Comprehensive electrophysiological study including ajmaline challenge to guide pacemaker implantation after transcatheter aortic valve replacement

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Abstract Background Electrophysiological studies (EPS) assessing conduction system parameters are being explored as predictors of high-grade atrioventricular block (HAVB) following TAVR. Both US and European guidelines support an EPS-guided approach but, because of conflicting data, the optimal risk stratification strategy remains debated. Moreover, in this setting, little is known about the added value of pharmacological challenge which has been suggested in patients with syncope and bundle branch block to increase EPS sensitivity. Purpose We aimed to investigate the value of a strategy of routine EPS including the use of Ajmaline pharmacological challenge for risk stratification in patients with new-onset conduction disturbances after TAVR. Methods The evaluated EPS-based strategy was as follows: i) in patients with a basal HV interval (HV) ≥70 ms, Pacemaker (PM) implantation was performed, ii) In cases with HV >55ms, an implantable loop recorder (ILR) was implanted, iii) In a subgroup of patients (with basal HV <70ms), systematic Ajmaline challenge was performed with PM implantation with post-Ajmaline HV ≥120ms or 100% increase from baseline (and ILR implantation for intermediate values). The primary outcome was defined as HAVB persisting beyond 24 hours post-TAVR or the need for ventricular pacing in patients who underwent prophylactic PM implantation. Results A total of 101 patients were included. Of these, 18 patients with HV ≥70 ms underwent PM implantation. In the remaining 83 patients with HV <70 ms, Ajmaline challenge was performed in 48 patients (58%). The primary outcome was observed in 10 patients (55%) with HV ≥70 ms versus 17 patients (20%) with HV <70 ms. Among patients with an HV interval <70 ms, the optimal cutoff value to identify those at risk of PM need was 60 ms, as determined by ROC analysis (AUC 0.779). The post-Ajmaline HV provided similar diagnostic accuracy compared to basal HV alone, with an optimal cutoff value of 83 ms (AUC 0.817) (Figure 1). However, post-Ajmaline HV did not help to reclassify a meaningful number of patients when used in combination with basal HV (Figure 2). The post-Ajmaline delta HV interval was less predictive than both basal and post-Ajmaline HV (AUC 0.585). Based on the optimal cutoff value for basal HV identified by ROC analysis, our strategy of using basal HV alone reasonably predicts the risk of PM (sensitivity 78%, specificity 74%, NPV 70%, and PPV 53%). Conclusion In patients with new-onset conduction disturbances after TAVR, an EPS-based risk strategy based on the basal HV is predictive of the risk of PM need with half of the identified patients who actually benefited from PM implantation. However, strategy aiming at reducing the 30% false negative rate should be pursued. In that respect, the adjunct of an ajmaline challenge to the EPS evaluation does not provide a meaningful added value.Figure 1 Figure 2

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