventricular (AV) conduction disturbances often recover over time, even after PMI, leading some patients to become non-dependent on the pacemaker. The optimal timing of PMI remains unclear. In our institution, we have been trying to extend the observation period before PMI to avoid unnecessary PMI. Purpose The aim of this study was to investigate the most appropriate timing of PMI in patients who develop periprocedural CAVB after ASA. Methods Consecutive 59 patients (mean age 66 years, 81% female) who developed periprocedural CAVB from 293 patients who underwent ASA at our institution between January 1998 and December 2023, after excluding those with pre-existing cardiac implantable electronic devices and insufficient follow-up data were retrospectively enrolled and the timing of PMI and recovery of AV conduction were investigated. To determine the optimal timing of PMI following periprocedural CAVB, we compared pacing dependency 1 year after ASA between two hypothetical strategies: the conventional strategy, assuming PMI on postoperative day (POD) 7, and the delayed strategy, assuming PMI on POD 14. Results Among the 59 patients, PMI was performed in 8 cases (2 cases on POD 7-14 and 6 cases after POD 14) and 51 cases showed recovered AV conduction. In most patients with recovered AV conduction, improvement was observed on the day of ASA; however, 12 patients (24%) showed delayed recovery, with AV conduction improvement after POD 7 (Fig. 1). At 1 year after ASA, 7 of 8 PMI cases remained pacing-dependent, while the remaining 52 cases maintained intrinsic AV conduction (in the case of PMI with non-pacing-dependent at 1 year, PMI was performed on POD 19 due to syncope associated with transient CAVB on POD 10, but CAVB was not observed after POD 10). When comparing the conventional and delayed hypothetical strategies, the delayed strategy significantly reduced the proportion of PMI for non-pacing-dependent cases compared to the conventional strategy (20.3% in the conventional strategy vs. 1.7% in the delayed strategy, p = 0.003) (Fig. 2). No adverse events, such as infection, were observed during the extended waiting period. Conclusion By extending waiting time before PMI to 14 days, unnecessary PMI for periprocedural CAVB after ASA may be reduced.Table 1 Figure 1 and 2
Koyama et al. (Sat,) reported a other. Delaying pacemaker implantation to 14 days after ASA reduced unnecessary PMI in periprocedural CAVB cases from 20.3% to 1.7% (p=0.003) without adverse events.