Utility of 30-Day Continuous Ambulatory Monitoring to Identify Patients With Delayed Occurrence of Atrioventricular Block After Transcatheter Aortic Valve Replacement

Abstract

Background: Mechanical injury in the conduction system requiring permanent pacemaker (PPM) associated with transcatheter aortic valve replacement (TAVR) procedure is a common complication. The objective of this study was to use ambulatory monitor BodyGuardian to assess late occurrence of atrioventricular block (AVB) after TAVR. Methods: This prospective study evaluated 365 patients who underwent TAVR at Mayo Clinic, Rochester, Minnesota between June 2016 and August 2017. Patients who received PPM for bradycardia after TAVR before discharge were considered as the PPM group. Those not requiring PPM received a BodyGuardian system (BodyGuardian group) for 30 days of continuous monitoring. Primary end point was Mobitz II or third-degree atrioventricular block (II/III AVB) at 30-day follow-up. Results: Of 365 patients, 74 who had a PPM or an implantable cardioverter-defibrillator before TAVR and 94 who were enrolled in other studies were excluded. Of 197 patients enrolled in the study, 70 (35.5%) received PPM and 127 had BodyGuardian before the hospital dismissal. Eleven of 127 (8.6%) BodyGuardian group required PPM within 30 days after TAVR for late occurrence of symptomatic bradycardia. In total, 33 of 197 (16.7%) patients developed II/III AVB (24 before and 9 after discharge). Thirty-four patients had preexisting right bundle branch block. Of them, 16 (47%) developed II/III AVB. Of 53 patients who developed new left bundle branch block after TAVR, 14% progressed to II/III AVB within 30 days. Conclusions: In patients without a standard post-TAVR pacing indication, yet a potential risk to develop AVB, a strategy of 30-day monitoring identifies additional patients who require permanent pacing.

Clinical management of conduction abnormalities following transcatheter aortic valve replacement: prospective evaluation of a standardized management pathway

“…The incidence and risk factors of delayed heart block are still not well understood and the optimal way to monitor these patients in the era of early hospital discharge remains an important clinical question. We report a rate of delayed heart block of 2%, which is in fact lower than previously reported rates ranging from 4.6 to 8% [9][10][11]. There may be several reasons for the discrepancy in observed rates, including variable definitions of delayed heart block by study, differences in valve type and structural factors like implantation depth, and, in our study, failure to detect asymptotic episodes of heart block in low-risk patients who did not receive an ECG at 1-month follow-up and were not discharged with a cardiac monitor.…”

Remote Ambulatory Cardiac Monitoring Before and After Transcatheter Aortic Valve Replacement

“…A recent publication by Ream et al., 8 using a 30-day loop monitoring device in 150 post-TAVI patients, demonstrated delayed AVB in 12 of them with a median of 6 days (range, 3-24 days). Also, in a more recent experience by Tian et al., 14 remote monitoring for 30 days after TAVR allowed detection of AVB that required a PM implant in an additional 8.6% of patients after discharge. The optimal duration of monitoring after TAVR is unclear and needs to balance the detection of high-risk arrhythmias vs the limitations of patient comfort and costs.…”

Remote Cardiac Rhythm Monitoring in the Era of Smart Wearables: Present Assets and Future Perspectives

“…In patients undergoing transcatheter aortic valve replacement (TAVR), prolonged, patch-based, rhythm monitoring, prior to the procedure, can detect significant bradyarrhythmias in one-fifth of the patients, some of which may require a change of treatment ( 111 ). Following TAVR, Tian et al, identified patients with late high degree atrioventricular block, using the BodyGuardian patch (Preventice Solutions, Inc, USA) ( 112 ). The same patch was also found to reliably assess the QT interval, both in healthy individuals and long QT syndrome patients and could be used to remotely monitor patients in risk of QT interval prolongation and arrhythmias ( 113 ).…”