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. 2025 Jan 20;21(2):e119-e129.
doi: 10.4244/EIJ-D-24-00850.

Development and validation of the D-PACE scoring system to predict delayed high-grade conduction disturbances after transcatheter aortic valve implantation

Francesco Bendandi  1   2 , Nevio Taglieri  1 , Leonardo Ciurlanti  1 , Alessandro Mazzapicchi  1 , Marco Foroni  1 , Laura Lombardi  1 , Francesco Palermo  1 , Francesco Filice  1 , Gabriele Ghetti  1 , Antonio Giulio Bruno  1 , Mateusz Orzalkiewicz  1 , Giuliano Costa  3 , Valentina Frittitta  3 , Alessandro Comis  3 , Sofia Sammartino  3 , Maria Chiara Calì  3 , Elena Dipietro  3 , Luigi La Rosa  3 , Corrado Tamburino  3 , Tullio Palmerini  1 , Marco Barbanti  3   4 , Francesco Saia  1
Affiliations

Development and validation of the D-PACE scoring system to predict delayed high-grade conduction disturbances after transcatheter aortic valve implantation

Francesco Bendandi et al. EuroIntervention. .

Abstract

Background: New conduction disturbances are frequent after transcatheter aortic valve implantation (TAVI). Refining our ability to predict high-grade atrioventricular block (AVB) occurring later than 24 hours after the procedure would be useful in order to select patients eligible for early discharge.

Aims: This study was designed to identify predictors of high-grade AVB occurring between 24 hours and 30 days after TAVI and to develop and validate a predictive risk score.

Methods: We analysed clinical, procedural, and electrocardiographic parameters of 1,290 TAVI patients. Independent predictors of delayed high-grade AVB were used to develop the predictive score, which was then externally validated in a cohort of 936 patients.

Results: Implantation of self-expanding valves, greater implantation depth, longer PR interval in preprocedural electrocardiogram (ECG) and greater increase of PR duration in next-day ECG, preprocedural right bundle branch block (RBBB) and new-onset left bundle branch block or RBBB that persisted in next-day ECG were independent predictors of delayed high-grade AVB and were combined to develop the Delayed atrioventricular block Prediction for eArly disChargE (D-PACE) score. The areas under the curve of the score were 0.879 (95% confidence interval [CI]: 0.835-0.923) and 0.799 (95% CI: 0.730-0.868) in the derivation and validation cohorts, respectively. Based on the score, patients can be classified into three risk categories; low-risk patients demonstrated an incidence of delayed AVB of less than 1% and are ideal candidates for next-day discharge.

Conclusions: The D-PACE score can be used to stratify TAVI patients according to their risk of delayed high-grade AVB and thereby identify those suitable for next-day discharge.

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Conflict of interest statement

F. Saia has received consulting and lecture fees from Abbott, Edwards Lifesciences, and Medtronic. T. Palmerini has received speaker fees from Edwards Lifesciences and Medtronic. The other authors have no conflicts of interest regarding the content of the study to declare.

Figures

Figure 1
Figure 1. Distribution of D-PACE scores in the derivation cohort and predicted AVB incidence.
Blue bars show the percentage of patients from the derivation cohort for each score value; the red line displays the mean predicted probability of late-onset high-grade AVB for each score value. AVB: atrioventricular block; D-PACE: Delayed atrioventricular block Prediction for eArly disChargE
Figure 2
Figure 2. Receiver operating characteristic curves for the D-PACE score.
A) Curve from the derivation cohort (area under the curve [AUC] 0.879, 95% confidence interval [CI]: 0.835-0.923). B) Curve from the validation cohort (AUC 0.799, 95% CI: 0.730-0.868). D-PACE: Delayed atrioventricular block Prediction for eArly disChargE; ROC: receiver operating characteristic
Figure 3
Figure 3. Distribution of patients across the three risk categories and observed and predicted rates of delayed high-grade AVB in each category.
Grey bars show the percentage of patients in each risk category; blue bars show the observed event rate; red bars show the predicted event rate. Observed and predicted risks were similar in both the derivation (A) and validation (B) cohorts, indicating good calibration of the model. AVB: atrioventricular block
Central illustration
Central illustration. Algorithm for delayed high-grade AVB risk stratification.
The algorithm should be applied 24 hours after TAVI if there have been no episodes of high-grade AVB in this time interval. Bundle branch blocks are considered persistent if they are present in both postprocedural and next-day (12-24 hours after TAVI) ECGs. Next-day PR variation is the difference in PR interval duration between preprocedural and next-day ECGs. *The D-PACE AF score requires additional validation, and there is no established cutoff for suggesting early discharge. Image adapted from Biorender.com. AF: atrial fibrillation/flutter; AVB: atrioventricular block; D-PACE: Delayed atrioventricular block Prediction for eArly disChargE; ECG: electrocardiogram; LBBB: left bundle branch block; RBBB: right bundle branch block; TAVI: transcatheter aortic valve implantation; ViV: valve-in-valve
See this image and copyright information in PMC

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