The Utility of Prophylactic Pacemaker Implantation in Patients with Pre-TAVI RBBB.

Background: Patients with right bundle branch block (RBBB) prior to transcatheter aortic valve implantation (TAVI) have high risk for immediate post procedural heart block and long term mortality when discharged without a pacemaker. Whether prophylactic permanent pacemaker implantation (PPI) is beneficial in these patients is unknown.

Methods: Data of 795 consecutive patients who underwent TAVI between 4/2012-12/2016 were reviewed and those with baseline RBBB were selected. We compared baseline characteristics and outcomes of those who underwent prophylactic PPI with those receiving a post-TAVI PPI. Pacer dependency was defined as >1% ventricular pacing.

Results: Ninety patients had baseline RBBB, 40 received a prophylactic PPI and in 50 the decision was based on post-TAVI indications for PPI. There were no significant differences in baseline characteristics. One patient developed tamponade following post-TAVI PPI. Patients receiving prophylactic PPI experienced shorter hospitalizations (4.9±1.6 vs 5.6±1.7, p=0.06). In long term follow up of 848±56 days, no differences were found in overall survival (65.8±14.9% vs 79.5±7.4%, p=0.77) or the composite of event free survival and hospitalizations (p=0.66), or mortality and syncope (p=0.65). On multivariate analysis, independent predictors of need for pacing included prolongation by 10ms of baseline PR interval (OR: 1.21 per 10ms increment [95% CI: 1.02-1.44], p=0.028) and use of new generation valves (OR: 3.92 [95% CI: [1.23-12.46], p=0.023).

Conclusions: In patients with baseline pre-TAVI RBBB no clinical outcome differences were found with prophylactic PPI. On multivariate analysis, predictors of the need for pacing included long baseline PR interval and use of newer generation valves.