Incidence, predictors, and clinical outcomes of permanent pacemaker insertion following transcatheter aortic valve implantation in an Arab population.

PURPOSE: Conduction defects requiring permanent pacemaker insertion (PPI) are one of the most common complications after transcatheter aortic valve implantation (TAVI). The purpose of this study was to identify the incidence and predictors of this complication as well as to assess clinical outcomes of patients requiring PPI after TAVI in an Arab population. METHODS: In this single-center, retrospective cohort analysis, all patients who underwent TAVI from 2010 to 2018 were reviewed; seventy-four independent variables were collected per patient, and multivariate analysis was performed to identify predictors. In-hospital outcomes were examined as well as 30-day and 1-year endpoints as defined by the Valve Academic Research Consortium-2. RESULTS: There were 48 of 170 patients (28.2%) who required PPI within 30 days of TAVI. The median time from TAVI to PPI was 2 days (interquartile range: 0 to 5 days). Positive predictors of 30-day PPI were prior right bundle branch block (odds ratio [OR]: 4.10; 95% confidence interval [CI]: 0.37 to 0.79; p < 0.001), post-procedural development of new right bundle branch block (OR: 3.59; 95% CI: 1.07 to 12.03; p = 0.038), post-procedural development of new left bundle branch block (LBBB) (OR: 1.85; 95% CI: 1.21 to 2.84; p = 0.005), post-procedural prolongation of PR interval (OR: 1.02; 95% CI: 1.01 to 1.02; p < 0.001), and post-procedural QRS duration (OR: 1.01; 95% CI: 1.00 to 1.03; p = 0.02). However, post-procedural development of new LBBB no longer remained a significant predictor of PPI after excluding six patients with LBBB who underwent prophylactic PPI (p = 0.093). Negative predictors of 30-day PPI were the presence of diabetes (OR: 0.54; 95% CI: 037 to 0.79; p = 0.001), the use of prosthesis size 29 compared to 23 (OR: 0.55; 95% CI: 0.35 to 0.87; p = 0.010), and the use of prosthesis size 26 compared to 23 (OR: 0.31; 95% CI: 0.20 to 0.50; p < 0.001). PPI was associated with longer median hospital stay, but the result was borderline significant after multivariate adjustment (19 vs. 14 days; p = 0.052). There was no statistically significant difference in 30-day and 1-year clinical outcomes. CONCLUSION: One-third of patients required PPI after TAVI. Several risk factors can identify patients at risk for PPI particularly pre-existing right bundle branch block. Further studies are needed to assess the association between PPI and negative clinical outcomes.

Coronary Artery Ectasia with Acute Myocardial Infarction, A Case Report.

Coronary artery ectasia (CAE), also known as aneurysmal coronary artery disease, is defined as an abnormal diffuse (ectasia) or segmental (aneurysmal) dilatation of any branch of the coronary arteries. It is a well-recognized entity with 1.2-4.9% prevalence. Our case is a 46 year old male with no prior medical problem who presented to the ER with inferior ST elevation myocardial infarction (STEMI). The Coronary angiogram revealed multiple ectatic segments in the right coronary artery (RCA) with 100% stenosis in the middle segment. Upon wiring the RCA a big clot burden was noted on the ectatic segment. We planned to keep him on aggrastat infusion for 24 hours then re-cath him. The second cath showed complete resolution of the clot and the lesion was stented with drug eluting stent showing excellent final result. We found that our case is interesting and unique in exploring the association of CAE that presents with STEMI and how to treat it safely in the cath lab, knowing that CAE is an uncommon finding during coronary angiography. CAE is associated with many coronary artery disease (CAD) risk factors and etiologies as well as pathologic progression. Patients with CAE are usually asymptomatic but can still present with symptoms of coronary artery occlusion. There is still no standard treatment specific for CAE itself, but when presenting with occlusive symptoms, management is guided by the extent of occlusion similar to CAD.