Device console programming in patients undergoing TAVI with preexisting cardiac implantable electronic devices: a practical guide

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) has emerged as the preferred therapeutic option across the full spectrum of surgical risk, and more recently its indications have expanded to include younger patients and those at low surgical risk.1-4 Patients undergoing TAVI are typically elderly and burdened with significant cardiovascular comorbidities, with a considerable proportion (8.7% to 23.1%) having preexisting cardiac implantable electronic devices (CIED).5-6

Temporary transvenous pacing is a well-established and integral component of TAVI, facilitating procedural success by reducing cardiac contractility during balloon aortic valvuloplasty and valve deployment. The target pacing rate varies according to the valve type: approximately 120 bpm for self-expanding valves and approximately 180 bpm for balloon-expandable valves.7 In the 2 scenarios, the objective is to mitigate the risk of micro- or macro-dislodgement or embolization during implantation.

Notwithstanding its utility, temporary right ventricular (RV) pacing is associated with potential complications, including myocardial injury, RV dysfunction, and perforation, which may culminate in cardiac tamponade.8-10 Furthermore, lead dislodgement and pacing failure have been reported among patients undergoing temporary pacing for a variety of indications, with incidence rates of approximately 4.6% and 9.5%, respectively. Although these figures are not specific to TAVI, they highlight that such complications are not rare and may result in ineffective pacing or sensing, thereby increasing the risk of critical intraoperative events, such as valve embolization or migration.11

To address these limitations, alternative pacing strategies have been proposed. Among them, left ventricular pacing via the valve delivery guidewire offers several advantages, such as elimination of the need for venous access, reduction of the risk of RV perforation, and potential reduction in procedural duration.12,13

In patients with preexisting CIED, use of the permanent device for procedural pacing appears to be a rational strategy to minimize complications.

The present article aims to address this unmet need by providing a concise and practical step-by-step guide for the use of the most widely encountered CIED programming consoles, thereby promoting safer and more efficient pacing management during TAVI.

METHODS

This step-by-step guide for pacing patients with preexisting CIED during TAVI is derived from the routine clinical practice of our high-volume TAVI center, developed in close collaboration with our Electrophysiology Unit and in full compliance with the usage recommendations provided by our industry partners.

RESULTS

Biotronik (Germany)

Not all pacemaker models support electrophysiological testing. However, this limitation can be overcome by using the threshold measurement section. Select “Test”, then “Pacing Threshold”, and choose “Manual” (figure 1A,B). First, select the pacing mode (eg, VVI), then set the desired pacing rate (up to 200 bpm) and ensure the output is set to the maximum (7.5V) to guarantee proper capture. Once all parameters are configured, press the “Start” button to begin stimulation, which will continue until manually stopped. If the device supports rapid pacing, such as non-Invasive programmed stimulation (NIPS), overdrive pacing can be performed using the VVI or V00 mode (figure 1C). Select the desired mode and basic rate, then press the “Start Backup Program” button.

Figure 1. A: main screen of the Biotronik console. Select “Test” as indicated by the arrow to proceed to the pacing tests. B: to proceed to the pacing tests, select “Manual,” then set the following parameters: pacing mode (arrow 1), basic rate (arrow 2), amplitude (arrow 3), and press “Start” to initiate pacing (arrow 4). C: configure the NIPS parameters by selecting VVI mode (arrow 1), setting the basic rate (arrow 2), and pressing “Start” to begin pacing (arrow 3). NIPS: Non-Invasive Programmed Stimulation.

Medtronic (United States)

Once on the main screen (figure 2A), press the “Test” tab, then navigate to “Electrophysiology Study” and select either “Fixed Burst” or “Burst” (figure 2B). The interface will prompt you to choose the chamber in which pacing will be applied — select “Right Ventricular”. Adjust the interval to the desired value (as the interval decreases, the frequency increases — for example, 200 bpm corresponds to 300 ms). Once all parameters are set, press and hold the “Press and Hold” button to begin stimulation; release it to stop.

Figure 2. A: main screen of the Medtronic console. Press “Tests” (arrow) to access the electrophysiology study screen. B: select “Fixed Burst” or “Burst” (arrow 1), adjust the interval as needed (arrow 2), and press and hold the “Burst” button (arrow 3) to deliver pacing.

Abbott/St Jude (United States)

Once on the main screen (figure 3A), press “Test”. There are 2 options to perform rapid ventricular pacing:

• –NIPS (figure 3B): Click “Ventricular NIPS”, then select “Burst”, set the “Pulse Amplitude” (the output should be high to ensure capture), and adjust the pacing rate. In this case, the S1–S1 interval corresponds to the cycle length of the stimuli applied and must be set according to the desired heart rate. For example, 200 bpm corresponds to an S1–S1 interval of 300 ms.
• –Temporary pacing (figure 3C): Select the pacing mode (in this case, VVI), the desired rate (up to 170 bpm), and the maximum output to ensure capture. Once all parameters are set, press “Start Temporary” to begin pacing. Stimulation will continue until manually stopped.

Figure 3. A: main screen of the Abbott/St. Jude console. Press “Test” to proceed to the electrophysiology study screen. B: ventricular NIPS screen. Select “Burst” (arrow 1), set the amplitude (arrow 2), adjust the S1–S1 interval (arrow 3), and press the green button to deliver pacing (arrow 4). C: temporary pacing screen. Select the pacing mode (arrow 1), desired rate (arrow 2), and pulse amplitude (arrow 3), then press the “Start Temporary” button (arrow 4).

Sorin (Italy)

Select ”Tests”, then choose ”NIPS”. Under ”Mode”, select either ventricular pacing or ventricular burst, depending on the desired function. Next, set the ”Basic Period” (figure 4A,B) by choosing the corresponding rate in milliseconds (for example, 200 bpm corresponds to 300 ms). Once all parameters are set, press ”Start NIPS” to initiate the test.

Figure 4. A: main screen of the Sorin console. Select “Tests EGM” (arrow) to access pacing options. B: “Tests EGM” screen. Select the pacing mode (arrow 1), the interval period (arrow 2), and then press the “Start NIPS” button (arrow 3).

Boston Scientific (United States)

Once on the main screen (figure 5A), select “Test”, then choose “Temp Brady” (figure 5B) From there, select VVI mode and set the desired heart rate under “Lower Rate Limit.” As in previous cases, ensure that the maximum output is selected to guarantee proper capture. After all parameters have been configured, press the ”Start” button to begin.

Figure 5. A: main screen of the Boston Scientific console. Select “Test” (arrow) to proceed to the pacing setup. B: select VVI mode (arrow 1), set the lower rate limit (arrow 2) and amplitude (arrow 3), then press the “Start” button to begin pacing (arrow 4).

DISCUSSION

While earlier permanent pacing devices had limitations in achieving instantaneous burst pacing —such as ramping up the ventricular rate instead of immediate increase and requiring time to reset the function—contemporary devices have largely overcome these issues.14 Most current models allow rapid burst pacing up to 180 bpm with immediate start and stop, using electrophysiology program mode settings or whenever electrophysiology program is not available (especially in some pacemakers) via a threshold test with maximum output and maximum duration. In cases where this is not possible or does not ensure adequate rapid pacing, the placement of a temporary pacing lead should be considered. Table 1 lists several of the most widely used CIED in our routine clinical practice and specifies whether they provide the capability for rapid temporary pacing or electrophysiological testing). It is always required to ensure that any changes in device programming are reversed and individually optimized; therefore, verification of the device settings at the beginning of the procedure is recommended, and any changes or modifications at the end should be avoided. In patients with implantable cardioverter defibrillator or cardiac resynchronization therapy-defibrillator devices, tachyarrhythmia therapies should be deactivated before the procedure to avoid inappropriate shocks. Of note, some temporary pacing algorithms have a programmed duration limit, so it is essential to verify in advance that high-rate temporary pacing can be maintained for the entire time required for prosthesis deployment, as this may vary depending on the device and pacing mode used.

Table 1.

Given the high ventricular rates required during this process and the deactivation of therapies in patients with implantable cardioverter defibrillator or cardiac resynchronization therapy-defibrillator devices, these maneuvers should be undertaken in a controlled environment with continuous monitoring, immediate availability of cardiopulmonary resuscitation, and access to external defibrillation equipment.

Currently, temporary RV pacing remains a common clinical practice during TAVI in this patient subgroup despite growing evidence that pacing via an implanted CIED is safe and feasible and may reduce pacemaker-related complications, such as cardiac tamponade and hemorrhage vs temporary RV pacing.9,15 However, certain challenges may arise, mainly of an organizational nature. During TAVI, a manufacturer-specific CIED programmer must be available, and the operator responsible for pacing should be adequately trained on how to operate the device programming functions. Because programming options vary by manufacturer and device type, operators must have thorough and specialized knowledge. In addition, the presence of trained nurses with specific expertise is essential to support device programming and ensure procedural safety. These devices can deliver rapid ventricular pacing through anti-tachycardia pacing functions but programming them often requires adjusting more complex parameters. Our proposed strategy is simpler and more practical, especially for professionals less experienced with advanced device programming.

CONCLUSIONS

In patients undergoing TAVI with preexisting cardiac implantable electronic devices, leveraging the implanted device for procedural pacing is a feasible and potentially safer alternative to temporary RV pacing. This strategy may reduce the risk of complications such as perforation, lead dislodgement, and bleeding. However, its broader adoption is hindered by the variability in device programming interfaces and limited operator familiarity. The step-by-step instructions provided in this guide aim to facilitate the practical implementation of this approach across the most widely encountered CIED platforms, ultimately promoting safer, more efficient, and complication-free TAVI procedures.

FUNDING

None declared.

ETHICAL CONSIDERATIONS

This is a step-by-step practical guide article; therefore, ethical committee approval was deemed unnecessary. No informed consent was required. Potential gender bias has been considered and excluded.

STATEMENT ON THE USE OF ARTIFICIAL INTELLIGENCE

Artificial intelligence has not been used in the development of this paper.

AUTHORS’ CONTRIBUTIONS

F. Pensotti and L.J. Garnacho elaborated the manuscript under the supervision of I.J. Amat-Santos that revised and drafted the manuscript. All the remaining authors conducted a critical review. All authors approved the final version.

CONFLICTS OF INTEREST

None declared.

REFERENCES