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

Abstract

Data regarding the impact of infra-Hisian conduction disturbances leading to permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) remain limited. The aim of this study was to determine the impact of right and/or left bundle branch block (RBBB/LBBB) on post-TAVI PPI. We performed a systematic literature review to identify studies reporting on RBBB and/or LBBB status and post-TAVI PPI. Study design, patient characteristics, and the presence of branch block were analyzed. Odds ratios (ORs) with 95% CI were extracted. The final analysis included 36 studies, reporting about 55,851 patients. Data on LBBB were extracted from 33 studies. Among 51,026 patients included, 5503 showed pre-implant LBBB (11.9% (10.4%–13.8%)). The influence of LBBB on post-TAVI PPI was not significant OR 1.1474 (0.9025; 1.4588), p = 0.2618. Data on RBBB were extracted from 28 studies. Among 46,663 patients included, 31,603 showed pre-implant RBBB (9.2% (7.3%–11.6%)). The influence of RBBB on post-TAVI PPI was significant OR 4.8581 (4.1571; 5.6775), p < 0.0001. From this meta-analysis, the presence of RBBB increased the risk for post-TAVI PPI, independent of age or LVEF, while this finding was not confirmed for patients experimenting with LBBB. This result emphasizes the need for pre-operative evaluation strategies in patient selection for TAVI.

Incidence and Outcomes of New-Onset Right Bundle Branch Block Following Transcatheter Aortic Valve Replacement

“…5,8,12,13 Given the close anatomic relationship between the aortic valve and the His bundle, as well as left bundle branch, studies on post-TAVR conduction system abnormalities have largely focused on high-grade/complete atrioventricular block and LBBB. 5,8,[14][15][16] In contrast, the mechanistic and clinical aspects of post-TAVR RBBB are far less understood.…”

“…In comparison, ≈10% to 20% of patients with post-TAVR LBBB were found to progress toward high-grade/complete atrioventricular block. 8,15,16 This suggests that post-TAVR RBBB may be a more potent indicator of severe infrahisian injury versus post-TAVR LBBB, although more studies are required to verify this hypothesis. Interestingly, all 3 patients who had left anterior fascicular block at baseline and new-onset RBBB post-TAVR manifested with high-grade atrioventricular block, indicating that multiple hits to the conduction system may result in eventual infrahisian failure.…”

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, a recent meta‐analysis found that baseline LBBB is associated with an increased incidence of PPI (odds ratio [OR]: 1.45; 95% confidence interval [CI]: 1.12−1.77) 19 .…”

“…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][5][6][7][8][10][11][12][13][14][15][16] In contrast, preexisting LBBB was previously known not to increase the risk of post-TAVR conduction abnormalities.…”

Risk Stratification for Pacemaker Implantation after Transcatheter Aortic Valve Implantation in Patients with Right Bundle Branch Block

“…Nevertheless, the indication for PPI is still an area of uncertainty [ 1 , 2 , 3 , 4 , 5 , 6 ]. The phenomenon of new onset left bundle branch block (LBBB) gained attention in several scientific reports [ 7 , 8 , 9 , 10 , 11 , 12 , 13 ], as it has been reported to be associated with increased all-cause and cardiovascular mortality and an increased necessity of subsequent PPI [ 11 , 14 ].…”