TAVR Length of Stay Declines, but Readmissions for New Pacemakers Increase

With the length of stay for transcatheter aortic valve replacement on the decline in the United States, there is a corresponding increase in the proportion of new pacemakers implanted during subsequent hospitalizations, a new analysis shows.

In 2012, for example, 7% of new permanent pacemakers were implanted on a follow-up visit to the hospital after TAVR. That number increased to 13% in 2017, report investigators.

“The need for pacemaker implantation has remained the same—it’s still in that 10% range—but what we saw was that there was a shift in the timing of pacemaker implantation,” said senior investigator Anil Gehi, MD (University of North Carolina, Chapel Hill). “Because patients are being discharged sooner, rather than getting their pacemaker during that initial hospitalization, more and more of them are having to come back for readmission and then getting their pacemaker.”

Injury to the conduction system resulting in high-degree atrioventricular block is a known complication of TAVR, and the need for a permanent pacemaker following the procedure varies not only by bioprosthetic valve type but also by operator and center experience. The trend toward earlier discharge following TAVR means that some of these conduction disturbances are not picked up by physicians during the index stay, said Gehi, and patients may develop complications outside the hospital.

The new study, published as a research letter November 9, 2020, in JACC: Cardiovascular Interventions, is slated for presentation at the upcoming virtual American Heart Association 2020 Scientific Sessions.

Led by Anthony J. Mazzella, MD (University of North Carolina, Chapel Hill), the analysis included 62,083 patients who underwent TAVR between 2012 and 2017 and were recorded in the Healthcare Cost and Utilization Project Nationwide Readmissions Database. Of these, 11.0% required a new permanent pacemaker following the procedure, with the vast majority implanted during the index hospitalization. From 2012 to 2017, the annual rate of permanent pacemaker implantation did not change (P = 0.632 for trend).

The overall length of stay for the index TAVR was significantly shortened over time, down from a median of 6 days in 2012 and 2013 to just 2 days in 2017 (P < 0.0001 for trend). Correspondingly, there was an increase in the number of pacemakers implanted during a subsequent hospital visit. In 2012, 2013, 2014, 2015, 2016, and 2017, the proportion of pacemakers implanted during a follow-up visit was 7.0%, 5.7%, 6.1%, 6.8%, 11.3%, and 13.0%, respectively (P < 0.0001 for trend). Of the 646 pacemakers implanted after TAVR discharge, nearly 80% were implanted within 14 days of valve replacement. 

“If somebody develops complete heart block, it might be associated with syncope and patients could have an accident of some sort,” said Gehi. “We’re already starting out with a relatively frail patient population and if they pass out that could lead to problems. People with complete heart block might also experience sudden cardiac arrest. That’s a possibility so the bottom line from our study is that if the patient has some high-risk features, it may be prudent to watch them a little longer in the hospital.”

In terms of patients who may be at risk for developing high-degree atrioventricular block after discharge, preexisting conduction disease, such as right bundle branch block, is a risk factor, as is the development of conduction abnormalities requiring transient pacing after the procedure, he said. Other periprocedural factors include the type of valve implanted and oversizing the prosthesis relative to the aortic annulus. If the high-risk patient is to be sent home, Gehi recommends continuous ambulatory monitoring.

As for physicians, Gehi simply reminded them to be vigilant for the potential of atrioventricular heart block. Early discharge for patients is a positive development for TAVR, he stressed, “but we just have to be careful about some of these complications and to watch for them.”