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Outcomes Worse in Patients with Persistent Conduction Abnormalities after TAVR

March 25, 2021
by Elisabeth Reitman

Transcatheter aortic valve replacement (TAVR) is a therapeutic alternative to surgery in high- risk patients with severe valvular aortic disease. Recent advances in TAVR have enabled lower-risk patients to benefit from this therapy. However, post-TAVR complications with the heart’s electrical impulses, known as conduction abnormalities, continue to undermine the next generation of valve repair devices.

An expert consensus document was published August 27, 2019 in Journal of the American College of Cardiology. Additional research — particularly on the long-term outcomes of these abnormalities — is needed to reduce conduction disturbances in these patients.

Alexandra Lansky MD, conducted a study with second-year medical student Claudia See ‘17, ‘23 MD, on the increased risk for permanent pacemaker (PPM) implantation following TAVR. The investigators analyzed data on 927 patients at Yale New Haven Hospital (YNHH) who underwent TAVR between July 2012 - August 2019. They used YNHH data to report on persistent vs. non-persistent conduction abnormalities following TAVR and their differential impact on 1-year mortality.

See presented the early findings on higher incidences of pacemaker implantation at the Cardiovascular Research Technologies (CRT) virtual conference.

See studied biomedical engineering at Yale College to learn how to improve health outcomes and medical device design. She worked with Stuart Campbell, PhD, associate professor of biomedical engineering & cellular and molecular physiology. See co-authored a previous study in the journal JCI Insight with Campbell’s Integrative Cardiac Biomechanics Laboratory.

See later joined Lansky’s Yale Cardiovascular Research Group as a medical student. “Working with Dr. Lansky's research group over the past year has been an excellent learning experience as well as an extremely supportive and collaborative environment,” she said.

The researchers hoped to learn what conditions led to more patients developing new abnormalities within 7 days post-TAVR. After comparing clinical outcomes, the initial analysis found that 396 TAVR patients (54%) developed new onset abnormalities, which persisted on EKGs post-TAVR for 1.5 years of follow-up.

The preliminary findings from Lansky and her team was that patients with new onset persistent abnormalities had a two-fold higher rate of all-cause mortality at 1-year compared to patients with non-persistent abnormalities, those that occurred intermittently post-TAVR. A reduced baseline left ventricular ejection fraction or LVEF and persistent conduction abnormality were the only two predictors found for 1-year mortality.

Takeaways:

  1. PPM: Persistent abnormalities resulted in a higher pacemaker implantation rate than non-persistent abnormalities.
  2. Outcomes at 30 days: No difference in major adverse cardiac events (MACE) or mortality.
  3. Outcomes at 1 year: Persistent abnormalities after TAVR increased the rate of all-cause mortality by two-fold.
  4. Outcomes at 30 days and one year: Non-persistent patients had no differences in outcomes compared to patients with no abnormalities, but had a higher pacemaker implantation rate.

“New advances in technology and patient indication for TAVR patients are being made at rapid speed,” said See. Valve replacement is a fitting example. “Twenty years ago, invasive surgery was the gold standard. Today we can restore heart function with a short two-hour procedure.”

Upcoming Abstracts

See will present a related abstract, “Impact of Pacemaker Implant ≤ 30 Days Post TAVR on Mortality: Results of a Single Center Prospective Registry,” at the American College of Cardiology virtual Scientific Session on May 15. She also contributed to an abstract on gender differences and outcomes by second-year clinical fellow Yanting Wang, MD, “Impact of Sex on Outcomes in TAVR: Results from a Single Center Prospective Registry,” which Yang will also present at the American College of Cardiology virtual Scientific Session.

“Dr. Yanting Wang has been an instrumental mentor as someone further along in her career, but also someone I can relate to on a peer level. She has also been a close collaborator as we worked on the same database over the past year. I am grateful for the opportunities to work with such a great research team here at Yale,” said See.

Submitted by Elisabeth Reitman on March 25, 2021