QRS duration after TAVI with self expanding bioprosthesis: a useful tool to predict permanent pacemaker implantation requirement

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Purpose: Pace maker implantation (PPM) after TAVI remains a frequent complication Corevalve device©. Post-implantation continuous ECG monitoring and temporary pacing catheter are required to identify and treat post TAVI high degree Atrio-ventricular block (AVB) leading to PPM. In a retrospective study, a cut-off value of less than 120 ms for QRS duration (QRSd) have been proposed to exclude patient requiring PPM. The purpose of the study was to prospectively evaluate a 12-Lead-EKG guided approach allowing an early removal of temporary pacing catheter resulting in an early discharge from intensive care unit (ICU) after TAVI. Methods: Patients with symptomatic severe aortic stenosis and without previous PPM were prospectively included for TAVI in our center between December 2010 and January 2013. Twelve-Lead EKG was performed immediately after the index procedure:Patients with high degree AVB were assigned to early PPM group and removed from analysis (group 1). Patients with QRSd< 120 ms were assigned to early pacing catheter removal group (group 2) and patients with QRSd≥120 ms were assigned to temporary pacing catheter and continuous EKG monitoring in ICU (group3). Results: A total of 194 patients (age 85±6 years; female sex: 58%) were included. A 12-Lead-EKG was performed immediately after TAVI: 21 (10%) patients presented acute high degree AVB and were assigned to group 1. Among 173 patients without immediate AVB, 43 (24%) patients had QRSd <120 ms, 130 (66%) patients had QRSd ≥120 ms and were assigned to group 2 and 3 respectively. After a mean follow-up of 187±222 days, none patient of Group 2 had PPM implantation. Among 130 patients of Group 3, 40 patients experienced PPM implantation. The patients who exhibited delayed AVB had significantly wider QRSd (158±17 ms vs. 128±25 ms, P<0.0001), with no difference in baseline. According to multivariate analysis, QRSd was the best predictor of PPM after TAVI with HR =1.321 95% CI (1.055; 1.654) p=0.02. Receiving Operating Characteristics analysis confirmed that QRSd <120 ms was the optimal cut-off value with 100% of sensitivity to identify patient without PPM requirement. Conclusion: PPM after TAVI remains a frequent complication after TAVI with Corevalve device© (31%). QRS duration after TAVI is the best predictor to identify patient with delayed AVB. QRSd <120 ms is a safety cut-off that allow early removal of pacing catheter resulting in early discharge from ICU.

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