Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Pre-Existing Permanent Pacemaker or Implantable Cardioverter-Defibrillator: A Nationwide Propensity-Matched Analysis

Abstract

Patients with severe aortic stenosis and a pre-existing permanent pacemaker (PPM) or implantable cardioverter-defibrillator represent a distinct subgroup in whom the usual pacemaker disadvantage of transcatheter aortic valve replacement (TAVR) is largely neutralized. We used the National Inpatient Sample 2016-2022 to compare isolated TAVR versus surgical aortic valve replacement (SAVR) in adults with aortic stenosis and pre-existing PPM/implantable cardioverter-defibrillator. After exclusions, 8776 hospitalizations were identified (8141 TAVR; 635 SAVR), and 501 well-balanced propensity-matched pairs were formed. The primary outcome was in-hospital all-cause mortality; secondary outcomes included major adverse cardiovascular and cerebrovascular events, procedural complications, length of stay, and discharge disposition. In the matched cohort, in-hospital mortality was lower after TAVR than SAVR (0.80% vs 2.59%; matched odds ratio 0.31, 95% confidence interval, 0.10-0.94; P = 0.049). TAVR was also associated with a lower major adverse cardiovascular and cerebrovascular events, stroke/transient ischemic attack, acute kidney injury, major bleeding/transfusion, cardiogenic shock, respiratory failure, lead revision, nonroutine discharge, and shorter length of stay, without excess new-pacemaker procedures. These findings support TAVR as a favorable strategy in selected patients already carrying cardiac rhythm devices.