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 accessOne-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 MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- 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
- Transcatheter aortic-valve replacement.N Engl J Med. 2016; 375: 700-701
- Two-year outcomes after transcatheter or surgical aortic-valve replacement.N Engl J Med. 2012; 366: 1686-1695
- Predicting early and late mortality after transcatheter aortic valve replacement.J Am Coll Cardiol. 2016; 68: 343-352
- Clinical outcomes at 1 year following transcatheter aortic valve replacement.JAMA. 2015; 313: 1019-1028
- Ischemic and bleeding outcomes in patients with atrial fibrillation and contraindications to oral anticoagulation.JACC Clin Electrophysiol. 2019; 5: 1384-1392
- 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
- Impact of pre-existing and new-onset atrial fibrillation on outcomes after transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2019; 12: 2119-2129
- 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
- Subclinical atrial fibrillation and the risk of stroke.N Engl J Med. 2012; 366: 120-129
- 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
- Oral anticoagulant type and outcomes after transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2019; 12: 1566-1576
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.
- 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
- Clinical impact of baseline right bundle branch block in patients undergoing transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2017; 10: 1564-1574
- Surgical or transcatheter aortic-valve replacement in intermediate-risk patients.N Engl J Med. 2017; 376: 1321-1331
- Pacemaker implantation and dependency after transcatheter aortic valve replacement in the REPRISE III Trial.J Am Heart Assoc. 2019; 8e012594
- Electrocardiographic and imaging predictors for permanent pacemaker requirement after transcatheter aortic valve implantation.J Heart Valve Dis. 2011; 20: 83-90
- Incidence and predictors of permanent pacemaker requirement after transcatheter aortic valve implantation with a self-expanding bioprosthesis.Pacing Clin Electrophysiol. 2010; 33: 1364-1372
- Predictors of advanced conduction disturbances requiring a late (>/=48 h) permanent pacemaker following transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2018; 11: 1519-1526
- Permanent pacemaker insertion after CoreValve transcatheter aortic valve implantation: incidence and contributing factors (the UK CoreValve Collaborative).Circulation. 2011; 123: 9519-9560
- Incidence and predictors of atrioventricular conduction impairment after transcatheter aortic valve implantation.Am J Cardiol. 2010; 106: 1473-1480
Article info
Publication history
Published online: April 20, 2020
Footnotes
Funding: None.
Conflicts of Interest: RS reports being a proctor for Edwards Lifesciences; BPD, KAS, KK, KL, TK, KL, JHI report none.
Authorship: All authors had access to the data and a role in writing this manuscript.
Identification
Copyright
© 2020 Elsevier Inc. All rights reserved.
