Cardiac resynchronization therapy in transcatheter aortic valve replacement recipients – insights in the GARY registry
J Kirchner, M Feisst, T Fink, P Sommer, A Beckmann, R Bekeredjian, S Ensminger, J Sinnig, M Seiffert, W Kim, T Walther, G ElHachem, V Rudolph, S Bleiziffer, T RudolphAbstract
Introduction
New-onset conduction disturbances (NCD) are common after transcatheter aortic valve replacement (TAVR) and frequently require permanent pacemaker implantation (PMI). While cardiac resynchronization therapy (CRT) is generally recommended in heart failure patients with reduced left ventricular ejection fraction (LVEF) who require ventricular pacing, its role following TAVR remains unclear.
Purpose
To evaluate the impact of CRT after TAVR on all-cause mortality compared to sole right ventricular pacing (RVP) and NCD without PMI.
Methods
We analyzed all patients undergoing TAVR between 2020 and 2023 in the prospective German Aortic Valve Registry (GARY). NCD was defined as new bundle branch block and/or atrioventricular block after TAVR. Outcomes were compared using 2:1 propensity score (PS) matching based on age, sex, intervention mode, and baseline LVEF. The primary endpoint was 1-year all-cause mortality.
Results
Of 16,779 patients undergoing TAVR between 2020 and 2023, 12% of patients received RVP and 1% CRT after TAVR. In the entire cohort, irrespective of baseline LVEF, CRT was not associated with improved 1-year survival compared with RVP (P=0.31).
Among 4,286 patients with baseline LVEF ≤50%, 636 (15%) underwent new PMI. Of those, 107 patients (20%) received CRT, while 529 patients (80%) underwent RVP. In the unmatched heart failure cohort, 1-year mortality was higher in RVP versus CRT patients (23% vs. 8%; Hazard ratio [HR] 3.26 [1.18-9.00]; P=0.016). After PS matching, RVP remained associated with increased mortality compared to CRT (HR 3.93 [1.37-11.28]; P=0.006). Compared to patients with reduced LVEF and NCD after TAVR, but who did not undergo PMI, CRT showed a trend toward lower 1-year mortality after matching (HR 0.37 [0.13-1.09]; P=0.06).
Conclusion
In TAVR patients with reduced LVEF, CRT was associated with improved 1-year survival compared with RVP and showed a trend toward benefit compared with NCD without device therapy. Randomized trials are needed to define optimal pacing strategies after TAVR in patients with impaired LVEF.