Association of Clinical and Economic Outcomes With Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement

Key Points

Question

What are the clinical and economic outcomes in patients who required permanent pacemaker implantation after transcatheter aortic valve replacement ?

Findings

In this population-based cohort study of 1263 patients who underwent transcatheter aortic valve replacement, implantation of a new permanent pacemaker was associated with significantly greater all-cause mortality, all-cause readmission, and all-cause emergency department visits. However, this did not translate to a statistically significant difference in cumulative postdischarge health care costs.

Meaning

The need for permanent pacemaker implantation after transcatheter aortic valve replacement is a complication associated with worse survival as well as increased risk of hospitalization.

Abstract

This cohort study uses registry data to examine associations between permanent pacemaker implantation during hospitalization for transcatheter aortic valve replacement (TAVR) and mortality, hospital readmission, emergency department visits, and health care costs.

Abstract

Importance

The literature is inconsistent regarding the impact of permanent pacemaker implantation after transcatheter aortic valve replacement.

Objective

To evaluate clinical and economic outcomes in patients who required permanent pacemaker implantation during the index hospitalization after transcatheter aortic valve replacement.

Design, Setting, and Participants

This retrospective, population-based cohort study using data from a multicenter registry included patients who underwent a transcatheter aortic valve replacement procedure from April 1, 2010, to March 31, 2015, in Ontario, Canada, with follow-up to March 31, 2017. Patients who had a previously implanted permanent pacemaker or who died during the index hospitalization were excluded. Inverse probability of treatment weighting using the propensity score was used to adjust for baseline differences between the pacemaker and nonpacemaker groups.

Exposures

Patients received a permanent pacemaker during the index hospitalization after transcatheter aortic valve replacement.

Main Outcomes and Measures

All-cause mortality, readmission, readmission for heart failure, emergency department visits, and cumulative 1-year health care costs.

Results

The study cohort consisted of 1263 patients (mean [SD] age, 82.3 [7.2] years; 595 [47.1%] female; 137 [10.8%] rural), of whom 186 (14.7%) required permanent pacemaker insertion during the index hospitalization after transcatheter aortic valve replacement. Mean follow-up was 990 days. After propensity score weighting, over the entire follow-up period, pacemaker implantation was associated with significantly higher all-cause mortality (43.9% vs 31.7%; hazard ratio [HR], 1.40; 95% CI, 1.01-1.94; P = .04), all-cause readmission (80.9% vs 70.6%; HR, 1.28; 95% CI, 1.15-1.43; P < .001), and emergency department visits (95.5% vs 87.3%; HR, 1.28; 95% CI, 1.08-1.52; P = .004). Pacemaker implantation was also associated with significantly greater readmission for heart failure (33.9% vs 19.1%; HR, 1.90; 95% CI, 1.53-2.36; P < .001). There were no statistically significant differences between groups in adjusted cumulative health care costs 1 year after discharge.

Conclusions and Relevance

New permanent pacemaker implantation after transcatheter aortic valve replacement was associated with significantly greater morbidity and mortality at long-term follow-up. However, this did not translate to a difference in cumulative health care costs after hospital discharge.