Background: Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure to treat abnormal narrowing of the aortic valve in non-surgical candidates. Rapid ventricular pacing often facilitates optimal positioning of the TAVI valve. Traditionally, this has been
Methods: The study was a retrospective service evaluation in sequential patients treated before and after the change from routine RV pacing to LV pacing in patients implanted with a variety of valves at Leeds Teaching Hospital NHS Trust (LTHT). Data was collected from all patients clinically eligible for a TAVI procedure between May 2018 and June 2019. Clinical and procedural data were obtained from Trust clinical databases with safety data and clinical outcomes including procedural complications evaluated.
Results: A total of 323 TAVI procedures were performed during this study period. 60 patients were excluded for having a permanent pacemaker in situ (n=57), unsuccessful valve deployment (n=1) and incomplete clinical data (n=2). 263 (81.4%) patients with a mean age of 80 ± 7.2 years were included in the analysis. Patients were grouped according to the pacing technique adopted; 151 patients received LV pacing; 112 patients received RV pacing. Patients were implanted with one of five different valves (Sapien 3, Evolut, Portico, Accurate Neo and Lotus). Procedural characteristics showed a significant reduction in procedure duration for the LV group (63.5 ± 16.78 mins vs 69.4 ± 22.55 mins; p=0.04) and screen time (15.3 ± 6.0 mins vs 18.6 ± 8.19 mins; p≤0.01) compared to the RV group. Effective pacing stimulation was similar in the LV and RV groups (96.7% versus 99.1%; p=0.16%) as was duration of inpatient stay (2.90 ± 2.29 days vs 3.06 ± 2.68 days; p=0.62). Patients undergoing RV pacing were significantly more likely to have the temporary wire left in post procedure (56.3% vs 21.8%; p≤0.01) and required a post procedure permanent pacemaker (PPM) (22.32% vs 12.58%; p=0.04). MACE (major adverse cardiac events) occurred in 13% for the LV group and 14.3% in the RV group (p=0.06). Lastly, conduction abnormalities, namely new third degree AV block, were more frequent in self expanding valves (12%) versus balloon expanding valves (1.9%; p=0.04) as were requirements for post procedural PPM insertion (21% vs 5.8% respectively; p=0.02).
Conclusion: This is the largest reported retrospective study within the UK comparing RV and LV pacing strategies in a real-world unselected population using a range of valve types. LV pacing can successfully achieve consistent pacing, reduced procedure duration and lower radiation screen time when compared with RV pacing. In addition, this study has confirmed the non-inferiority of LV pacing in terms of complication rates as defined by MACE criteria. However, it should be noted that in patients with pre-existing conduction abnormalities, RV pacing and balloon expandable valves should still be utilised due to the increased incidence of new conduction abnormalities and post procedure PPM.
