The Impact of Balloon Aortic Valvuloplasty on the Native Conduction System in Transcatheter Aortic Valve Replacement

Background
Transcatheter aortic valve replacement (TAVR) has advanced to the forefront of the treatment of severe symptomatic aortic stenosis in intermediate or high-risk patients. Over time, the use of pre-TAVR balloon aortic valvuloplasty (BAV) has steadily decreased, but use of post-TAVR BAV remains an option to treat paravalvular leak (PVL). Additionally, despite refinements, permanent pacemaker (PPM) requirements have increased in third generation TAVR valves. The purpose of this study was to compare PPM rates post-TAVR among patients with and without BAV.

Methods
In this retrospective, observational, study from 2016-2018, we reviewed data on 727 patients who underwent TAVR at our institution using third generation TAVR valves. Excluded were patients with valve in valve TAVR (n=70) or those who had previous PPM (n=109). We collected baseline clinical characteristics, as well as whether or not patients underwent pre-TAVR BAV, or post-TAVR BAV. Our primary outcome of interest was new requirement for PPM following TAVR. Our secondary outcomes of interest were length of stay (LOS) and inpatient death. Statistical analyses of outcome were performed using, Fisher’s exact test, two-sample t-test and multivariate binary logistic regression.

Results
Of the 727 patients screened, there were 548 patients who were included in the study. Cohort 1 consisted of 101 PPM naïve patients who went on to require PPM. Cohort 2 consisted of 447 PPM naïve patients who did not go on to require PPM. Pre-TAVR BAV did not correlate with requiring PPM. Patients who had post-TAVR BAV were 1.79 times more likely (CI 0.348, 0.893, p=0.0150) to require PPM. Patients who required PPM post-TAVR had similar rates of inpatient death (p=0.3753) but longer median post-TAVR LOS (2.0 vs. 3.0, p=0.0235).

Conclusions
Conduction disturbances remain common following TAVR, often requiring PPM. In our study, post-TAVR BAV was associated with an increased risk of requiring PPM following TAVR. Patients who required PPM post-TAVR had a longer median length of stay with similar rates of inpatient mortality. The use of post-TAVR BAV to reduce PVL appears to be at the cost of new conduction disturbances and may have an impact on LOS following TAVR.