Single Lead AV Sequential Pacing for Acquired Atrioventricular Block During TAVI Procedures

Background: Atrioventricular block (AVB) after TAVI is common. Comparative data on various pacing strategies in this patient population does not exist.

Objective: To compare AV sequential pacing with a single lead (VDD) to dual lead (DDD) pacemaker (PPM) implantation in TAVI patients with acquired AVB.

Methods: Two center retrospective case-control study of consecutive patients (n=120) requiring an AV sequential PPM for acquired AVB between 2012-2017. Patients were classified as receiving a VDD (n=73) or DDD (n=47) PPM. T- and Fisher’s exact tests were used to assess for differences between the groups.

Results: 16% of all TAVI patients required PPM implantation. Of these patients, 61% received a VDD PPM whereas 39% received a DDD PPM. No differences in baseline clinical characteristics were observed between the two groups except for more AF in the group receiving DDD PPM (47% vs. 21%, p<0.01). Implantation time (51 vs. 66 minutes, p<0.01) and radiation exposure (fluoroscopy time: 3.6 vs. 7.7 minutes, p=0.004; dose area product: 6 vs. 15 mGy/cm2, p=0.006) were lower in patients receiving a VDD PPM. P wave amplitude at implant was lower in the VDD group (1.2 vs. 2.3 mV, p<0.01), but remained stable with time. Average atrial pacing percentage in the DDD group was 18%. History of AF was not associated with a higher burden of atrial pacing. Complication rate was similar. One patient underwent upgrade of VDD to DDD due to the need for ventricular active fixation lead. Despite an overall reduction in ventricular pacing with time, the majority of patients required >50% ventricular pacing at 12 months follow-up.

Conclusions: VDD PPM implantation is associated with shorter procedure times, lower radiation dose, and similar safety outcomes compared to DDD PPM implantation in patients post-TAVI. Given the overall low burden of atrial pacing, a single lead AV sequential pacemaker is preferred.

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