Cardiac conduction abnormalities associated with pacemaker implantation after transcatheter aortic valve replacement

Abstract

Background: Complete heart block is a known complication after transcatheter aortic valve replacement (TAVR), often requiring pacemaker implantation within 24 hours of the procedure.However, clinical markers for delayed progression to complete heart block after TAVR remain unclear. Objectives:We examined electrocardiographic data that may correlate with delayed progression to complete heart block and need for pacemaker.Methods: This is a single-center retrospective study of 608 patients who underwent TAVR between April 2008 and June 2017. We excluded 164 (27.0%) patients due to having a pacemaker before the procedure or expiring within 24 hours of the procedure (8, 1.3%). We excluded an additional 50 (8.2%) patients who received a pacemaker within 24 hours of the procedure. Electrocardiograms (EKGs) obtained after the procedure were compared to the preprocedural EKG to detect new changes.Results: Left bundle branch block, intraventricular conduction delay, left anterior fascicular block, and right bundle branch block were the most commonly seen conduction abnormalities after TAVR (25.1%, 10.9%, 7.5%, and 3.6%, respectively). Both left bundle branch block (odds ratio [OR] = 2.77 [95% confidence interval (CI): 1.24-6.22]) and right bundle branch block (OR = 13.2 [95% CI: 4.18-41.70]) carried an increased risk of pacemaker implantation after TAVR. Additionally, ΔPR greater than 40 ms from baseline also carried an increased risk of pacemaker implantation (OR = 3.53 [95% CI: 1.49-8.37]). Conclusion:Left bundle branch block, right bundle branch block, and ΔPR greater than 40 ms were all associated with delayed progression to complete heart block and need for pacemaker implantation after TAVR. K E Y W O R D SEKG, pacemaker implantation, transcatheter aortic valve replacement 846

Impact of Bundle Branch Block on Permanent Pacemaker Implantation after Transcatheter Aortic Valve Implantation: A Meta-Analysis

“…Table 1 shows the baseline characteristics of the included studies. The 36 studies included a total of 55,851 patients in the final analysis, from 2005 to 2018 [ 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 ]. The mean age of the patients was 81.9 years, with a mean STS score of 8.3.…”

Time Course and Risk Factors of New-Onset Complete Atrioventricular Block After Transcatheter Aortic Valve Implantation

“…Cresse, et al reported that the lengthening of the PR interval by more than 40 msec after the procedure was associated with delayed episodes of complete heart block and the need for PPM implantation. 19) Riverd, et al performed electrophysiologic studies on TAVI patients and found that postprocedural prolongation of the HV interval was strongly associated with CAVB development. 20) In the MARE study, Rodes-Cabau, et al proposed the use of implantable cardiac monitoring devices in patients at a high risk of developing CAVB.…”

Predictors, clinical impact, and management strategies for conduction abnormalities after transcatheter aortic valve replacement: an updated review

“…Data from a Chinese TAVR cohort indicated that new-onset LBBB ( p = 0.004) and lead I T-wave elevation ( p = 0.016) were the primary predictors of PPI ( 52 ). It was also suggested in some studies that ΔPR (the difference between the postoperative and preoperative PR intervals) was probably an independent predictor of delayed late conduction disorders (≥48 h) after TAVR ( 53 ), with ΔPR > 40 ms linked notably to an increased risk of PPI ( 54 ). In particular, a study on delayed total atrioventricular block (DT-AVB) morbidity and potential predictors after TAVR highlighted that intraoperative HV interval prolongation (OR: 1.07; 95% CI: 1.02–1.14; p = 0.015) and PQ interval prolongation between the next day post-TAVR and baseline (OR: 1.04; 95% CI: 1.01–1.09; p = 0.032) might predict the occurrence of DT-AVB ( 55 ).…”

“…As highlighted by Wang et al in a case report, other new-onset conduction abnormalities beyond AVB or LBBB after TAVR pose risks of potentially progressing to severe conduction blocks or indicating significant damage to the cardiac conduction system, prompting the development of adverse events ( 116 ). Cresse et al, in a single-center retrospective study, reported that patients with new-onset RBBB after TAVR had a higher incidence of complete atrioventricular block (CHB) and PPI requirement than those without new-onset RBBB (OR: 13.2; 95% CI: 4.18–41.70; p < 0.0001) ( 54 ). Moreover, anatomic studies suggest that owing to early anatomic separation of the right and left bundle branches, the proximal branch of the right bundle branch may emerge first to the left of the interventricular septum, which is susceptible to valve-related damage ( 117 ).…”