Abstract
Transcatheter aortic valve replacement (TAVR) is a widely accepted treatment strategy for patients with severe aortic stenosis across all risk profiles. Pacing stimulation of the right ventricle (RV) is the conventional method used during TAVR for rapid pacing during balloon dilatation and transcatheter heart valve deployment and for the management of acute bradyarrhythmias. However, RV pacing requires additional venous access and carries a risk of RV perforation and cardiac tamponade. An alternate strategy of utilizing the stiff guidewire in the left ventricle for direct left ventricle pacing during valve deployment is increasingly being adopted, as it may reduce procedure cost, duration, and radiation exposure and potentially mitigate the risks associated with RV pacing. The current review aims to discuss contemporary rapid pacing techniques for TAVR, including their relative safety, efficiency, and outcomes.
Highlights
- •
Rapid ventricular pacing is necessary during transcatheter aortic valve replacement and is typically done via stimulation of the right ventricle.
- •
Left ventricular pacing has similar efficacy to right ventricular pacing, with possible improved safety.
- •
Large prospective trials are needed to compare the safety and efficacy of these pacing strategies.
Graphical abstract
Introduction
Over the past 2 decades, transcatheter aortic valve replacement (TAVR) has become an established treatment for patients with symptomatic, severe aortic stenosis. Refinements in the design of valve prostheses and their delivery systems, new implantation techniques, and increasing operator experience have led to a substantial reduction in TAVR-related adverse events. Furthermore, various measures have been implemented aiming to transform TAVR into a “minimalist” procedure to simplify and shorten the procedure, reduce costs, and improve overall outcomes. Examples include the use of conscious sedation rather than general anesthesia, radial artery for secondary arterial access, and the avoidance of Foley catheters. As the field continues to evolve, further such refinements are of paramount importance.
Rapid ventricular pacing has been utilized during TAVR to create a temporary reduction in cardiac output in order to facilitate balloon aortic valvuloplasty (BAV), implantation of transcatheter heart valves (THVs), and valve postdilatation. Although the stage at which rapid pacing may be necessary differs between valve types and operators, some form of rapid ventricular pacing is required in most TAVR procedures. In addition, high-degree heart block or other bradyarrhythmias may occur during the procedure, which requires back-up pacing.
Conventionally, rapid ventricular pacing has been carried out using a temporary pacing lead introduced via the jugular or femoral vein with the lead tip placed in the right ventricular (RV) apex. However, RV pacing necessitates venous access and conveys risks related to the access site (bleeding, vascular complication, thrombosis, or infection) and to the placement of the lead in the RV (RV perforation). Rapid pacing through the left ventricular (LV) stiff guidewire has the potential to eliminate these risks while also improving procedural efficiency and has been demonstrated to be a viable technique. In this article, we review the current state of knowledge regarding the safety and efficacy of rapid pacing with the LV stiff guidewire vs. a temporary transvenous RV lead during transcatheter aortic valve deployment.
Methods
A systematic literature search for relevant articles published prior to March 2023 was carried out in the PubMed, EMBASE, and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Two preliminary reviewers (E.B. and N.M.) screened the searched databases for inclusion. Studies were eligible if they included patients receiving LV pacing during TAVR. Case series with fewer than 20 patients were excluded from the current review, as were studies discussing only RV pacing or rapid pacing for BAV. Studies without mention of complication rates were also excluded. Studies were restricted to those published in English and those conducted on humans. All preliminary screened studies underwent a second round of eligibility screening before investigators independently evaluated and subsequently extracted all relevant data from the selected studies. The extracted data were then organized and reported in the tables. The full Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart outlining the study selection process can be found in Supplementary Figure 1 . In total, 11 studies were included in the current review. A single randomized trial, EASY TAVI, prospectively assessed the impact of rapid pacing strategies (LV vs. RV) on total procedure duration and clinical outcomes ( Table 1 ). Five other studies , , retrospectively examined the clinical outcomes of TAVR with direct LV rapid pacing and compared them with those of patients who underwent TAVR with RV pacing ( Table 1 ). The remaining five studies , , evaluated only patients receiving LV pacing to determine its efficacy ( Table 1 ). Table 2 describes the patient characteristics in the included studies.
| Study (ref. #) | Study type | N | Exclusion criteria | ||
|---|---|---|---|---|---|
| Total | LV | RV | |||
| Faurie et al., 2019 | Prospective, multicenter, randomized | 303 | 151 (49.8%) | 152 (50.2%) | Patients undergoing transapical or transaortic procedures |
| Savvoulidis et al., 2022 | Prospective, single center | 1226 | 756 (61.7%) | 470 (38.3%) | Patients undergoing TAVR with a planned access route other than femoral or previous enrollment in this or another trial; patients who received a valve other than SAPIEN 3 or XT |
| Hokken et al., 2021 | Retrospective, single center | 672 | 488 (72.6%) | 45 (6.7%) | Patients undergoing transapical or transaortic procedures; patients with pre-existing conduction disturbances |
| Stąpór et al., 2020 | Retrospective, single center | 143 | 82 (57.3%) | 61 (42.7%) | Patients receiving non-LV pacing (RV-TPW pacing or pacing with PPM) |
| Kotronias et al., 2019 | Retrospective multicenter | 529 | 226 (42.7%) | 303 (57.3%) | Patients receiving RV-TPW pacing |
| Scarsini et al., 2019 | Retrospective multicenter | 263 | 263 | — | Patients receiving RV-TPW pacing |
| Spaziano et al., 2017 | Prospective, single center | 184 | 142 (77.2%) | 42 (22.8%) | Patients with pre-existing conduction disturbances |
| Hilling-Smith et al., 2017 | Prospective, single center | 132 | 132 | — | Patients receiving RV-TPW pacing; patients undergoing TAVR with a planned access route other than femoral |
| Faurie et al., 2016 | Prospective observational multicenter | 87 | 87 | — | — |
| Tamura et al., 2021 | Retrospective, single center | 252 | 204 | — | ∗∗Patients under 18, not referred for BAV or TAVI; patients receiving RV-TPW pacing |
| Díaz de la Llera et al., 2018 | Prospective, single center | 25 | 25 | — | — |
| Study (ref. #) | N | Age (y) | Female sex | Risk score(s) | LVEF (%) | NYHA class | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| EuroSCORE (%) | STS score (%) | I | II | III | IV | |||||
| Faurie et al., 2019 | 303 | 82.94 ± 5.62 | 75/303 (49.5%) | 12.99 ± 10.05 | 4.85 ± 4.81 | 59.08 ± 12.37 | — | — | — | — |
| Savvoulidis et al., 2022 | 1226 | 82 (77-86) | 529/1226 (43.1%) | 12.3 (8.44-19.84) | — | >50 : 859 (70%) 30-49 : 230 (18.8%) <30 : 137 (11.2%) | 156 (12.7%) | 1070 (87.3%) | ||
| Hokken et al., 2021 | 672 | 80 (74-84) | 307/672 (45.7%) | — | — | — | — | — | — | — |
| Stąpór et al., 2020 | 143 | 81 (78-84) | 88/143 (61.5%) | 3.2 (1.9-5.4) | 3.7 (2.7-5.8) | 60 (50-65) | 5/143 (3.7%) | 59/143 (43.4%) | 60/143 (44.1%) | 12/143 (8.8%) |
| Kotronias et al., 2019 | 529 | 83 (79-86) | 239/529 (45.2%) | — | — | — | — | — | — | — |
| Scarsini et al., 2019 | 263 | 83 (79-86) | 111/226 (49.1%) | — | — | >50 : 170 (75%) <50 : 56 (25%) | 6 (0.7%) | 220 (97.3%) | ||
| Spaziano et al., 2017 | 184 | 83 ± 5.9 | 88/142 (47.8%) | 16.5 ± 11.6 | 5.3 ± 4.7 | — | — | — | — | — |
| Hilling-Smith et al., 2017 | 132 | 83.2 | 50/132 (37.5%) | — | — | — | — | — | — | — |
| Faurie et al., 2016 | 87 | 85.5 ± 5.3 | 44/87 (54.3%) | 19.7 ± 11.7 | — | — | 15/87 (18.5%) | 4/87 (4.9%) | 34/87 (42.0%) | 28/87 (34.6%) |
| Tamura et al., 2021 | 252 | 85.1 ± 5.1 | 152/204 (74.5%) | 3.2 (2.1-5.4) | 5.8 (4.1-8.0) | 64 (59-67) | — | — | — | — |
| Díaz de la Llera et al., 2018 | 25 | 79.2 ± 4.6 | — | 5.35 ± 3.9 | 5.81 ± 4.2 | — | 14/25 (56%) | 11/25 (44%) | ||
Rapid Ventricular Pacing in TAVR
Rapid ventricular pacing was first reported as an essential step in BAV. It provides assisted cardiac standstill to optimize balloon dilatation and prevent balloon migration during inflation. The technique typically requires either femoral or internal jugular venous access with a <SPAN role=presentation tabIndex=0 id=MathJax-Element-1-Frame class=MathJax style="POSITION: relative" data-mathml='≥’>≥≥
≥
5 French (Fr) sheath and a temporary pacing lead delivered to the RV apex. In TAVR, the role of rapid pacing is more important than in BAV, as it enables accurate valve implantation while minimizing the risk of device embolization. Rapid pacing is invariably used during balloon-expandable THV deployment; however, it is used more selectively for self-expanding TAVR and often at variable, slower rates. Pacing is essential for balloon postdilatation on all THV devices.
Complications of Right Ventricular Pacing
Temporary pacemaker leads placed in the RV carry inherent risks including infection, access site-related bleeding, vascular complications, and cardiac perforation with potential tamponade. , Deep venous thrombosis, pulmonary embolism, and pneumothorax, which are access-site-specific, have also been reported. , A recent review by Tjong et al. summarized 32 studies from 1990 to 2019, which included 4546 patients who underwent transvenous temporary pacing for various indications (e.g., atrioventricular block, cardiac arrest, myocardial infarction, and drug toxicity). The authors reported an overall access-related complication rate of 2.0% during temporary pacing, of which 0.5% was attributable to minor bleeding, 0.5% to unintended arterial puncture, and 0.7% to excessive bleeding. Cardiac tamponade and cardiac perforation occurred in 0.6% and 1.6% of patients, respectively. Fever (>38 °C) and local wound infection were less common, occurring in 0.4 and 1.3%, respectively. Overall, the death rate related to temporary pacing was low (0.2%). Of note, there was a significant decrease in the total complication rates between the 10-year intervals from 1990 to 2019.
Similar complications have been reported with RV pacing during TAVR. However, since the TAVR procedure is different in nature and complexity from temporary pacing for other indications, it is challenging to assess the rates of vascular and structural complications that are directly related to temporary pacing in TAVR. Furthermore, during TAVR, heparin is given to patients to prevent thromboembolic complications, which increase the risk and rates of bleeding and vascular complications. On the other hand, unlike the use of temporary pacing for other acquired bradyarrythmias, the requirement for pacing for TAVR is relatively short, minimizing the duration the wire remains in situ and the risk for complications. Reported cardiac tamponade rates with RV pacing during TAVR range between 0.2 and 4.3%, , with the majority (52.9%) attributed to RV perforation by the temporary pacing wire. The remainder were due to annular rupture or aortic dissection (23.5%) or LV perforation by the stiff guidewire (23.5%). Similarly, in the EASY TAVI randomized trial, the cardiac tamponade rate in the RV pacing group was 2.6%, with half attributed to RV injury caused by the pacing lead. Importantly, these inherent risks associated with RV pacing remain a concern when bailout from LV pacing due to persistent pacemaker dependence is needed. Of note, in the early days of TAVR, non-balloon-tipped leads were used for rapid pacing, though currently, balloon-tipped leads are more commonly used as this has been shown to be a safer alternative. Most studies included in the current review of pacing strategies in TAVR utilized balloon-tipped leads ( Table 3 ).
| Study | Valve type | Balloon tipped lead used for RV pacing | Guidewire type | Balloon predilatation | Balloon postdilatation | Rate of pacing (bpm) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Balloon expandable (Sapien XT/S3/S3 Ultra) | Self-expandable/other (CoreValve, Evolut, Acurate, Lotus) | Amplatz Extra Stiff/Super Stiff | Confida | Safari (Extra Small/Small) | Other (Lunderquist) | LV | RV | LV | RV | |||||
| LV | RV | LV | RV | |||||||||||
| Faurie et al., 2019 | 151/151 (100%) | 152/152 (100%) | 0/151 (0%) | 0/152 (0%) | Yes | 128/151 (84.8%) | 3/151 (2.0%) | 20/151 (13.2%) | 0/151 (0%) | 14/151 (9.2%) | 10/152 (6.6%) | — | — | 160-220 |
| Savvoulidis et al., 2022 | 672/756 (88.9%) | 410/470 (87.2%) | 84/756 (11.1%) | 60/470 (12.8%) | Yes | 672/756 (88.9%) | — | 85/756 (11.1%) | — | 98/756 (12.96%) | 207/470 (44.1%) | 197 (26.1%) | 126 (30.7%) | 140-200 |
| Hokken et al., 2021 | 262/488 (53.7%) | 22/45 (48.9%) | 226/488 (46.3%) | 23/45 (51.1%) | Yes | — | — | — | — | 181/488 (37.1%) | 15/45 (33.3%) | 188/488 (38.5%) | 12/45 (26.7%) | — |
| Stąpór et al., 2020 | 9/82 (11%) | 17/61 (27.9%) | 73/82 (89%) | 41/61 (67.2%) | No | — | — | — | — | 71/82 (86.6%) | 41/61 (67.2%) | 59/82 (72%) | 37/61 (60.7%) | 140-180 |
| Kotronias et al., 2019 | 85/529 (16.0%) | 444/529 (84.0%) | — | — | — | — | — | — | — | — | — | — | ||
| Scarsini et al., 2019 | 37/226 (16.4%) | — | 189/226 (83.6%) | — | — | — | — | — | — | 121/226 (53.5%) | — | 34/226 (15.0%) | — | — |
| Spaziano et al., 2017 | 97/142 (52.7%) | 87/142 (47.3%) | — | — | — | — | — | — | — | — | — | — | ||
| Hilling-Smith et al., 2017 | 8/132 (6.1%) | — | 124/132 (93.9%) | — | — | — | — | — | — | 110/132 (83.3%) | — | — | — | — |
| Faurie et al., 2016 | — | — | — | — | Yes | — | — | — | — | — | — | — | — | 160-200 |
| Tamura et al., 2021 | 79/204 (38.7%) | — | 125/204 (61.3%) | — | — | 0/204 (0%) | 34/204 (16.6%) | 163/204 (80%) | 7/204 (3.4%) | — | — | — | — | — |
| Díaz de la Llera et al., 2018 | 25/25 (100%) | — | 0/25 (0%) | — | Yes | — | — | — | — | — | — | — | — | 180-240 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
