Clinical Impact of Preexisting Right Bundle Branch Block after Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Abstract

Introduction. Transcatheter aortic valve replacement (TAVR) is now the treatment of choice for patients with severe aortic stenosis regardless of their surgical risk. Right bundle branch block (RBBB) can be a predictor for development of significant atrioventricular (AV) block after TAVR, requiring permanent pacemaker implantation (PPI). However, data related to the risk of PPI requirement with preexisting RBBB is scarce. Hence, this systematic review and meta-analysis aims to assess clinical outcomes of patients undergoing TAVR with RBBB on preexisting electrocardiogram. Methods. We performed a systematic literature review to identify randomized and nonrandomized clinical studies that reported any clinical impact of patients undergoing TAVR with preexisting RBBB. A total of eight databases including PubMed (Medline), Embase, Cochrane Library, ACP Journal Club, Scopus, DARE, and Ovid containing articles from January 2000 to May 2020 were analyzed. Results. We identified and screened 224 potential eligible publications through the databases and found 14 relevant clinical trials for a total of 15,319 participants. There was an increased 30-day pacemaker implantation rate of 38.1% in the RBBB group compared to 11.4% in the no RBBB group with a risk ratio of 3.56 (RR 3.56 (95% CI 3.21–3.93, p<0.01)). There was an increased 30-day all-cause mortality in the RBBB group of 9.5% compared with 6.3% in the no RBBB group with an odds ratio of 1.60 (OR 1.60 (95% CI 1.14–2.25, p<0.01)). Conclusion. This study indicates that patients with preexisting RBBB have higher incidence of PPI and all-cause mortality after TAVR compared with patients without RBBB. Further trials are needed to compare the clinical outcomes based on TAVR valve types and assess the benefit of PPI in patients with new-onset RBBB after TAVR.

Predictors of Permanent Pacemaker Implantation in Patients Undergoing Transcatheter Aortic Valve Replacement ‐ A Systematic Review and Meta‐Analysis

“…On review, we found 40 previous meta‐analyses discussing the risk factors of PPM implantation, however in light of the current evidence the applicability of those studies is limited. 92 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 Most of these meta‐analyses included a smaller number of previously published studies ranging from 4 to 41 articles, missing a large amount of contemporary data. The selection criteria and measured predictors were limited with respect to conduction abnormalities evaluated, indications for TAVR, and in some incidences inclusive of SAVR patients.…”

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

“…Pre-existing RBBB has been demonstrated in 6.9% [ 67 ] up to 13.6% [ 44 ] of patients undergoing TAVI and is a common underlying conduction disturbance in TAVI patients [ 10 ]. In this study, the cumulative proportion of RBBB among the included studies reached 9.2%, also in accordance with the studies of Auffret and colleagues [ 45 ], reporting a prevalence of RBBB of 10.3% in TAVI candidates.…”

“…Our findings confirm the impact of such a condition on post-TAVI PPI, without the influence of age or LVEF. As previous studies emphasized the higher all-cause mortality and the poorer clinical outcomes in patients with pre-existing RBBB [ 10 , 45 ], bradyarrhythmia events may participate in the poorer outcomes of these patients. However, this analysis does not provide the cause of such discrepancies between RBBB and LBBB.…”

“…Therefore, better patient selection and identification of pre-operative risk factors for progression of conduction disturbances, and subsequently PPI, are decisive [ 8 ]. Current data about the clinical impact of bundle branch block on post-TAVI PPI remain controversial [ 9 , 10 ]. Left bundle branch block (LBBB) occurs in 5 to 65% in TAVI patients and leads to PPI in 15 of 20% of cases [ 11 ].…”

“…Pre-operative right bundle branch block (RBBB) is present in 10 to 21% of patients and results in up to 40% of post-operative PPI, making pre-operative RBBB the most important patient-related factor [ 2 , 12 ]. However, the prognostic value on pre-existing infra-Hisian conduction disturbances on post-TAVI PPI remains unclear [ 10 , 11 , 12 ].…”