The Value of EPS in Decision Making Regarding the Need for Pacemaker Implantation after TAVI. The Tel-Aviv Medical Center Experience

Aims: Conduction disturbances are frequent after transcatheter aortic valve implantation (TAVI), yet the indications for pacemaker implantation are still debatable. We investigate the value of EPS in these patients.

Methods: Two patient cohorts were included: (1) 272 consecutive patients who underwent TAVI between 4/2012 and 4/2014 (of whom, 39 were excluded due to atrial fibrillation or mortality prior to discharge). Patients were classified according to PR prolongation from baseline ECG (∆PR≤20ms or ∆PR>20ms) and the presence of LBBB. (2) 30 pts who underwent EPS after TAVI mainly due to the occurrence of BBB with or without ∆PR>20ms and in whom a pacemaker was implanted when significant infranodal disease was demonstrated. All patients were followed during 1 year for the composite endpoint of mortality or pacemaker implantation after hospital discharge.

Results: In the 30 patients who underwent EPS, conduction disturbances were mainly located in the AV node (n=22, 73.3%), the His (n=3, 10%) and the infra-His system (n=5, 16.7%). Event free survival of the composite endpoint was 100% in this patient group. In comparison with patients with narrow QRS and ∆PR<20ms (n=66): 1) Event free survival of the composite endpoint was significantly lower in patients with LBBB + ∆PR>20ms (n=26) (76.9% vs.93.8% p=0.02); 2) There was a trend for lower event free survival in patients with narrow QRS + ∆PR>20ms (n=29) (82.8%, p=0.09); 3) No significant difference was observed in patients with LBBB + ∆PR<20ms (n=31) (87% p=0.26), or between patients with permanent pacemaker (PPM) (n=81) (91.4%, p=0.56).

Conclusion: Patients with LBBB + ∆PR>20ms, but not with LBBB alone, are at higher risk of mortality and late pacemaker implantation at 1 year follow up. Patients with narrow QRS + ∆PR>20ms might also be at risk. EPS can be used to identify patients in whom a PPM implantation is needed.