Arrhythmia Burden in Elderly Patients With Severe Aortic Stenosis as Determined by Continuous Electrocardiographic Recording

Abstract

T he occurrence of new conduction abnormalities and the need for permanent pacemaker implantation (PPI) are frequent complications of transcatheter aortic valve replacement (TAVR) and may potentially jeopardize the use of this technology in a lower-risk and younger population. 1,2 In addition to the aortic stenosis itself, it has been shown that advanced age and comorbidities such as heart failure, hypertension, and diabetes mellitus, all of which are very frequent in candidates for TAVR, are associated with a high prevalence of left bundle-branch block (LBBB) and severe bradyarrhythmias, irrespective of TAVR.3-8 Furthermore, it is well known that these conduction disorders may be paroxysmal and asymptomatic 9 or lead to symptoms similar to those of aortic stenosis, and the occurrence of these abnormalities may therefore be overlooked unless ECG Background-This study sought to evaluate the prevalence of previously undiagnosed arrhythmias in candidates for transcatheter aortic valve replacement (TAVR) and to determine the impact on therapy changes and arrhythmic events after the procedure. Methods and Results-A total of 435 candidates for TAVR underwent 24-hour continuous ECG monitoring the day before the procedure. Newly diagnosed arrhythmias were observed in 70 patients (16.1%) before TAVR: paroxysmal atrial fibrillation (AF)/atrial tachycardia (AT) in 28, advanced atrioventricular block or severe bradycardia in 24, nonsustained ventricular tachycardia in 26, and intermittent left bundle-branch block in 3 patients. All arrhythmic events but one were asymptomatic and led to a therapy change in 43% of patients. In patients without known AF/AT, the occurrence of AF/AT during 24-hour ECG recording was associated with a higher rate of 30-day cerebrovascular events (7.1% versus 0.4%; P=0.030). Among the 53 patients with new-onset AF/AT after TAVR, 30.2% had newly diagnosed paroxysmal AF/AT before the procedure. In patients who needed permanent pacemaker implantation after the procedure (n=35), 31.4% had newly diagnosed advanced atrioventricular block or severe bradycardia before TAVR. New-onset persistent left bundle-branch block after TAVR occurred in 37 patients, 8.1% of whom had intermittent left bundle-branch block before the procedure. Conclusions-Newly diagnosed arrhythmias were observed in approximately a fifth of TAVR candidates, led to a higher rate of cerebrovascular events, and accounted for a third of arrhythmic events after the procedure. This high arrhythmia burden highlights the importance of an early diagnosis of arrhythmic events in such patients to implement the appropriate therapeutic measures earlier.

Clinical and Echocardiographic Outcomes Following Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement

“…12,16 It is also possible that unrecognized episodic high-grade conduction disease before TAVR resulted in higher mortality in the non-PPM group. 43 We also found that although difference in risk of stroke at 1 year did not reach statistical significance, there was a trend toward reduced risk in patients with PPM (RR, 0.70; 95% CI, 0.47-1.04). One possible explanation for this may be unmatched baseline characteristics.…”

Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association

“…AF is also common after TAVR. 243,244 Current consensus documents recom mend continuous monitoring early after the procedure (at least 3 days). 236 In a recent analysis 245 of 32 studies of TAVR, including >5000 patients without pacemaker before the procedure, the need for a pacemaker was reported in 25% of Medtronic CoreValve and in 6% of the Edwards SAPIEN valve recipients.…”

Transcatheter aortic valve implantation. Expert Consensus of the Association of Cardiovascular Interventions of the Polish Cardiac Society and the Polish Society of Cardio-Thoracic Surgeons, approved by the Board of the Polish Cardiac Society…

“…Current guidelines do not recommend a prophylactic implantation of pacemakers based on the existence of risk factors for conduction defects. However, early detection of such defects allows shortening of the time needed for decision-making if such complications occur after TAVI [109].…”

“…In the case of a complete AVB with a low rate escape rhythm, the time of monitoring may be shortened, due to a low probability of recovery. Unfortunately, current registry data indicate that clinical practice does not follow the published guidelines: 33% of pacemaker implantations occur in the first 24 h, and 50% of them in the first 48 h, after TAVI [109,111].…”