Conduction disorders in the setting of transcatheter aortic valve implantation: a clinical perspective

Abstract

The presence of periprocedural conduction disorders (CDs) and the need for permanent pacemaker (PPM) after transcatheter aortic valve implantation (TAVI) are frequent findings in clinical practice. Notwithstanding, robust information on the prognostic and therapeutic implications of these complications are lacking. The newly occurrence of CD after TAVI seems related to the trauma of the conduction system during procedure. On the contrary, major predictors for PPM implantation after TAVI seem to be the use of CoreValve prosthesis (Medtronic, Minneapolis, MN) and the presence of CD before TAVI. An accurate pre-TAVI screening, careful valve implantation, as well as post-TAVI monitoring must be pursued to prevent avoidable PPM implantation. The aim of this report is to analyze the available data on this field and to propose some practical clinical tips to prevent or to manage these complications.

Ventricular Conduction Defects After Transcatheter Aortic Valve Implantation: A Single‐Institute Analysis

“…Vice versa, patients with preoperative left BBB receiving Edwards Sapien/XT valve were also not prone to heart block. Such associations reported in larger series were not apparent in the current study probably due to the small number of cases, the most important limitation of the current study. In particular, the differences between early and delayed development of heart block were not clear enough to allow identification of, and hopefully exclude patients who had poor outcomes even after TAVI followed by PM implantation.…”

“…It later became apparent that the incidence was significantly higher with the use of Medtronic CoreValves at 19.8% , 21.0% , 22.6% in our series, 33.3% , and 38.6% . Incidences reported from institutes using either valve alone were partly dependent on institutional PM strategy, prophylactic or conservative , and not being able to compare among institutes or between the devices. Although such policy may not influence the incidence of PM implantation in single‐institute experiences with both valves, few such reports could depend on statistical power to detect significant differences .…”

“…Because the impact of annular dilatation at implantation was so strong, the incidence immediately and early after valve deployment (POD 0 or 1) was high with both Edwards valve and CoreValve , which blurred the difference between the valves in our experience as well ( P = 0.266, Table ). However, the delayed development of heart block (POD 1 or later) was more common after implantation of CoreValve ( P = 0.049), which has been reported to be related to its self‐expansion for a few days after deployment . Therefore, the time course and extent may require follow‐up studies to delineate the efficacy of self‐expansion that is aimed at reducing valve instability or perivalvular leakage.…”

“…Because ventricular conduction problems were recognized at an early stage, their incidence was compared with that in BAV and surgical AVR . Such analyses were carried out in experiences with Edwards valves (Edwards Lifesciences, Irvine, CA, USA) , Medtronic valves (Medtronic, Inc., Minneapolis, MN, USA) , and both , and the incidence was compared between devices in single‐institute studies , multicenter registries , meta‐analyses , and reviews . While it is natural to consider pressure and shear stress at predilatation and implantation to be causative , single institutional studies may not have statistical power and larger studies might be devoid of details to identify exact mechanism(s).…”

Conduction Disorders and Transcatheter Aortic Valve. Clinically Relevant or Just a Mild Complication?

“…7 Other factors are thickening of the noncoronary leaflet, a small LV outflow tract, a smaller indexed effective orifice area following implantation, a large aortic annulus, mitral annular calcification, calcification at the level of the valve or in LV outflow tract, female sex, a reduced ejection fraction, and the presence of porcelain aorta. 8 However, there are 3 factors on which the different published series appear to be in closest agreement: the previous existence of right bundle branch block (RBBB), the type of valve employed, and the depth of implantation of the prosthesis.…”