Current Opinions on New-Onset Left Bundle Branch Block after Transcatheter Aortic Valve Replacement and the Search for Physiological Pacing

Abstract

Transcatheter aortic valve replacement possesses a high validity for patients with aortic stenosis who are considered high risk for aortic valve replacement surgery, nowadays it is also considered for patients with intermediate risk or even lower risk in certain situations. The incidence of new conduction abnormalities remains to be a tough problem, in particular, left bundle branch block. New-onset left bundle branch block is a major concern despite improvements in valve technology, and it may affect postoperative prognosis. Understanding the anatomical relationship between the conduction system and the aortic root, clarify factors related to the procedure, devices, and patients, might help to reduce the conduction abnormalities. Physiological pacing has emerged as a reasonable pacing strategy for patients with cardiac insufficiency post-valve replacement, especially combined with left bundle branch block. The purpose of this review is to summarize the current opinion on the incidence of new-onset left bundle branch block associated with transcatheter aortic valve replacement, to offer insights into its anatomical and procedural causes, clinical consequences, and more importantly, the prospect of applying physiological pacing as a therapeutic method for these patients.

Analysis of electrocardiographic signs in hypertrophic cardiomyopathy before and after septal myectomy. New criterion for proximal left bundle branch block

“…Однако оценка динамики ЭКГкартины при повреждении проксимальных волокон ЛНПГ у людей упрощает трансляцию результатов исследования в реальную клиническую практику. Другой патофизиологической моделью проксимальной БЛНПГ является ятрогенная блокада проведения, формируемая после транскатетерной имплантации аортального клапана [8]. Несмотря на более изолированное повреждение проводящих путей за счет использования эндоваскулярной техники, патогенез повреждения ЛНПГ при такой модели включает отек, воспаление и ишемию.…”

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

“…Recently, His-Purkinje conduction system pacing (HPCSP) has emerged as a more physiological pacing method that involves directly stimulating the His bundle or left bundle branch area. This technique drives stimulation down the physiological conduction pathway and promotes ventricular electrical activity synchronization, encompassing His bundle pacing (HBP) and left bundle branch pacing (LBBP) ( 42 , 127 ). Compared to RVP, the HPCSP has been proven to be effective in shortening QRS intervals and improving cardiac function in TAVR patients ( 128 ).…”

“…Due to the close anatomical proximity of the conduction system to the distal landing zone of the transcatheter heart valve (THV) located in the left ventricular outflow tract (LVOT), particularly the direct exposure of the His bundle after crossing the membranous septum near the aortic root, the His bundle and the originating portion of the LBB are closely associated with the base of the NC and RC leaflets' apical triangle at the aortic valve (Figure 1B). Technical maneuvers near the aortic root, such as fragmenting the calcified valve or implanting a prosthesis, can pressure surrounding tissues, potentially causing edema, inflammation, ischemia, or hematoma, and consequently new conduction abnormalities, which are a concern during TAVR (38,(41)(42)(43). There is correlative evidence linking TAVRinduced conduction abnormalities to calcific aortic stenosis: calcium deposits may also affect the nearby conduction system, and aortic valve stenosis-associated left ventricular (LV) dysfunction may increase the risk of advanced AV block and LBBB (37).…”