Advertisement

Arrhythmias in Relation to Mortality After Transcatheter Aortic Valve Replacement

      Abstract

      Background

      The purpose of this study was to identify predictors of mortality and potentially modifiable factors related to arrhythmias in patients that undergo transcatheter aortic valve replacement (TAVR). Patients that undergo TAVR are at risk for complete heart block requiring pacemaker implant. Additionally, other arrhythmias, specifically atrial fibrillation (AF), are common in this population. It is unclear how arrhythmias and their management contribute to mortality risk.

      Methods

      The study analyzed 176 patients who underwent TAVR at a single center. Factors associated with pacemaker implantation within 30 days were analyzed by logistic regression. Factors associated with mortality were analyzed by Kaplan-Meier and Cox regression analyses.

      Results

      Mean age was 80 ± 8.5 years. AF was present in 69 patients, and 39 received anticoagulation. Post-TAVR, a pacemaker was implanted in 25 patients within 30 days. Over a follow up of 566 ± 496 days, 49 patients died. In multivariable analysis, right bundle branch block remained significant (odds ratio 4.212, P = 0.012) for pacemaker implant within 30 days. The AF (hazard ratio [HR] 3.905, P = 0.001), albumin level (HR 0.316, P = 0.034), and diabetes (HR 2.323, P = 0.027) were predictors of death in a multivariate analysis, while pacemaker implant within 30 days was not. Patients with AF who were anticoagulated had improved survival in a stratified Kaplan-Meier analysis compared with those who were not anticoagulated (P = 0.0001).

      Conclusion

      AF, diabetes, and low albumin levels are independently associated with mortality after TAVR. In particular, patients with AF who are not anticoagulated are at highest risk for death. Efforts to identify AF and consider anticoagulation should be emphasized.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • January CT
        • Wann LS
        • Calkins H
        • et al.
        2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
        J Am Coll Cardiol. 2019; 74: 104-132
        • Leon MB
        • Smith CR
        Transcatheter aortic-valve replacement.
        N Engl J Med. 2016; 375: 700-701
        • Kodali SK
        • Williams MR
        • Smith CR
        • et al.
        Two-year outcomes after transcatheter or surgical aortic-valve replacement.
        N Engl J Med. 2012; 366: 1686-1695
        • Hermiller Jr, JB
        • Yakubov SJ
        • Reardon MJ
        • et al.
        Predicting early and late mortality after transcatheter aortic valve replacement.
        J Am Coll Cardiol. 2016; 68: 343-352
        • Holmes Jr, DR
        • Brennan JM
        • Rumsfeld JS
        • et al.
        Clinical outcomes at 1 year following transcatheter aortic valve replacement.
        JAMA. 2015; 313: 1019-1028
        • Steinberg BA
        • Ballew NG
        • Greiner MA
        • et al.
        Ischemic and bleeding outcomes in patients with atrial fibrillation and contraindications to oral anticoagulation.
        JACC Clin Electrophysiol. 2019; 5: 1384-1392
        • Vora AN
        • Dai D
        • Matsuoka R
        • et al.
        Incidence, management, and associated clinical outcomes of new-onset atrial fibrillation following transcatheter aortic valve replacement: an analysis from the STS/ACC TVT Registry.
        JACC Cardiovasc Interv. 2018; 11: 1746-1756
        • Mentias A
        • Saad M
        • Girotra S
        • et al.
        Impact of pre-existing and new-onset atrial fibrillation on outcomes after transcatheter aortic valve replacement.
        JACC Cardiovasc Interv. 2019; 12: 2119-2129
        • Boriani G
        • Glotzer TV
        • Santini M
        • et al.
        Device-detected atrial fibrillation and risk for stroke: an analysis of >10,000 patients from the SOS AF project (Stroke preventiOn Strategies based on Atrial Fibrillation information from implanted devices).
        Eur Heart J. 2014; 35: 508-516
        • Healey JS
        • Connolly SJ
        • Gold MR
        • et al.
        Subclinical atrial fibrillation and the risk of stroke.
        N Engl J Med. 2012; 366: 120-129
        • Megaly M
        • Garcia S
        • Anzia LE
        • et al.
        Detection of atrial fibrillation and atrial flutter by pacemaker device interrogation after transcatheter aortic valve replacement (TAVR): implications for management.
        J Invasive Cardiol. 2019; 31: E177-E183
        • Jochheim D
        • Barbanti M
        • Capretti G
        • et al.
        Oral anticoagulant type and outcomes after transcatheter aortic valve replacement.
        JACC Cardiovasc Interv. 2019; 12: 1566-1576
      1. Kapadia, S. WATCH-TAVR, WATCHMAN for Patients with Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement. ClinicalTrials.gov Identifier: NCT03173534. Available at: https://clinicaltrials.gov/ct2/show/NCT03173534. Accessed May 5, 2020.

        • Nazif TM
        • Dizon JM
        • Hahn RT
        • et al.
        Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement: the PARTNER (Placement of AoRtic TraNscathetER Valves) trial and registry.
        JACC Cardiovasc Interv. 2015; 8: 60-69
        • Auffret V
        • Webb JG
        • Eltchaninoff H
        • et al.
        Clinical impact of baseline right bundle branch block in patients undergoing transcatheter aortic valve replacement.
        JACC Cardiovasc Interv. 2017; 10: 1564-1574
        • Reardon MJ
        • Van Mieghem NM
        • Popma JJ
        • et al.
        Surgical or transcatheter aortic-valve replacement in intermediate-risk patients.
        N Engl J Med. 2017; 376: 1321-1331
        • Meduri CU
        • Kereiakes DJ
        • Rajagopal V
        • et al.
        Pacemaker implantation and dependency after transcatheter aortic valve replacement in the REPRISE III Trial.
        J Am Heart Assoc. 2019; 8e012594
        • Koos R
        • Mahnken AH
        • Aktug O
        • et al.
        Electrocardiographic and imaging predictors for permanent pacemaker requirement after transcatheter aortic valve implantation.
        J Heart Valve Dis. 2011; 20: 83-90
        • Ferreira ND
        • Caeiro D
        • Adao L
        • et al.
        Incidence and predictors of permanent pacemaker requirement after transcatheter aortic valve implantation with a self-expanding bioprosthesis.
        Pacing Clin Electrophysiol. 2010; 33: 1364-1372
        • Mangieri A
        • Lanzillo G
        • Bertoldi L
        • et al.
        Predictors of advanced conduction disturbances requiring a late (>/=48 h) permanent pacemaker following transcatheter aortic valve replacement.
        JACC Cardiovasc Interv. 2018; 11: 1519-1526
        • Khawaja MZ
        • Rajani R
        • Cook A
        • et al.
        Permanent pacemaker insertion after CoreValve transcatheter aortic valve implantation: incidence and contributing factors (the UK CoreValve Collaborative).
        Circulation. 2011; 123: 9519-9560
        • Roten L
        • Wenaweser P
        • Delacretaz E
        • et al.
        Incidence and predictors of atrioventricular conduction impairment after transcatheter aortic valve implantation.
        Am J Cardiol. 2010; 106: 1473-1480