THE COST OF PERMANENT PACEMAKER IMPLANTATION FOLLOWING TRANSCATHETER AORTIC VALVE REPLACEMENT

Purpose: The need for permanent pacemaker implantation is a common complication following Transcatheter Aortic Valve Replacement (TAVR), with rates between 5% and 25% depending on the valve system selected.   Several studies have assessed the clinical impact of this complication; however, the economic consequences are not well defined.  The purpose of this study was to analyze the incremental hospital resource consumption associated with new pacemaker implantation after TAVR.

Methods: Using the Medicare Provider Analysis and Review File, we retrospectively analyzed 5,456 Medicare beneficiaries who underwent TAVR in fiscal year 2012.  The incremental hospital resource consumption, which included hospital length of stay and cost, was estimated for patients who underwent permanent pacemaker implantation during their index TAVR hospitalization.  Multivariate regression models were used to control for differences in patient demographics, comorbidities and complications.

Results:  Among 5,456 Medicare beneficiaries receiving TAVR, the mean length of stay for the index hospitalization was 8.43 days, and the mean cost was $55,036.  8.4% (460) of patients developed severe conduction disturbances requiring permanent pacemaker implantation.  After adjusting for patient demographics, comorbid conditions and complications, those requiring a new permanent pacemaker experienced a significantly longer hospital length of stay (+2.23 days; p <0.00) and consumed more hospital resources (+$18,240; p <0.00).

Conclusion: In the Medicare population, permanent pacemaker implantation after TAVR was associated with a significantly longer hospital length of stay and higher cost.  Preventing this complication may generate substantial cost savings to hospitals.  Future quality improvement initiatives in TAVR should focus on minimizing this costly complication.

Table 1.  Adjusted Incremental Hospital Resource Utilization Associated With Permanent Pacemaker Implantation Following TAVR

Cost Category	Incremental Cost, $	p Value
ICU/CCU	+2,566	<.001
OR/Cardiology/Cath Lab	+3,997	<.001
Supplies	+8,782	<.001
Pharmacy/Lab/Radiology	+1,304	<.001
Other	+1,591	<.001
Total	+18,240	<.001

ICU = intensive care unit; CCU = cardiac care unit; OR = operating room.  Other includes routine care, therapy services, ER, blood, inhalation, anesthesia and other.