Transcatheter aortic valve implantation and need for post-discharge pacemaker implantation in the modern era of fast discharge

Background Up to 20% of transcatheter aortic valve implantations (TAVIs) are followed by post-procedural conduction disturbances. As next-day discharge is becoming standard of care, predictors of permanent high-degree conduction disturbances requiring permanent pacemaker implantation (PPMI) are of increasing clinical relevance. Purpose This study was set out to study ECG characteristics associated with post-discharge PPMI. Post-TAVI, pre-discharge ECGs were compared between patients subjected to PPMI before and after TAVI-discharge, and patients not subjected to PPMI. Methods The target population was patients undergoing TAVI without pre-existing PPM. All patients undergoing TAVI from 4th of Nov. 2016 through 28th of April 2023 in Eastern Denmark, were retrospectively included. Patients with prior aortic valve replacement were excluded. To characterise patients requiring PPMI after TAVI-discharge, post-TAVI, pre-discharge ECGs were identified and considered abnormal if heart rate < 50 (bradycardia), PR-interval > 240 ms (AV-block), or QRS-duration > 120 ms (BBB). BBB configuration was further described as LBBB, RBBB, or unspecified. Next, patients were classified according to timing of PPMI. “Late” included patients subjected to PPMI within 1 to 30 days after TAVI-discharge. “Early” and “None” included patients subjected to PPMI before TAVI-discharge and patients not requiring PPMI within the first 30 days after TAVI-discharge, respectively. The association between post-TAVI ECG abnormality and patient classification was assessed by means of a χ2-test. Significance level was set to 0,05. Results A total of 2055 patients (57,3% males) were included. Mean age at TAVI was 79,3 years. We identified 217 patients (11,0%) and 28 patients (1,4%) classified as “Early” and “Late”, respectively. Among patients classified as “Late”, 46,4% (n = 13) had an abnormal ECG with the most prevalent ECG abnormality being BBB. It was identified in 92,3% of patients with an abnormal ECG (n = 12). LBBB was the most common configuration and was observed in 50% of patients with BBB (n = 6). RBBB was observed in 2 patients (16,7%), whereas the BBB configuration was unspecified in 4 patients (33,3%). Bradycardia and AV-block were equally prevalent among patients classified as “Late” with prevalences of 7,1% (n = 2). For patients classified as “Early” and “None”, prevalences of abnormal ECGs were 55,1% (n = 114) and 33,1% (n = 583), respectively (Figure 1). Patients classified as "Late" were more likely to have an abnormal post-TAVI, pre-discharge ECG compared to patients classified as “Early” and less likely in comparison to patients classified as “None” (p-value < 0,001). Conclusion In this study of 2055 patients subjected to TAVI between years 2016 and 2023, the incidence of PPMI within 1 to 30 days after TAVI discharge was 1,4%. Roughly half of these patients had an abnormal ECG at discharge with BBB being the most prevalent abnormality.