The increasing adoption of transcatheter aortic valve replacement (TAVR) as a treatment for symptomatic severe aortic stenosis among younger and lower-risk patients requires heightened awareness of procedural risk. Every effort should be made to mitigate these risks, particularly for young patients for whom long-term consequences may amplify over time. This is especially true for TAVR-related conduction system injury, including both the need for a permanent pacemaker and new onset persistent left bundle branch block. These injuries occur due to the proximity of the aortic valve to the conduction pathways, resulting in approximately 10% of TAVR patients requiring a pacemaker. While transvenous pacemakers have been the standard, the emergence of leadless pacemakers offers a promising alternative, both for elderly and frail patients who are at higher risk for complications and for younger patients who may have long-term complications of transvenous systems.
Ueyama and colleagues recently reported comparing outcomes of patients who received leadless pacemakers versus traditional transvenous pacemakers following TAVR. The study, which analyzed data from over 10,000 Medicare beneficiaries between 2017 and 2020, sought to provide insights into the real-world effectiveness of these two approaches.
The study found that leadless pacemaker usage after TAVR increased 3.5-fold during the study period, although it only accounted for 7% of all pacemaker implantations. Notably, patients who received leadless pacemakers tended to have more comorbidities, such as atrial fibrillation and end-stage renal disease, compared to those who received transvenous pacemakers.
In terms of outcomes, the study revealed that patients with leadless pacemakers experienced fewer in-hospital complications (7.2% vs. 10.1%, p = 0.014) and a lower risk of midterm device-related complications (subdistribution hazard ratio [sdHR]: 0.37; 95% confidence interval [CI]: 0.21-0.64, p < 0.001) compared to those with transvenous pacemakers. However, there were no significant differences in midterm all-cause mortality, heart failure hospitalizations, or infective endocarditis between the two groups, suggesting that both types of pacemakers offer similar long-term outcomes in these critical areas.
This valuable study explores alternative strategies to manage conduction disturbances after TAVR. Leadless pacemakers, which eliminate the need for transvenous leads and subcutaneous pacemaker generator pockets, reduce the risk of complications such as lead dislodgement, infection, and vascular injury—common issues associated with transvenous systems. Despite these advantages, the adoption of leadless pacemakers remains limited, likely due to concerns about cost, pacing functionality, and the relative novelty of the technology. However, as the study demonstrates, leadless pacemakers present a viable and potentially safer alternative to transvenous pacemakers for patients undergoing TAVR, particularly in those with multiple comorbidities.
The increasing adoption of transcatheter aortic valve replacement (TAVR) as a treatment for symptomatic severe aortic stenosis among younger and lower-risk patients requires heightened awareness of procedural risk. Every effort should be made to mitigate these risks, particularly for young patients for whom long-term consequences may amplify over time. This is especially true for TAVR-related conduction system injury, including both the need for a permanent pacemaker and new onset persistent left bundle branch block. These injuries occur due to the proximity of the aortic valve to the conduction pathways, resulting in approximately 10% of TAVR patients requiring a pacemaker. While transvenous pacemakers have been the standard, the emergence of leadless pacemakers offers a promising alternative, both for elderly and frail patients who are at higher risk for complications and for younger patients who may have long-term complications of transvenous systems.
Ueyama and colleagues recently reported comparing outcomes of patients who received leadless pacemakers versus traditional transvenous pacemakers following TAVR. The study, which analyzed data from over 10,000 Medicare beneficiaries between 2017 and 2020, sought to provide insights into the real-world effectiveness of these two approaches.
The study found that leadless pacemaker usage after TAVR increased 3.5-fold during the study period, although it only accounted for 7% of all pacemaker implantations. Notably, patients who received leadless pacemakers tended to have more comorbidities, such as atrial fibrillation and end-stage renal disease, compared to those who received transvenous pacemakers.
In terms of outcomes, the study revealed that patients with leadless pacemakers experienced fewer in-hospital complications (7.2% vs. 10.1%, p = 0.014) and a lower risk of midterm device-related complications (subdistribution hazard ratio [sdHR]: 0.37; 95% confidence interval [CI]: 0.21-0.64, p < 0.001) compared to those with transvenous pacemakers. However, there were no significant differences in midterm all-cause mortality, heart failure hospitalizations, or infective endocarditis between the two groups, suggesting that both types of pacemakers offer similar long-term outcomes in these critical areas.
This valuable study explores alternative strategies to manage conduction disturbances after TAVR. Leadless pacemakers, which eliminate the need for transvenous leads and subcutaneous pacemaker generator pockets, reduce the risk of complications such as lead dislodgement, infection, and vascular injury—common issues associated with transvenous systems. Despite these advantages, the adoption of leadless pacemakers remains limited, likely due to concerns about cost, pacing functionality, and the relative novelty of the technology. However, as the study demonstrates, leadless pacemakers present a viable and potentially safer alternative to transvenous pacemakers for patients undergoing TAVR, particularly in those with multiple comorbidities.
As technology and experience with leadless pacemakers evolve, they may become an increasingly common choice for managing post-TAVR conduction disorders. Future investigations should clarify ways to personalize device selection as well as explore the utility of retrievable devices for patients in whom the conduction system may improve with time.
References
Ueyama HA, Miyamoto Y, Hashimoto K, et al. Comparison of Patient Outcomes Between Leadless vs Transvenous Pacemakers Following Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv. 2024;17(15):1779-1791. doi:10.1016/j.jcin.2024.05.030
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