Evaluation and Management of Heart Block After Transcatheter Aortic Valve Replacement

Abstract

Transcatheter aortic valve replacement (TAVR) has developed substantially since its inception. Improvements in valve design, valve deployment technologies, preprocedural imaging and increased operator experience have led to a gradual decline in length of hospitalisation after TAVR. Despite these advances, the need for permanent pacemaker implantation for post-TAVR high-degree atrioventricular block (HAVB) has persisted and has well-established risk factors which can be used to identify patients who are at high risk and advise them accordingly. While most HAVB occurs within 48 hours of the procedure, there is a growing number of patients developing HAVB after initial hospitalisation for TAVR due to the trend for early discharge from hospital. Several observation and management strategies have been proposed. This article reviews major known risk factors for HAVB after TAVR, discusses trends in the timing of HAVB after TAVR and reviews some management strategies for observing transient HAVB after TAVR.

Post‐TAVR conduction abnormalities leading to permanent pacemaker implantation: Risk factors, prevention, and management

“…Baseline right bundle branch block (RBBB) is a major electrical disturbance, independent of age or left ventricular ejection fraction, 9 increasing the risk for atrioventricular block (AVB) leading to PPI 4–8,10–16 . In contrast, preexisting LBBB was previously known not to increase the risk of post‐TAVR conduction abnormalities 8,9,15,17,18 .…”

“…However, based on five observational cohort studies recruiting a total of 1901 patients, Ullah et al 15 found that age >80 was not a statistically significant predictor of PPI, and the risk is comparable to younger patients (OR: 1.19; 95% CI: 0.95–1.49). Furthermore, male sex is a risk factor for periprocedural PPI, independent of age, ventricular function, type of prosthesis, or access site 4,5,12,15,26 . A possible explanation may be that male patients receive larger THVs and have more preprocedural comorbidities compared to female patients.…”

“…This is called the valve index and is calculated as [prosthesis size/annulus diameter] or [prosthesis size/LVOT diameter] × 100. Research shows that a valve index >128 and that oversizing increases the risk for conduction defects 4,6–8,12–14,24,34 . In particular, women are at an increased post‐op risk for PPI following oversizing, especially with balloon‐expandable valves (BEV), due to their smaller annulus size 26 .…”

“…Deeper or lower implantations below the aortic annulus plane translates into a higher risk of PPI 4–8,10,13–15,21,22,34 . Some studies deduce that the lone difference between the MS length and ID (ΔMSID) is an important anatomical predictor for pacemaker implantation and dependency after TAVR 8,12,14 . Certain valves, such as self‐expandable valves (SEV), especially the Medtronic CoreValve (MCV) and first‐generation valves, require deeper implantation and have been associated with an increased risk of PPI.…”

“…Overall, most studies agree that BEV is associated with a lower incidence of PPI, followed by SEV and then MEV. One explanation is that SEV and MEV require deeper implantation, leading to higher radial force exertion against the subannular wall, thus increasing the chances of AV node and left bundle branch compression 7,12–16,18,19,22,35 . However, this concern is mitigated with the introduction of the “cusp overlap view” (discussed later).…”