Author + information
- Received November 30, 2016
- Revision received March 10, 2017
- Accepted March 30, 2017
- Published online June 19, 2017.
- Rajiv Rampat, MDa,
- M. Zeeshan Khawaja, MBBSa,
- Roland Hilling-Smith, MDa,
- Jonathan Byrne, MDb,
- Philip MacCarthy, MDb,
- Daniel J. Blackman, MDc,
- Arvindra Krishnamurthy, MDc,
- Ashan Gunarathne, MDd,
- Jan Kovac, MDd,
- Adrian Banning, MDe,
- Raj Kharbanda, MDe,
- Sami Firoozi, MDf,
- Stephen Brecker, MDf,
- Simon Redwood, MDg,
- Vinayak Bapat, MDg,
- Michael Mullen, MDh,
- Suneil Aggarwal, MDh,
- Ganesh Manoharan, MDi,
- Mark S. Spence, MDi,
- Saib Khogali, MDj,
- Maureen Dooley, MBBSa,
- James Cockburn, MDa,
- Adam de Belder, MDa,
- Uday Trivedi, MDa and
- David Hildick-Smith, MDa,∗ ()
- aDepartment of Cardiology, Brighton and Sussex University Hospitals, Brighton, United Kingdom
- bDepartment of Cardiology, Kings College Hospital, London, United Kingdom
- cDepartment of Cardiology, Leeds Teaching Hospitals, Leeds, United Kingdom
- dDepartment of Cardiology, University Hospitals of Leicester, Leicester, United Kingdom
- eDepartment of Cardiology, Oxford University Hospitals, Oxford, United Kingdom
- fDepartment of Cardiology, St George’s Hospital, London, United Kingdom
- gDepartment of Cardiology, Guy’s and St Thomas’s Hospitals, London, United Kingdom
- hUniversity College London Hospitals, London, United Kingdom
- iDepartment of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom
- jDepartment of Cardiology, Royal Wolverhampton Hospital, Wolverhampton, United Kingdom
- ↵∗Address for correspondence:
Dr. David Hildick-Smith, Sussex Cardiac Center, Brighton and Sussex University Hospitals, Eastern Road, Brighton BN2 5BE, United Kingdom.
Objectives The authors report the incidence of pacemaker implantation up to hospital discharge and the factors influencing pacing rate following implantation of the LOTUS bioprosthesis (Boston Scientific, Natick, Massachusetts) in the United Kingdom.
Background Transcatheter aortic valve replacement (TAVR) is associated with a significant need for permanent pacemaker implantation. Pacing rates vary according to the device used. The REPRISE II (Repositionable Percutaneous Replacement of Stenotic Aortic Valve Through Implantation of Lotus Valve System) trial reported a pacing rate of 29% at 30 days after implantation of the LOTUS device.
Methods Data were collected retrospectively on 228 patients who had the LOTUS device implanted between March 2013 and February 2015 across 10 centers in the United Kingdom. Twenty-seven patients (12%) had pacemakers implanted pre-procedure and were excluded from the analysis.
Results Patients were aged 81.2 ± 7.7 years; 50.7% were male. The mean pre-procedural QRS duration was 101.7 ± 20.4 ms. More than one-half of the cohort (n = 111, 55%) developed new left bundle branch block (LBBB) following the procedure. Permanent pacemakers were implanted in 64 patients (32%) with a median time to insertion of 3.0 ± 3.4 days. Chief indications for pacing were atrioventricular (AV) block (n = 46, 72%), or LBBB with 1st degree AV block (n = 11, 17%). Amongst those who received a pacemaker following TAVR the pre-procedural electrocardiogram findings included: No conduction disturbance (n = 41, 64%); 1st degree AV block (n = 10, 16%); right bundle branch block (n = 6, 9%) and LBBB (n = 5, 8%). LBBB (but not permanent pacemaker) occurred more frequently in patients who had balloon aortic valvuloplasty before TAVR (odds ratio [OR]: 1.25; p = 0.03). Pre-procedural conduction abnormality (composite of 1st degree AV block, hemiblock, right bundle branch block, LBBB) was independently associated with the need for permanent pacemaker (OR: 2.54; p = 0.048). The absence of aortic valve calcification was also associated with a higher pacing rate (OR: 0.55; p = 0.031). Multivariate regression analysis did not show an independent association between depth of implant, valve oversizing, balloon post-dilatation, and the need for pacing post-procedure.
Conclusions Following implantation of the repositionable LOTUS valve, 55% of patients developed LBBB and 32% of patients required a pacemaker during their index hospital admission. Patients with pre-procedural conduction disturbance and non-calcified aortic valves were more likely to need pacing. No other anatomic features were identified with increased pacing requirement with the LOTUS device.
Dr. MacCarthy is a proctor for Edwards Lifesciences. Dr. Blackman is a proctor and consultant for Boston Scientific and Medtronic. Drs. Kovac, Spence, de Belder, and Hildick-Smith are proctors for Boston Scientific. Dr. Manoharan is a proctor for Medtronic, Boston Scientific, and St. Jude Medical. Dr. Khogali is a proctor for Medtronic and Boston Scientific and has received honoraria from both companies. Dr. Banning has received institutional research funding for an interventional fellow from Boston Scientific. Dr. Brecker is a proctor and consultant for Boston Scientific and Medtronic; and is on the advisory board for Boston Scientific. Dr. Redwood has received funding for a research fellow from Boston Scientific. Dr. Bapat is a consultant for Edwards Lifesciences, Medtronic, Boston Scientific, and Abbott; and has received speakers fees from LivaNova. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 30, 2016.
- Revision received March 10, 2017.
- Accepted March 30, 2017.