Predictors for permanent pacemaker requirement after transcatheter aortic valve implantation with the CoreValve bioprosthesis Hasan Jilaihawi, BSc, MBChB, MRCP, Derek Chin, BS, FRCP, Mariuca Vasa-Nicotera, MD, Mohamed Jeilan, BM, MRCP, Tomasz Spyt, MD, FRCS (CTh), G Andre Ng, MBChB, PhD, MRCP, Johan Bence, MD, Elaine Logtens, BSc, and Jan Kovac, MUDr, FACC Leicester, United Kingdom Introduction Changes in atrioventricular (AV) conduction and need for permanent pacemaker (PPM) are a recognized complication after open aortic valve replacement. We hypothesized that the need for PPM after CoreValve (Corevalve Inc, Irvine, CA) can be predicted with a combination of baseline variables. Methods In patients undergoing transcatheter aortic valve implantation, potential clinical, electrocardiographic and echocardiographic predictors of permanent pacing requirement were studied. Results Between January 2007 and March 2008, 34 patients with severe symptomatic aortic stenosis were recruited in a single center. Mean age was 84.4 years (SD 5.4, range 71-93). Of 34 cases paced at baseline, 3 (8.8%) were excluded from this analysis, as was the single periprocedural mortality. Of the remaining 30, 10 underwent permanent pacemaker implantation during the same admission (33.3%). PPM was for prolonged high-grade AV block in 4 cases, episodic high-grade AV block in 5, and sinus node disease in 1. Need for pacemaker was correlated to left axis deviation at baseline (P = .004, r = 0.508) and left bundle-branch block with left axis deviation (P = .002, r = 0.548). It was related to diastolic interventricular septal dimension on transthoracic echocardiography N17 mm (P = .045, r = 0.39) and the baseline thickness of the native noncoronary cusp (P = .002, r = 0.655). A susceptibility model was generated, and if at least one of (1) left bundle-branch block with left axis deviation, (2) interventricular septal dimension N17 mm, or (3) noncoronary cusp thickness N8 mm was present, the likelihood of PPM could be predicted with 75% sensitivity and 100% specificity and a receiver operating characteristic curve area of 0.93 ± 0.055 (P b .001). Conclusions After transcatheter aortic valve implantation with CoreValve, permanent pacing was performed in around a third of patients and we present preliminary concepts towards a predictive model for this phenomenon. (Am Heart J 2009;157:860-6.) Transcatheter aortic valve implantation (TAVI) has shown great promise in the treatment of severe aortic stenosis (AS) in patients regarded at high risk from or inoperable by conventional surgery. 1-8 In contrast to conventional valve replacement surgery, TAVI involves the exclusion of valve tissue by a prosthetic stent, with inevitable compression of the annulus and surrounding structures which comprise the fibrous skeleton of the heart. The atrioventricular (AV) node and its left bundle branch comprise one such structure, passing adjacent to the noncoronary cusp (NCC) of the aortic valve within the central fibrous body. 9,10 Indeed, the close proximity of the NCC to the AV node has been used therapeutically in catheter ablation. 11,12 The reported incidence of new left bundle-branch block (LBBB) after aortic valve replacement (AVR) is 16%, 13 with permanent pacing for AV block of 3% to 18%, 14-19 depending on type of prosthesis. Only limited data are available for requirement and predictors for permanent pacemaker (PPM) after TAVI. 20 We therefore studied changes in AV conduction and the incidence of permanent pacemaker implantation after TAVI with the CoreValve (Corevalve Inc, Irvine, CA) bioprosthesis in an elderly population with severe calcific aortic stenosis at high risk of conventional surgery and sought to work towards a predictive model for this complication. Methods No extramural funding was used to support this work. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the paper and its final contents. From the Glenfield Hospital, Leicester, United Kingdom. Submitted September 7, 2008; accepted February 7, 2009. Reprint requests: Jan Kovac, MUDr, FACC, Department of Cardiology, Glenfield Hospital, LE3 9QP Leicester, United Kingdom. E-mail: jankovac2@hotmail.com 0002-8703/$ - see front matter © 2009, Mosby, Inc. All rights reserved. doi:10.1016/j.ahj.2009.02.016