Transcatheter aortic valve replacement in bicuspid aortic valve stenosis: where do we stand?
Yoon Sung-Han,Sharma Rahul,Chakravarty Tarun,Miyasaka Masaki,Ochiai Tomoki,Nomura Takahiro,Gellada Norman,Nemanpour Shadi,Nakamura Mamoo,Chen Wen,Makkar Raj
The Journal of cardiovascular surgery
Bicuspid aortic valve is the most common congenital cardiac defect in adults, and symptom typically develops in adulthood. In the majority of cases, bicuspid aortic valve disease progress with ages and surgical aortic valve replacement is performed with excellent operative outcomes. However, with the relatively slow progression of disease, surgical aortic valve replacement is required in elderly patients but the surgical risk often deemed extremely high due to old age and multiple comorbidities. Transcatheter aortic valve replacement (TAVR) has evolved from a novel technology to an established therapy for intermediate- and high-risk patients with symptomatic severe aortic valve stenosis (AS). Numerous studies have demonstrated the safety and efficacy of TAVR, and more than 250,000 patients have been treated with this technology. Although randomized trials have established TAVR as the standard treatment, these trials excluded congenital bicuspid AS due to its unique morphological features. Nevertheless, the growing experience, accumulated knowledge, and advancements of new technology lead to the expand use of TAVR to other pathologies or other populations such as bicuspid AS. With integration of imaging multimodalities (computed tomography and echocardiography), the diagnosis and classification of bicuspid aortic valve has been changing. Due to unfavorable anatomic features of bicuspid AS, the outcomes of TAVR in bicuspid AS was suboptimal, particularly when using the first-generation transcatheter valves. However, the newer-generation transcatheter valves significantly improved the outcomes of TAVR in bicuspid AS. Nonetheless, several issues still remain to be resolved. Given longer life expectancy in patients with bicuspid AS undergoing TAVR, durability of transcatheter valves is concerned. In addition, patients with bicuspid aortic valves often have concomitant dilatation of proximal part of ascending aorta (aortopathy), but limited data exist about the clinical prognosis of bicuspid aortic valve with concomitant aortopathy in elderly patients. Considering the expanding indication of TAVR to lower surgical risk and younger population, these issues should be evaluated in future studies.
10.23736/S0021-9509.18.10350-8
The ACURATE neo Transcatheter Heart Valve: A Comprehensive Analysis of Predictors of Procedural Outcome.
Kim Won-Keun,Möllmann Helge,Liebetrau Christoph,Renker Matthias,Rolf Andreas,Simon Philippe,Van Linden Arnaud,Arsalan Mani,Doss Mirko,Hamm Christian W,Walther Thomas
JACC. Cardiovascular interventions
OBJECTIVES:The aim of this study was to perform a comprehensive analysis of factors that affect procedural outcomes of transcatheter aortic valve replacement using the ACURATE neo prosthesis (Symetis/Boston, Ecublens, Switzerland). BACKGROUND:Predictors of procedural outcomes using the ACURATE neo prosthesis are poorly understood. METHODS:A total of 500 patients underwent transfemoral aortic valve replacement with the ACURATE neo prosthesis. Device landing zone calcification was stratified as severe, moderate, or mild. Anatomic and procedural predictors of second-degree or greater paravalvular leakage and permanent pacemaker implantation were assessed. RESULTS:Post-procedural second-degree or greater paravalvular leakage was more frequent with increasing device landing zone calcification (mild 0.8% vs. moderate 5.0% vs. severe 13.0%; p < 0.001), whereas permanent pacemaker implantation was independent of device landing zone calcification. More severe periannular calcification (odds ratio [OR]: 1.007; 95% confidence interval [CI]: 1.003 to 1.010; p < 0.001), less oversizing (OR: 0.867; 95% CI: 0.773 to 0.971; p = 0.014), the presence of annular plaque protrusions (OR: 2.756; 95% CI: 1.138 to 6.670; p = 0.025), and aortic movement of the delivery system after full deployment (OR: 5.593; 95% CI: 1.299 to 24.076; p = 0.02), and sinotubular junction height (OR: 1.156; 95% CI: 1.007 to 1.328; p = 0.04) independently predicted second-degree or greater paravalvular leakage. Predictors of permanent pacemaker implantation were pre-existing right bundle branch block (OR: 3.122; 95% CI: 1.261 to 7.731; p = 0.01) and more oversizing (OR: 1.111; 95% CI: 1.009 to 1.222; p = 0.03). CONCLUSIONS:Successful transcatheter aortic valve replacement using the ACURATE neo device predominantly depends on careful patient selection with appropriate oversizing and taking into account the individual anatomy and calcium distribution of the aortic root.
10.1016/j.jcin.2018.04.039
A new electrocardiographic definition of left bundle branch block (LBBB) in patients after transcatheter aortic valve replacement (TAVR).
Alqarawi Wael,Sadek Mouhannad M,Golian Mehrdad,Hibbert Benjamin,Redpath Calum J,Nair Girish M,Nery Pablo B,Davis Darryl R,Klein Andres,Birnie David H,Green Martin S
Journal of electrocardiology
BACKGROUND:Current LBBB definitions cannot always distinguish LBBB from left ventricular conduction delay. Only patients with LBBB are expected to normalize with His bundle pacing. Patients who develop new LBBB immediately post transcatheter aortic valve replacement (TAVR) provide an excellent model to define electrocardiogram (ECG) features of LBBB. We sought to describe their ECG features and develop a new ECG definition of LBBB. METHODS:We screened ECGs from 264 consecutive patients who underwent TAVR at the University of Ottawa Heart Institute. Patients with a baseline QRS of ≤100 ms who developed QRS ≥120 ms immediately after TAVR were included. Two electrocardiologists reviewed all ECG independently. Baseline demographics and echocardiographic data were retrospectively collected. RESULTS:36 patients were included in the analysis. The median age was 85.5 years (IQR, 81.8-89 years) and 52.8% were males. The minimum QRS duration was 126 ms. The median QRS axis was -18° (IQR, -40-4.5°), which is 18.5° leftward compared to the median QRS axis before TAVR. Fourteen patients (38.9%) had left axis deviation. All patients had a notched/slurred R wave in at least one lateral lead and an R wave duration of ≤20 ms in V1 when present. CONCLUSION:We developed a new ECG definition of LBBB that includes 2 novel findings: notching/slurring of the R wave in at least one lateral lead and an R wave ≤20 ms in V1. Further larger studies are warranted to confirm these findings.
10.1016/j.jelectrocard.2019.10.005
Open-Heart Cardio-Thoracic Biological Valve Replacement Following Complicated Transcatheter Aortic Valve Implantation.
Journal of personalized medicine
Transcatheter aortic valve implantation (TAVI) is currently becoming the method of choice in high-risk patients with severe aortic valve stenosis. Post-TAVI complications are more common owing to the increasing use of the method. The majority of TAVI complications derive from concomitant aortic stenosis with moderate/severe aortic insufficiency, paravalvular leak, and atrioventricular block. The contemporary TAVI qualification process includes a thorough echocardiography and angio-CT of the aorta, which is crucial in assessing valve measurements, determining the position of the coronary arteries branching from the aorta, and choosing the optimal valve size. We present the case report of an 81-year-old patient admitted to our hospital because of exacerbation of the clinical condition and development of pulmonary edema a few days after TAVI. Despite the reduction of the initial leak, an echocardiographic examination revealed the remaining severe paravalvular aortic leakage. We performed open-heart cardio-thoracic surgery, explanted the TAVI valve, and implanted the biological prosthesis (Edwards Perimount Magna size 25). Introduction of new interventional treatment approaches and the availability of imaging tools have substantially reduced the incidence of significant paravalvular leak and offered a better prognosis for patients undergoing TAVI.
10.3390/jpm13050838
Syncope After Transcatheter Aortic Valve Replacement: Two Faces of Abnormal Intraventricular Conduction.
Kocherla Cyrus,Ward Chard,Horwitz Phillip A,Mazur Alexander
The Journal of innovations in cardiac rhythm management
Conduction system damage is the most common complication of transcatheter aortic valve replacement (TAVR), which frequently requires placement of a permanent pacemaker. Bundle branch reentry (BBR) is a well-recognized mechanism of ventricular tachycardia (VT) in the setting of abnormal intraventricular conduction. We describe a case of a patient with post-TAVR intraventricular conduction abnormalities who presented with intermittent advanced atrioventricular block and BBR VT and discuss the potential risks, diagnosis, and management of BBR after TAVR.
10.19102/icrm.2020.110301
New insights on potential permanent pacemaker predictors in TAVR using the largest self-expandable device.
Veulemans Verena,Frank Derk,Seoudy Hatim,Wundram Steffen,Piayda Kerstin,Maier Oliver,Jung Christian,Polzin Amin,Frey Norbert,Kelm Malte,Zeus Tobias
Cardiovascular diagnosis and therapy
Background:Post-procedural conduction disorders following transcatheter aortic valve replacement (TAVR) still remain frequent, especially using the largest self-expandable device (Medtronic Corevalve Evolut R, 34 mm, STHV-34). We, therefore, assessed previously described, predictive factors of permanent pacemaker (PPM) implantation in the context of the STHV-34, including calcification distribution, implantation depth and membranous septum length (MSL). Methods:We performed a dual centre analysis of 130 of 182 consecutive patients treated with STHV-34, further stratified into subjects without post-procedural PPM (-PPM n=100, 76.9%) and those requiring post-procedural PPM (+PPM n=30, 23.1%). These events were further analyzed by univariate and multivariate analysis according to several underlying conditions. Results:Multivariate analysis only depicted previous right bundle branch block [RBBB; OR: 11.52 (2.63-50.44), P=0.001] and eccentricity index of the left ventricular outflow tract (LVOT-EI) >0.3 [OR: 3.07 (1.22-7.77), P=0.018] as highly predictive for PPM-need, being also confirmed by c-statistics [area under the curve (AUC) =0.68; 95% confidence interval (CI): 0.57-0.80; P=0.0025]. There was only moderate correlation of implantation depth over the MSL in terms of PPM prediction (r=0.23; P<0.0001). Conclusions:This study offers new insights into potential PPM predictors using the STHV-34: previous RBBB and a pronounced LVOT-EI were independent predictors of PPM, while most of the previously reported determinants failed to predict PPM-need including MSL and implantation depth.
10.21037/cdt-20-680
Long-term pacemaker dependency and impact of pacing on mortality following transcatheter aortic valve replacement with the LOTUS valve.
Alasti Mohammad,Rashid Hashrul,Rangasamy Karthikeyan,Kotschet Emily,Adam David,Alison Jeff,Gooley Robert,Zaman Sarah
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions
OBJECTIVES:To determine permanent pacemaker (PPM) dependency following transcatheter aortic valve replacement (TAVR) with the Lotus valve system (Boston Scientific), and the impact of PPM implantation on long-term morbidity and mortality. BACKGROUND:Conduction abnormalities are among the most common complications following TAVR. Limited studies have assessed pacing dependency following TAVR. METHODS:Consecutive patients (n = 166) with severe aortic stenosis who underwent TAVR with the Lotus valve system were prospectively recruited from a single-center. PPMs were implanted according to standard clinical criteria. Patients were followed in-hospital and at 1, 3, 6, and 12 months to determine pacemaker dependency and clinical outcomes. RESULTS:Fourteen patients with a pre-existing PPM (8%) were excluded with the remaining 152 patients aged 83.6 ± 5.6 years and 46% male. PPMs were implanted 3.8 ± 4 days post-TAVR in 38/152 patients (25%). Indication for PPM was complete heart block in 29 (76%) of patients. At 30-day and one-year follow up, 57% and 38% of patients were pacemaker dependent, respectively. The mean ventricular pacing percentage decreased in the first three months after PPM implantation and remained relatively stable after that. CONCLUSION:Only 38% of Lotus recipients who require a PPM following TAVR with the Lotus valve remain pacing dependent at one year.
10.1002/ccd.27463
Respective role of surface electrocardiogram and His bundle recordings to assess the risk of atrioventricular block after transcatheter aortic valve replacement.
Badenco N,Chong-Nguyen C,Maupain C,Himbert C,Duthoit G,Waintraub X,Chastre T,Gandjbakhch E,Hidden-Lucet F,Le Prince P,Collet J-P,Frank R
International journal of cardiology
BACKGROUND:Atrioventricular block (AVB) is common after transcatheter aortic valve replacement (TAVR) and permanent pacemaker (PPM) implantation is needed in up to 30% of patients. Main predictors of long term AVB are electrocardiographic. The purpose of this study is to assess the prognostic value of serial HV intervals measured before and after TAVR to shorten the timing of PPM implantation. METHODS:His bundle recordings were performed before (HV1), immediately after TAVR (HV2) and at day 2 for Edwards Sapien (ES) and 5 for Medtronic CoreValve (CV) (HV3). PPM indications were high degree AVB before day 5 or prolonged HV interval ≥80ms at the last recording. High degree AVB after discharge was evaluated from the pacemaker memories and ECG at 1 and 6months. RESULTS:Data were obtained in 84 patients (33% CV and 67% ES). HV values were not associated with early or late AVB. PPM were implanted in 27 patients (34%) for documented AVB (n=17, 24%), prolonged HV interval (n=9) or sick sinus syndrome (n=1). Persistent complete AVB during the procedure and postoperative high degree AVB were the only perioperative factors associated with further long term occurrence of high degree AVB (p=0.001 and p<0.001). On multivariate analysis, only postoperative high degree AVB was significant (p=0.001). CONCLUSION:Pre- and post-operative HV measurements were not correlated with late AVB after TAVR. Perioperative persistent complete AVB and postoperative high degree AVB are the only factors to predict late AVB and should be considered for the decision of PPM implantation.
10.1016/j.ijcard.2017.02.029
Short- and Long-Term Outcomes in Patients With New-Onset Persistent Left Bundle Branch Block After Transcatheter Aortic Valve Replacement.
Megaly Michael,Abraham Bishoy,Abdelsalam Mahmoud,Saad Marwan,Omer Mohamed,Elbadawi Ayman,Mentias Amgad,Narayanan Mahesh Anantha,Gafoor Sameer,Brilakis Emmanouil S,Goessl Mario,Cavalcante João L,Garcia Santiago,Kapadia Samir,Pershad Ashish,Sorajja Paul,Sengupta Jay
Cardiovascular revascularization medicine : including molecular interventions
BACKGROUND:The impact of new-onset persistent left bundle branch block (LBBB) after transcatheter aortic valve replacement (TAVR) on all-cause mortality has been controversial. METHODS:We conducted a systematic review and meta-analysis of eleven studies (7398 patients) comparing the short- and long- outcomes in patients who had new-onset LBBB after TAVR vs. those who did not. RESULTS:During a mean follow-up of 20.5±14months, patients who had new-onset persistent LBBB after TAVR had a higher incidence of all-cause mortality (29.7% vs. 23.6%; OR 1.28 (1.04-1.58), p=0.02), rehospitalization for heart failure (HF) (19.5% vs. 17.3%; OR 1.4 (1.13-1.73), p=0.002), and permanent pacemaker implantation (PPMi) (19.7% vs. 7.1%; OR 2.4 (1.64-3.52), p<0.001) compared with those who did not. Five studies (4180 patients) reported adjusted hazard ratios (HR) for all-cause mortality; new LBBB remained associated with a higher risk of mortality (adjusted HR 1.43 (1.08-1.9), p<0.01, I=81%). CONCLUSION:Post-TAVR persistent LBBB is associated with higher PPMi, HF hospitalizations, and all-cause mortality. While efforts to identify patients who need post-procedural PPMi are warranted, more studies are required to evaluate the best follow-up and treatment strategies, including the type of pacing device if required, to improve long-term outcomes in these patients.
10.1016/j.carrev.2020.03.009
Reduction of permanent pacemaker implantation by using the cusp overlap technique in transcatheter aortic valve replacement: a meta-analysis.
Clinical research in cardiology : official journal of the German Cardiac Society
BACKGROUND:The need for permanent pacemaker (PPM) implantation is a common complication after transcatheter aortic valve replacement (TAVR). Deep implantation position is a risk factor for PPM implantation. Thus, in the field of self-expandable (SE) transcatheter heart valves (THV) cusp overlap projection (COP) technique was implemented to reduce parallax, allowing a more precise guidance of implantation depth. AIMS:This meta-analysis aims to report the outcome of patients undergoing TAVR with SE THV using COP versus conventional implantation technique (CIT). METHODS:Systematical search in MEDLINE and EMBASE yielded five observational controlled studies comparing both implantation techniques for the SE Evolut prosthesis (Medtronic Intern. Ltd., CA, USA) and fulfilling the inclusion criteria for meta-analysis. RESULTS:Totally, 1227 patients were included, comprising 641 who underwent COP and 586 CIT TAVR. Incidence of post-procedural need for PPM implantation was significantly lower in COP group (9.8% vs 20.6%; OR = 0.43; p < 0.00001). This was accompanied by significantly higher implantation position in COP group (mean difference distance from distal end of the intraventricular portion of the THV to the non-coronary cusp (NCC): - 1.03 mm; p = 0.00001). Incidence of new-onset left bundle branch block did not differ. Regarding procedural and 30-day mortality, technical success, post-procedural aortic regurgitation, and rates of multiple device implantation, no difference between COP and CIT was found. CONCLUSION:COP is an effective and safe implantation technique to reduce the need for a permanent pacemaker implantation during TAVR with SE Evolut prosthesis.
10.1007/s00392-022-02150-8
Computed tomography (CT) assessment of the membranous septal anatomy prior to transcatheter aortic valve replacement (TAVR) with the balloon-expandable SAPIEN 3 valve.
Oestreich Brett A,Mbai Mackenzie,Gurevich Sergey,Nijjar Prabhjot S,Adabag Selcuk,Bertog Stefan,Kelly Rosemary,Garcia Santiago
Cardiovascular revascularization medicine : including molecular interventions
OBJECTIVES:The lower limit of the membranous septum (MS) is considered an anatomic landmark for the emergence of the Bundle of His into the left ventricle. Computed tomography (CT) assessment of MS anatomy may provide useful information about the risk of conduction abnormalities following transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS:The study included 102 consecutive patients undergoing TAVR with the Edwards Sapien 3 (S3) valve. Using pre-TAVR CT and post-procedure angiography we evaluated for the presence of calcium in the left ventricular outflow tract (LVOT), calcium depth (CD), implantation depth (ID) and MS length. The MS length minus the prosthesis ID was calculated (Delta MSID). Outcomes included new left bundle branch block (LBBB) or permanent pacemaker (PPM) within 30days. Seventeen patients (17%) received a PPM and 28 (27%) developed new LBBB following TAVR. Mean (±SD) MS length and delta MSID were 7.5mm (2) and 0.9mm (4.5), respectively. Twenty-one patients (20%) had calcium in the device landing zone and the mean (SD) CD was 6.8mm (±4). Calcium in the device landing zone (37% versus 16%, p=0.02) and implantation depth (6mm (4-8) versus 4mm (4-5), p=0.02) predicted new conduction abnormalities after TAVR. CONCLUSIONS:The presence of calcium in the device landing zone is associated with increased risk of conduction abnormalities after TAVR with S3. In such cases, a more aortic deployment of the prosthesis may be warranted.
10.1016/j.carrev.2017.12.012
Impact of Aortic Root Anatomy and Geometry on Paravalvular Leak in Transcatheter Aortic Valve Replacement With Extremely Large Annuli Using the Edwards SAPIEN 3 Valve.
Tang Gilbert H L,Zaid Syed,George Isaac,Khalique Omar K,Abramowitz Yigal,Maeno Yoshio,Makkar Raj R,Jilaihawi Hasan,Kamioka Norihiko,Thourani Vinod H,Babaliaros Vasilis,Webb John G,Htun Nay M,Attinger-Toller Adrian,Ahmad Hasan,Kaple Ryan,Sharma Kapil,Kozina Joseph A,Kaneko Tsuyoshi,Shah Pinak,Hirji Sameer A,Desai Nimesh D,Anwaruddin Saif,Jagasia Dinesh,Herrmann Howard C,Basra Sukhdeep S,Szerlip Molly A,Mack Michael J,Mathur Moses,Tan Christina W,Don Creighton W,Sharma Rahul,Gafoor Sameer,Zhang Ming,Kapadia Samir R,Mick Stephanie L,Krishnaswamy Amar,Amoroso Nicholas,Salemi Arash,Wong S Chiu,Kini Annapoorna S,Rodés-Cabau Josep,Leon Martin B,Kodali Susheel K
JACC. Cardiovascular interventions
OBJECTIVES:The aim of this study was to determine factors affecting paravalvular leak (PVL) in transcatheter aortic valve replacement (TAVR) with the Edwards SAPIEN 3 (S3) valve in extremely large annuli. BACKGROUND:The largest recommended annular area for the 29-mm S3 is 683 mm. However, experience with S3 TAVR in annuli >683 mm has not been widely reported. METHODS:From December 2013 to July 2017, 74 patients across 16 centers with mean area 721 ± 38 mm (range: 684 to 852 mm) underwent S3 TAVR. The transfemoral approach was used in 95%, and 39% were under conscious sedation. Patient, anatomic, and procedural characteristics were retrospectively analyzed. Valve Academic Research Consortium-2 outcomes were reported. RESULTS:Procedural success was 100%, with 2 deaths, 1 stroke, and 2 major vascular complications at 30 days. Post-dilatation occurred in 32%, with final balloon overfilling (1 to 5 ml extra) in 70% of patients. Implantation depth averaged 22.3 ± 12.4% at the noncoronary cusp and 20.7 ± 9.9% at the left coronary cusp. New left bundle branch block occurred in 17%, and 6.3% required new permanent pacemakers. Thirty-day echocardiography showed mild PVL in 22.3%, 6.9% moderate, and none severe. There was no annular rupture or coronary obstruction. Mild or greater PVL was associated with larger maximum annular and left ventricular outflow tract (LVOT) diameters, larger LVOT area and perimeter, LVOT area greater than annular area, and higher annular eccentricity. CONCLUSIONS:TAVR with the 29-mm S3 valve beyond the recommended range by overexpansion is safe, with acceptable PVL and pacemaker rates. Larger LVOTs and more eccentric annuli were associated with more PVL. Longer term follow-up will be needed to determine durability of S3 TAVR in this population.
10.1016/j.jcin.2018.03.034
Different dynamics of new-onset electrocardiographic changes after balloon- and self-expandable transcatheter aortic valve replacement: Implications for prolonged heart rhythm monitoring.
Coeman Mathieu,Kayaert Peter,Philipsen Tine,Calle Simon,Gheeraert Peter,Gevaert Sofie,Czapla Jens,Timmers Liesbeth,Van Heuverswyn Frédéric,De Pooter Jan
Journal of electrocardiology
BACKGROUND:New onset electrocardiographic (ECG) changes after transcatheter aortic valve replacement (TAVR) are used to assess the risk for late atrioventricular block. However, the time of ECG evaluation remains controversial. We aimed to compare the time course and dynamics of new onset ECG changes according to valve design in balloon- (BEV) and self-expandable (SEV) TAVR. METHODS AND RESULTS:This single center study enrolled 133 consecutive TAVR patients (28.6% SEV, 71.4% BEV). Patients with pre-existent permanent pacemaker implant (PPMI), procedural death or incomplete ECG registration were excluded. Standard 12‑lead ECG was performed before the procedure, at 1, 24, 48 and 120 h and 1 month. In BEV patients, no significant PR prolongation occurred, whereas in SEV patients the PR interval prolonged significantly with 33.7 ± 22.0 ms (p < 0.001, compared to pre-TAVR) but only after 48 h after TAVR. Widening of QRS duration was comparable among both BEV and SEV patients (6.7 ± 21.5 versus 17.0 ± 26.9 ms, p = 0.061) and occurred immediately after TAVR. New-onset left bundle branch block was seen in 18.5% of BEV and 30.8% of SEV patients (p = 0.120) and occurred within 24 h after TAVR in both groups. Late PPMI (>24 h after TAVR) was higher in SEV compared to BEV patients (15.3% versus 1.5%, p = 0.008). CONCLUSION:Self-expandable valves cause more impairment in atrioventricular conduction with a delayed time course compared to balloon expandable valves. This might explain the higher pacemaker need beyond 24 h after TAVR. Our findings suggest that patients with self-expandable valves require at least 48 h ECG monitoring post TAVR.
10.1016/j.jelectrocard.2020.01.005
Delayed Onset Atrioventricular Block After Surgical Aortic Valve Replacement: A Rare Entity.
Cureus
Surgical aortic valve replacement (SAVR) is the mainstay treatment for aortic valve diseases in patients with low surgical risk. Trans aortic valve replacement (TAVR) has also grown over the past few years, although limited durability data is available. Atrioventricular conduction abnormalities (AVCA) are known complications in the immediate period post-TAVR and SAVR. There are no case reports regarding the development of the delayed onset AVCA years after SAVR. In this case report, we present a male patient who developed a complete heart block six years after SAVR, following which he got the permanent pacemaker implantation (PPMI).
10.7759/cureus.25606
Arrhythmic burden in patients with new-onset persistent left bundle branch block after transcatheter aortic valve replacement: 2-year results of the MARE study.
Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology
AIMS:We determined the incidence and type of arrhythmias at 2-year follow-up in patients with new-onset persistent left bundle branch block (LBBB) following transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS:Multicentre prospective study including 103 consecutive patients with new-onset persistent LBBB post-TAVR (SAPIEN XT/3: 53; CoreValve/Evolut R: 50). An implantable cardiac monitor (Reveal XT, Reveal Linq) was implanted before hospital discharge and patients had continuous monitoring for up to 2 years. Arrhythmic events were adjudicated in a central core lab. 1836 new arrhythmic events (tachyarrhythmias: 1655 and bradyarrhythmias: 181) occurred at 2 years. Of these, 283 (15%) occurred beyond 1 year (tachyarrhythmias 212, bradyarrhythmias 71) in 33 (36%) patients, without differences between valve type. Most late (>1 year) arrhythmic events were asymptomatic (94%) and led to a treatment change in 17 (19%) patients. A total of 71 late bradyarrhythmias [high-degree atrioventricular block (HAVB): 3, severe bradycardia: 68] were detected in 17 (21%) patients. At 2 years, 18 (17%) patients had received a permanent pacemaker (PPM) or implantable cardiac-defibrillator. PPM implantation due to HAVB predominated in the early phase post-TAVR, with only 1 HAVB event requiring PPM implantation after 1 year. CONCLUSION:Patients with new-onset LBBB post-TAVR exhibited a very high burden of arrhythmic events within the 2 years post-procedure. While new tachyarrhythmic events were homogeneously distributed over time, the vast majority of new HAVB episodes leading to PPM implantation occurred early after the procedure. These results should help to guide the management of this challenging group of patients. (clinicaltrials.gov: NCT02153307).
10.1093/europace/euaa213
Prognostic Outcome of New-Onset Left Bundle Branch Block After Transcatheter Aortic Valve Replacement in Patients With Aortic Stenosis: A Systematic Review and Meta-Analysis.
Frontiers in cardiovascular medicine
Background:Left bundle branch block (LBBB) is a common complication of the transcatheter aortic valve replacement (TAVR), and its impact on prognosis is controversial. Methods:A comprehensive electronic search was conducted in databases (PubMed, Embase, Cochrane Library, and The Web of Science), from the date of database establishment till March 2021, to screen for studies on new-onset LBBB after TAVR. We next performed a meta-analysis to evaluate the effect of new-onset LBBB after TAVR on patient prognosis, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results:A total of 17 studies, including 9205 patients, were eligible for our analysis. Patients with new-onset LBBB had elevated all-cause mortality risk verses patients without new-onset LBBB, during all follow ups. The relevant data are as follows: 30-day (RR:1.71; 95%CI:1.27-2.29; < 0.001), 1-year (RR:1.31; 95%CI:1.12-1.52; < 0.001), and 2-year (RR:1.31; 95%CI:1.09-1.56; = 0.003) follow ups. Likewise, new-onset LBBB patients also experienced increased cardiovascular mortality, compared to non-new-onset LBBB patients, but only in the 1-year follow up (RR:1.49; 95%CI:1.23-1.82; < 0.001). Hospitalization for heart failure was dramatically elevated in patients with new-onset LBBB verses non-new-onset LBBB, in all follow ups. The relevant data are as follows: 30-day (RR:1.56; 95%CI:1.13-2.12; = 0.007), 1-year (RR:1.35; 95%CI:1.08-1.68; = 0.007), and 2-year (RR:1.49; 95%CI:1.21-1.84; < 0.001). Similarly, new-onset LBBB patients had higher PPI risk than non-new-onset LBBB patients, in all follow ups. The relevant data are as follows: 30-day (RR:3.05; 95%CI:1.49-6.22; = 0.002), 1-year (RR:2.15; 95%CI:1.52-3.03; < 0.001), and 2-year (RR:2.52; 95%CI:1.68-3.78; < 0.001). Conclusion:Patients with new-onset LBBB have worse prognosis after TAVR than those without new-onset LBBB. Recognition of the adverse effects of post-TAVR new-onset LBBB can lead to the development of new strategies that enhance clinical outcomes. Systematic Trial Registration:https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197224, identifier: 19722.
10.3389/fcvm.2022.842929
Permanent-temporary pacemakers in the management of patients with conduction abnormalities after transcatheter aortic valve replacement.
Leong Derek,Sovari Ali A,Ehdaie Ashkan,Chakravarty Tarun,Liu Qiang,Jilaihawi Hasan,Makkar Rajendra,Wang Xunzhang,Cingolani Eugenio,Shehata Michael
Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing
BACKGROUND:Damage to the cardiac conduction system requiring permanent pacemaker (PPM) implantation is a known adverse outcome of transcatheter aortic valve replacement (TAVR). A permanent-temporary pacemaker (PTPM) is a device that involves an active-fixation lead attached to an external pulse generator taped to the skin. We reviewed the utility of PTPMs as a temporary bridge measure after TAVR in patients with conduction abnormalities that do not meet conventional criteria for PPM placement. METHODS:Between January 01, 2013 and December 31, 2015, we analyzed 67 patients who received PTPM after TAVR. Baseline demographics, comorbidities, type and size of the valve, pre-TAVR electrocardiograms (ECGs), post-TAVR ECGs at 1 day, 1 month, and 6 months, and pacemaker interrogation results were reviewed for each patient if available. RESULTS:The mean age of patients was 80.5 ± 9.1 years. PTPM were placed for 2.3 ± 2.4 days. Among these patients, 44.8% (n = 30) received a PPM prior to discharge. Male gender (OR 2.84, 95% CI 1.05-7.69, p = 0.05) and an increase in QRS duration post-TAVR (p = 0.01) were associated with PPM placement. Pacemaker interrogation data of 11 patients with PPM revealed that 27% (n = 3) had < 1% V-pacing requirements and < 10% A-pacing requirements. CONCLUSIONS:In post-TAVR patients who develop conduction abnormalities that do not meet conventional PPM implantation indications, PTPM safely provides a time period for further assessment and may prevent unnecessary PPM implantation. Male gender and an increase in QRS duration post-TAVR are associated with PPM implantation. Additionally, some patients may recover from their conduction disturbances and demonstrate low pacemaker utilization.
10.1007/s10840-018-0345-z
Impact of tapered-shape left ventricular outflow tract on pacemaker rate after transcatheter aortic valve replacement.
Heart and vessels
Mechanical compression of left ventricular outflow tract (LVOT) was reported to be a leading cause of conduction impairment requiring permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR). However, the association between tapered-shape LVOT and PPI after TAVR has not been elucidated. Of 272 consecutive patients treated with SAPIEN 3 in our institute, we retrospectively analyzed the clinical data of 256 patients without previous PPI or bicuspid valve. In-hospital PPI was performed in 20 (7.8%) patients at 8.2 ± 2.9 days after TAVR. Patients requiring PPI had smaller LVOT area (356.3 vs. 399.4 mm, p ≤ 0.011). Moreover, receiver operating characteristic statistics showed that LVOT area /annulus area possessed significantly higher predictive ability than LVOT area (c-statistic: 0.91 [95% confidence interval [CI]: 0.84-0.95] vs. 0.67 [95% CI: 0.57-0.77], p < 0.001). Multivariable analysis revealed that LVOT area /annulus area (odds ratio [OR]: 1.93 [95% CI: 1.38-2.71]; p < 0.001 per % of decreasing), the difference between membranous septum length and implantation depth (ΔMSID) (OR: 6.82 [95% CI 2.39-19.48]; p < 0.001 per mm of decreasing) and pre-existing complete right bundle branch block (CRBBB) (OR: 32.38 [95% CI2.30-455.63]; p ≤ 0.002) were independently associated with PPI. In our study, tapered-shape LVOT as well as short ΔMSID and pre-existing CRBBB were identified as independent predictors for PPI after TAVR. Higher valve implantation is required to minimize the risk of post-procedural PPI especially for patients with short MS length, pre-procedural CRBBB, or tapered-shape LVOT.
10.1007/s00380-021-01999-5
A single-centre cohort and short-term follow-up of patients who developed persistent new onset left bundle branch block after transcatheter aortic valve replacement.
Akdemir Baris,Roukoz Henri
Acta cardiologica
The most common conduction abnormality after transcatheter aortic valve replacement (TAVR) is new-onset left bundle branch block (LBBB) with an exact frequency that varies based on the valve system used for TAVR. PPM implantation in patients with persistent new onset LBBB post TAVR is controversial. The primary objective of this study is to report PPM utilisation and mortality in this patient population. A TAVR registry included patients older than 18 years who underwent TAVR between March 2012 and June 2015 at University of Minnesota Medical Centre. After exclusion, 151 patients were divided into two groups; patients with persistent new onset LBBB after TAVR (new LBBB, = 47) and patients without persistent new onset LBBB (no new LBBB, = 104). Among the 151 patients, 47 (31.1%) patients developed new-onset LBBB after the procedure and persisted at discharge. Left ventricular ejection fraction (LVEF) (52.5 ± 11.1 vs. 56.4 ± 10.8, : .047) and mean aortic valve gradient (40.6 ± 11.5 vs. 45.7 ± 14.1, : .022) were significantly higher in no new LBBB group. Among those with new LBBB, there was a significantly higher rate of PPM implant during index hospitalisation (14.9%, vs. 0%, < .001). LVEF remained significantly lower at 1 year follow up in new LBBB group compared to no new LBBB group (51.8 ± 11.2 vs. 57.6 ± 8.3, 002). Also in new LBBB group, there was a non-significantly higher rate of all-cause mortality in 1 year compared to no new LBBB group (14.9% vs. 9.6% : .34). There were no significant differences between patients with and without new LBBB with respect to PPM implant after discharge in 1 year (2.13% vs. 3.8% : .58), length of stay (7.3 ± 7.3 vs. 5.9 ± 2.7 : .09), post-op atrial fibrillation (AF) (16.3% vs. 8.5% : .20). New onset LBBB was frequent conduction problem post TAVR and one-third of patients with new onset LBBB persisted at discharge. New LBBB after TAVR was associated with a higher risk of PPM implantation during the index hospitalisation but not after discharge. Our findings suggest that early PPM implantation for post-TAVR LBBB is not indicated without complete or high degree AV block. Further research is required to identify the patients with new LBBB who would progress to advanced AV block or heart failure.
10.1080/00015385.2020.1713520
Late onset complete heart block after transcatheter aortic valve replacement treated with permanent His-bundle pacing.
Patel Sati,Jamoor Khaled,Khan Arfaat,Maskoun Waddah
Pacing and clinical electrophysiology : PACE
Transcatheter aortic valve replacement (TAVR) is a rapidly growing procedure. Conduction disease post-TAVR is frequent and routinely monitored for periprocedurally. Permanent pacemaker placement is relatively common and usually associated with worse outcomes post-TAVR. We report a case of very late presenting complete heart block post-TAVR treated with His-bundle pacing. Our case underscores the need for larger studies to further evaluate the utility of long-term cardiac monitoring post-TAVR and outcomes of His-bundle pacing in this population.
10.1111/pace.14074
Anatomical risk models for paravalvular leak and landing zone complications for balloon-expandable transcatheter aortic valve replacement.
Condado Jose F,Corrigan Frank E,Lerakis Stamatios,Parastatidis Ioannis,Stillman Arthur E,Binongo Jose N,Stewart James,Mavromatis Kreton,Devireddy Chandan,Leshnower Bradley,Guyton Robert,Forcillo Jessica,Patel Ateet,Thourani Vinod H,Block Peter C,Babaliaros Vasilis
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions
BACKGROUND:Though several anatomical characteristics have been reported separately as risk factors for paravalvular leak (PVL) and landing zone (LZ) complications after transcatheter aortic valve replacement (TAVR), multivariate risk models are needed. METHODS:Patients that underwent balloon-expandable TAVR with multidetector cardiac computed tomography (MDCT) sizing were studied. MDCT images were analyzed and the association between anatomical factors and ≥mild PVL, ≥moderate PVL, and LZ complications (annular rupture, requirement of new permanent pacemaker, and coronary obstruction) was determined, and subsequently competing predictive models were developed and validated. RESULTS:A total of 316 consecutive TAVR patients were included. Median age was 82.0 years (74.0-87.0) and STS score was 8.3% (5.4-10.9). Factors associated with ≥mild PVL included TAVR with Sapien/Sapien XT vs. Sapien 3 (OR = 2.50, 95% CI = 1.24-5.07), LVOT nontubularity (OR = 1.02, 95% CI = 1.01-1.04), LZ calcification (OR = 1.01, 95% CI = 1.00-1.01), and low cover index (OR = 0.94, 95% CI = 0.91-0.96). Factors associated with LZ complications included LZ calcification (OR = 1.01, 95% CI 1.00-1.01), leaflet asymmetry (OR = 1.01, 95% CI 1.01-1.02), and cover index (OR = 1.09, 95% CI 1.03-1.14). Predictive models for ≥mild PVL (AUC = 0.71, 95% CI = 0.66-0.77), ≥moderate PVL (AUC = 0.75, 95% CI = 0.65-0.84), and LZ complications (AUC = 0.77, 95% CI = 0.67-0.87) were created using procedural details and anatomical data from the MDCT. Clinical variables were not included as they were poorly correlated with the occurrence of PVL and LZ complications. For each outcome, the area under the curve (AUC) of the multivariate model was superior to the model consisting only of individual factors. CONCLUSIONS:A model using procedural/anatomical characteristics derived from MDCT predicts ≥mild PVL, ≥moderate PVL, and LZ complications post-TAVR. Incorporation of anatomical risks into clinical practice may help stratify patients before TAVR. © 2017 Wiley Periodicals, Inc.
10.1002/ccd.26987
Predictors of Permanent Pacemaker Implantation in Patients Undergoing Transcatheter Aortic Valve Replacement - A Systematic Review and Meta-Analysis.
Ullah Waqas,Zahid Salman,Zaidi Syeda Ramsha,Sarvepalli Deepika,Haq Shujaul,Roomi Sohaib,Mukhtar Maryam,Khan Muhammad Atif,Gowda Smitha Narayana,Ruggiero Nicholas,Vishnevsky Alec,Fischman David L
Journal of the American Heart Association
Background As transcatheter aortic valve replacement (TAVR) technology expands to healthy and lower-risk populations, the burden and predictors of procedure-related complications including the need for permanent pacemaker (PPM) implantation needs to be identified. Methods and Results Digital databases were systematically searched to identify studies reporting the incidence of PPM implantation after TAVR. A random- and fixed-effects model was used to calculate unadjusted odds ratios (OR) for all predictors. A total of 78 studies, recruiting 31 261 patients were included in the final analysis. Overall, 6212 patients required a PPM, with a mean of 18.9% PPM per study and net rate ranging from 0.16% to 51%. The pooled estimates on a random-effects model indicated significantly higher odds of post-TAVR PPM implantation for men (OR, 1.16; 95% CI, 1.04-1.28); for patients with baseline mobitz type-1 second-degree atrioventricular block (OR, 3.13; 95% CI, 1.64-5.93), left anterior hemiblock (OR, 1.43; 95% CI, 1.09-1.86), bifascicular block (OR, 2.59; 95% CI, 1.52-4.42), right bundle-branch block (OR, 2.48; 95% CI, 2.17-2.83), and for periprocedural atriorventricular block (OR, 4.17; 95% CI, 2.69-6.46). The mechanically expandable valves had 1.44 (95% CI, 1.18-1.76), while self-expandable valves had 1.93 (95% CI, 1.42-2.63) fold higher odds of PPM requirement compared with self-expandable and balloon-expandable valves, respectively. Conclusions Male sex, baseline atrioventricular conduction delays, intraprocedural atrioventricular block, and use of mechanically expandable and self-expanding prosthesis served as positive predictors of PPM implantation in patients undergoing TAVR.
10.1161/JAHA.121.020906
A Highly Predictive Risk Model for Pacemaker Implantation After TAVR.
Maeno Yoshio,Abramowitz Yigal,Kawamori Hiroyuki,Kazuno Yoshio,Kubo Shunsuke,Takahashi Nobuyuki,Mangat Geeteshwar,Okuyama Kazuaki,Kashif Mohammad,Chakravarty Tarun,Nakamura Mamoo,Cheng Wen,Friedman John,Berman Daniel,Makkar Raj R,Jilaihawi Hasan
JACC. Cardiovascular imaging
OBJECTIVES:This study sought to develop a robust and definitive risk model for new permanent pacemaker implantation (PPMI) after SAPIEN 3 (third generation balloon expandable valve) (Edwards Lifesciences, Irvine, California) transcatheter aortic valve replacement (third generation balloon expandable valve TAVR), including calcification in the aortic-valvular complex (AVC). BACKGROUND:The association between calcium in the AVC and need for PPMI is poorly delineated after third generation balloon expandable valve TAVR. METHODS:At Cedars-Sinai Heart Institute in Los Angeles, California, a total of 240 patients with severe aortic stenosis underwent third generation balloon expandable valve TAVR and had contrast computed tomography. AVC was characterized precisely by leaflet sector and region. RESULTS:The total new PPMI rate was 14.6%. On multivariate analysis for predictors of PPMI, pre-procedure third generation balloon expandable valve TAVR, right bundle branch block (RBBB), shorter membranous septum (MS) length, and noncoronary cusp device-landing zone calcium volume (NCC-DLZ CA) were included. Predictive probabilities were generated using this logistic regression model. If 3 pre-procedural risk factors were present, the c-statistic of the model for PPMI was area under the curve of 0.88, sensitivity of 77.1%, and specificity of 87.1%; this risk model had high negative predictive value (95.7%). The addition of the procedural factor of device depth to the model, with the parameter of difference between implantation depth and MS length, combined with RBBB and NCC-DLZ CA increased the c-statistic to 0.92, sensitivity to 94.3%, specificity to 83.8%, and negative predictive value to 98.8% CONCLUSIONS: By using a precise characterization of distribution of calcification in the AVC in a single-center, retrospective study, NCC-DLZ CA was found to be an independent predictor of new PPMI post-third generation balloon expandable valve TAVR. The findings also reinforce the importance of short MS length, pre-existing RBBB, and ventricular implantation depth as important synergistic PPMI risk factors. This risk model will need validation by future prospective multicenter studies.
10.1016/j.jcmg.2016.11.020
Utility of rapid atrial pacing before and after TAVR with balloon-expandable valve in predicting permanent pacemaker implantation.
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions
BACKGROUND:High-grade or complete atrioventricular block (AVB) requiring permanent pacemaker (PPM) implantation is a known complication of transcatheter aortic valve replacement (TAVR). Wenckebach AVB induced by rapid atrial pacing (RAP) after TAVR was previously demonstrated in an observational analysis to be an independent predictor for PPM. We sought to investigate the utility of both pre- and post-TAVR RAP in predicting PPM implantation. METHODS:In a single-center, prospective study, 421 patients underwent TAVR with balloon-expandable valves (BEV) between April 2020 and August 2021. Intraprocedural RAP was performed in patients without a pre-existing pacemaker, atrial fibrillation/flutter, or intraprocedural complete AVB to assess for RAP-induced Wenckebach AVB. The primary outcome was PPM within 30 days after TAVR. RESULTS:RAP was performed in 253 patients, of whom 91.3% underwent post-TAVR RAP and 61.2% underwent pre-TAVR RAP. The overall PPM implantation rate at 30 days was 9.9%. Although there was a numerically higher rate of PPM at 30 days in patients with RAP-induced Wenckebach AVB, it did not reach statistical significance (13.3% vs. 8.4%, p = 0.23). In a multivariable analysis, RAP-induced Wenckebach was not an independent predictor for PPM implantation at 30 days after TAVR. PPM rates at 30 days were comparable in patients with or without pre-TAVR pacing-induced Wenckebach AVB (11.8% vs. 8.2%, p = 0.51) and post-TAVR pacing-induced Wenckebach AVB (10.2% vs. 5.8%, p = 0.25). CONCLUSION:In patients who underwent TAVR with BEV, there were no statistically significant differences in PPM implantation rates at 30 days regardless of the presence or absence of RAP-induced Wenckebach AVB. Due to conflicting results between the present study and the prior observational analysis, future studies with larger sample sizes are warranted to determine the role of RAP during TAVR as a risk-stratification tool for significant AVB requiring PPM after TAVR.
10.1002/ccd.30817
Aortic Valve Calcification as a Predictor of Post-Transcatheter Aortic Valve Replacement Pacemaker Dependence.
Cardiology research
BACKGROUND:Atrioventricular block requiring permanent pacemaker (PPM) implantation is a common complication of transcatheter aortic valve replacement (TAVR). The mechanism of atrioventricular (AV) block during TAVR is not fully understood, but it may be due to the mechanical stress of TAVR deployment, resulting in possible injury to the nearby compact AV node. Aortic valve calcification (AVC) may worsen this condition and has been associated with an increased risk for post-TAVR PPM implantation. We performed a retrospective analysis to determine if AVC is predictive for long-term right ventricular (RV) pacing in post-TAVR pacemaker patients at 30 days. METHODS:A total of 262 consecutive patients who underwent TAVR with a balloon-expandable valve were analyzed. AVC data were derived from contrast-enhanced computed tomography and characterized by leaflet sector and region. RESULTS:A total of 25 patients (11.1%) required post-TAVR PPM implantation. Seventeen patients did not require RV pacing at 30 days. Nine of these 17 patients had no RV pacing requirement within 10 days. The presence of intra-procedural heart block (P = 0.004) was the only significant difference between patients who did not require PPM and those who required PPM but they were not RV pacing-dependent at 30 days. Non-coronary cusp (NCC) calcium volume was significantly higher in patients who were pacemaker-dependent at 30 days (P = 0.01) and a calcium volume of > 239.2 mm in the NCC was strongly predictive of pacemaker dependence at 30 days (area under the curve (AUC) = 0.813). Pre-existing right bundle branch block (RBBB) (odds ratio (OR) 105.4, P = 0.004), bifascicular block (OR 12.5, P = 0.02), QRS duration (OR 70.43, P = 0.007) and intra-procedural complete heart block (OR 12.83, P = 0.03) were also predictive of pacemaker dependence at 30 days. CONCLUSIONS:In patients who required PPM after TAVR, quantification of AVC by non-coronary leaflet calcium volume was found to be a novel predictor for RV pacing dependence at 30 days. The association of NCC calcification and PPM dependence may be related to the proximity of the conduction bundle to the non-coronary leaflet. Further studies are necessary to improve risk prediction for long-term RV pacing requirements following TAVR.
10.14740/cr1011
The Utility of Rapid Atrial Pacing Immediately Post-TAVR to Predict the Need for Pacemaker Implantation.
Krishnaswamy Amar,Sammour Yasser,Mangieri Antonio,Kadri Amer,Karrthik Antonette,Banerjee Kinjal,Kaur Manpreet,Giannini Francesco,Pagliaro Beniamino,Ancona Marco,Pagnesi Matteo,Laricchia Alessandra,Weisz Giora,Lyden Megan,Bazarbashi Najdat,Gad Mohamed,Ahuja Keerat,Mick Stephanie,Svensson Lars,Puri Rishi,Reed Grant,Rickard John,Colombo Antonio,Kapadia Samir,Latib Azeem
JACC. Cardiovascular interventions
OBJECTIVES:The aim of this study was to determine the utility of rapid atrial pacing immediately after transcatheter aortic valve replacement (TAVR) to predict the need for permanent pacemaker implantation (PPI). BACKGROUND:Risk stratification for patients without high-grade atrioventricular block (AVB) after TAVR is imprecise and based on anatomic considerations, electrocardiographic characteristics, and clinical suspicion. A more reliable assessment is necessary to minimize inpatient rhythm monitoring and/or reduce unnecessary PPI. METHODS:Consecutive patients undergoing TAVR at 2 centers were included. After valve implantation in patients without pacemakers who did not have complete heart block or atrial fibrillation, the temporary pacemaker was withdrawn from the right ventricle and placed in the right atrium. Rapid atrial pacing was performed from 70 to 120 beats/min, and patients were assessed for the development of Wenckebach AVB. Patients were then followed for clinical outcomes, including PPI. RESULTS:A total of 284 patients were included. Of these, 130 (45.8%) developed Wenckebach AVB. There was a higher rate of PPI within 30 days of TAVR among the patients who developed Wenckebach AVB (13.1% vs. 1.3%; p < 0.001), with a negative predictive value for PPI in the group without Wenckebach AVB of 98.7%. A greater percentage of patients receiving self-expanding valves required PPI than those receiving a balloon-expandable valves (15.9% vs. 3.7%; p = 0.001), though these rates were still relatively low among patients who did not develop Wenckebach AVB (2.9% and 0.8%). CONCLUSIONS:Atrial pacing post-TAVR is easily performed and can help identify patients who may benefit from extended rhythm monitoring. Patients who did not develop pacing-induced Wenckebach AVB demonstrated an extremely low likelihood of PPI.
10.1016/j.jcin.2020.01.215
Recovery of atrioventricular conduction in patients with heart block after transcatheter aortic valve replacement.
Raelson Colin A,Gabriels James,Ruan Jonathan,Ip James E,Thomas George,Liu Christopher F,Cheung Jim W,Lerman Bruce B,Patel Apoor,Markowitz Steven M
Journal of cardiovascular electrophysiology
INTRODUCTION:Recovery of conduction has been demonstrated in >50% of patients who receive pacemakers (PPMs) for high-degree atrioventricular block (HD-AVB) after transcatheter aortic valve replacement (TAVR). Little information is available about the time course of conduction recovery in these patients and if any features predict early recovery of conduction. METHODS:A retrospective review was performed of patients who underwent TAVR with balloon and self-expanding valves who required PPMs for HD-AVB. Serial PPM interrogations were analyzed to detect recovery of AV conduction. Analysis was performed to identify predictors and timing of conduction recovery. RESULTS:Of a total population of 578 patients, 54 (9%) received PPMs for HD-AVB. In multivariate analysis, predictors of HD-AVB requiring a PPM included age (P = 0.014), right bundle branch block (OR 7.33 [3.64-14.8], P < 0.0001), atrial fibrillation (OR 2.16 [1.16-4.05], P = 0.016), and self-expanding valves (OR 4.19 [2.20-7.97], P < 0.0001). Of the 54 patients who received PPMs, 38 had follow-up sufficient to evaluate AV conduction recovery. Of these, 23 (61%) showed recovery of AV nodal conduction; 20 had already recovered by their first interrogation, a median of 22 days (IQR 14-31) post-PPM placement. There were no statistically significant predictors of AV nodal conduction recovery, including type of valve implanted. CONCLUSIONS:A majority of patients who receive PPMs for HD-AVB after TAVR recover AV conduction during follow-up, and in most patients conduction recovery occurs within weeks. These findings imply that programming to minimize ventricular pacing may be beneficial in a majority of these patients.
10.1111/jce.13291
Mortality and Heart Failure Hospitalization in Patients With Conduction Abnormalities After Transcatheter Aortic Valve Replacement.
Jørgensen Troels H,De Backer Ole,Gerds Thomas A,Bieliauskas Gintautas,Svendsen Jesper H,Søndergaard Lars
JACC. Cardiovascular interventions
OBJECTIVES:The aim of this study was to assess mortality and rehospitalization in patients with new bundle branch block (BBB) and/or permanent pacemaker (PPM) after transcatheter aortic valve replacement (TAVR). BACKGROUND:Previous studies have provided inconsistent results on the clinical impact of new BBB or new PPM after TAVR. METHODS:A total of 816 consecutive patients without pre-procedural BBB or PPM undergoing TAVR between 2007 and 2017 were followed for 5 years or until data extraction in September 2017. Data on vital status and hospitalization were obtained through national registries. RESULTS:Within 30 days post-TAVR, new BBB without PPM and new PPM occurred in 247 (30.3%) and 132 (16.2%) patients, respectively, leaving 437 patients (53.6%) without conduction abnormalities. Median follow-up was 2.5 years (interquartile range: 1.0 to 4.9 years). One-year all-cause mortality was increased for new BBB (hazard ratio [HR]: 2.80; 95% confidence interval [CI]: 1.18 to 3.67) but not for new PPM (HR: 1.64; 95% CI: 0.72 to 3.74) compared with patients with no conduction abnormalities. The risk for late all-cause mortality (≥1 year after TAVR) was higher both for patients with new BBB (HR: 1.79; 95% CI: 1.24 to 2.59) and for those with new PPM (HR: 1.58; 95% CI: 1.01 to 2.46) compared with patients with no conduction abnormalities. Patients with new BBB (HR: 1.47; 95% CI: 1.02 to 2.12) and new PPM (HR: 1.66; 95% CI: 1.09 to 2.54) had a higher risk for heart failure hospitalization and reduced left ventricular ejection fraction (p < 0.0001 for both groups) during follow-up. CONCLUSIONS:New BBB and new PPM developed frequently after TAVR. New BBB was associated with increased early and late all-cause mortality, whereas new PPM was associated with late all-cause mortality. Furthermore, both new BBB and new PPM increased the risk for heart failure hospitalizations.
10.1016/j.jcin.2018.10.053
Long-Term Ventricular Pacing Dependency and Pacemaker Implantation Predictors after Transcatheter Aortic Valve Replacement - A 1-Year Follow-Up.
Arquivos brasileiros de cardiologia
BACKGROUND:Conduction disturbances (CD) are the most frequent complication after transcatheter aortic valve replacement (TAVR), and there continues to be a lack of consensus on their management. OBJECTIVE:To assess new CD and permanent pacemaker (PPM) implantation after TAVR and to evaluate the ventricular pacing percentage (VP) up to 1 year of follow-up. METHODS:Patients who underwent TAVR from October 2014 to November 2019 were enrolled; patients with previous PPM were excluded. Clinical, procedure, ECG, and PPM data were collected up to 1 year after implantation. The significance level adopted in the statistical analysis was 0.05. RESULTS:A total of 340 patients underwent TAVR. The most frequent CD was the new left bundle branch block (LBBB; 32.2%), which 56% resolved after 6 months. Right bundle branch block (RBBB) was the biggest risk factor for advanced atrioventricular block (AVB) [OR=8.46; p<0.001] and PPM implantation [OR=5.18, p<0.001], followed by previous low-grade AVB [OR=2.25; p=0.016 for PPM implantation]. Regarding procedure characteristics, newer generation valves and valve-in-valve procedures were associated with fewer CDs. Overall, 18.5% of patients had a PPM implanted post-TAVR. At first PPM evaluation, patients with advanced AVB had a median percentage of VP of 80% and 83% at one year. Regarding patients with LBBB plus low-grade AVB, median VP was lower (6% at first assessment, p=0.036; 2% at one year, p = 0.065). CONCLUSION:LBBB was the most frequent CD after TAVR, with more than half being resolved in the first six months. RBBB was the major risk factor for advanced AVB and PPM implantation. Advanced AVB was associated with a higher percentage of VP at 1 year of follow-up.
10.36660/abc.20210613
Incidence, predictors and clinical impact of permanent pacemaker insertion in women following transcatheter aortic valve implantation: Insights from a prospective multinational registry.
Nicolas Johny,Guedeney Paul,Claessen Bimmer E,Mehilli Julinda,Petronio Anna Sonia,Sartori Samantha,Lefèvre Thierry,Presbitero Patrizia,Capranzano Piera,Iadanza Alessandro,Cao Davide,Chiarito Mauro,Goel Ridhima,Roumeliotis Anastasios,Chandiramani Rishi,Chen Siyan,Sardella Gennaro,Van Mieghem Nicolas M,Sorrentino Sabato,Meliga Emanuele,Tchétché Didier,Dumonteil Nicolas,Fraccaro Chiara,Trabattoni Daniela,Mikhail Ghada W,Ferrer-Gracia Maria-Cruz,Naber Christoph,Kievit Peter C,Baber Usman,Sharma Samin K,Morice Marie-Claude,Dangas George D,Chandrasekhar Jaya,Chieffo Alaide,Mehran Roxana
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions
OBJECTIVES:To describe the incidence, predictors, and clinical impact of permanent pacemaker insertion (PPI) following transcatheter aortic valve replacement (TAVR) in women. BACKGROUND:Data on pacemaker insertion complicating TAVR in women are scarce. METHODS:The Women's International Transcatheter Aortic Valve implantation (WIN-TAVI) is a prospective registry evaluating the safety and efficacy of TAVR in women. We included patients without preprocedural pacemakers and divided them into two groups: (1) PPI and (2) no-PPI. We identified PPI predictors using logistic regression and studied its clinical impact on the Valve Academic Research Consortium (VARC)-2 efficacy and safety endpoints. RESULTS:Out of 1019 patients, 922 were included in the analysis. Post-TAVR PPI occurred in 132 (14.3%) patients. Clinical and procedural characteristics were similar in both groups. Pre-existing right bundle branch block (RBBB) was associated with a high risk of post-TAVR PPI (OR 3.62, 95% CI 1.85-7.06, p < 0.001), while implantation of balloon-expandable prosthesis was associated with a lower risk (OR 0.47, 95% CI 0.30-0.74, p < 0.001). Post-TAVR PPI prolonged in-hospital stay by a median of 2 days (11 [9-16] days in PPI vs. 9 [7-14] days in no-PPI, p = 0.005), yet risks of VARC-2 efficacy and safety endpoints at 1 year were similar in both groups ( HR 0.95, 95% CI 0.60-1.52, p = 0.84 and HR 1.22, 95% CI 0.83-1.79, p = 0.31, respectively). CONCLUSION:Pacemaker implantation following TAVR is frequent among women and is associated with pre-existing RBBB and valve type. PPI prolongs hospital stay, albeit without any significant impact on 1-year outcomes.
10.1002/ccd.29807
Predictors of right ventricular pacing and pacemaker dependence in transcatheter aortic valve replacement patients.
Sharma Esseim,Chu Antony F
Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing
PURPOSE:Transcatheter aortic valve replacement (TAVR) is an increasingly prevalent therapy in patients with severe symptomatic aortic stenosis. Conduction disturbances requiring permanent pacemaker (PPM) implantation are a known complication of TAVR. This study investigated the progression of cardiac conduction disease in the post-TAVR pacemaker population and identified predictors of post-TAVR right ventricular (RV) pacing dependence. METHODS:Prospectively collected echocardiographic, ECG, and PPM interrogation data of 262 consecutive patients who underwent TAVR with placement of a balloon-expandable valve at one institution from March 2012 to October 2016 were analyzed. RESULTS:A total of 25 patients (11.1%) required post-TAVR PPM implantation. Seventeen patients who received PPMs did not require RV pacing at 30 days. Nine of these 17 patients had no RV pacing requirement within 10 days. Pre-existing right bundle branch block (RBBB) (OR 105.4, 4.52-2458.5, p = 0.0002), bifascicular block (OR 12.50, 1.60-97.65, p = 0.02), intra-procedural complete heart block (OR 12.83, 1.26-130.52, p = 0.03), and QRS duration > 120 ms (OR 70.43, 3.23-1535.22, p = 0.0002) on pre-TAVR ECG were associated with RV pacing dependence at 30 days. CONCLUSIONS:Sixty-eight percent of patients meeting post-procedural guideline indications for PPM did not require RV pacing at 30 days. Fifty-two percent of these patients demonstrated recovery of sinus node function or AV conduction within 10 days post-implant. RBBB, intra-procedural complete heart block, bifascicular block, and QRS duration > 120 ms were associated with RV pacing dependence at 30 days. These findings suggest that post-TAVR conduction disturbances may be acutely reversible in a significant proportion of patients receiving PPM within 10-30 days of implant.
10.1007/s10840-017-0303-1
Impact of Preexisting Left Bundle Branch Block in Transcatheter Aortic Valve Replacement Recipients.
Fischer Quentin,Himbert Dominique,Webb John G,Eltchaninoff Helene,Muñoz-García Antonio J,Tamburino Corrado,Nombela-Franco Luis,Nietlispach Fabian,Moris Cesar,Ruel Marc,Dager Antonio E,Serra Vicenç,Cheema Asim N,Amat-Santos Ignacio J,de Brito Fabio Sandoli,Ribeiro Henrique,Abizaid Alexandre,Sarmento-Leite Rogério,Dumont Eric,Barbanti Marco,Durand Eric,Alonso Briales Juan H,Bouleti Claire,Immè Sebastiano,Maisano Francesco,Del Valle Raquel,Miguel Benitez Luis,García Del Blanco Bruno,Côté Mélanie,Philippon François,Urena Marina,Rodés-Cabau Josep
Circulation. Cardiovascular interventions
BACKGROUND:The impact of preexisting left bundle branch block (LBBB) in transcatheter aortic valve replacement (TAVR) recipients is unknown. The aim of this study was to determine the impact of preexisting LBBB on clinical outcomes after TAVR. METHODS AND RESULTS:This multicenter study evaluated 3404 TAVR candidates according to the presence or absence of LBBB on baseline ECG. TAVR complications and causes of death were defined according to Valve Academic Research Consortium-2 definitions. Follow-up outpatient visits or telephone interviews were conducted at 30 days, 12 months, and yearly thereafter. Echocardiography examinations were performed at baseline, at hospital discharge, and at 1-year follow-up. Preexisting LBBB was present in 398 patients (11.7%) and was associated with an increased risk of permanent pacemaker implantation (PPI; 21.1% versus 14.8%; adjusted odds ratio, 1.51; 95% CI, 1.12-2.04) but not death (7.3% versus 5.5%; adjusted odds ratio, 1.33; 95% CI, 0.84-2.12) at 30 days. At a mean follow-up of 22±21 months, there were no differences between patients with and without preexisting LBBB in overall mortality (adjusted hazard ratio, 0.94; 95% CI, 0.75-1.18) and cardiovascular mortality (adjusted hazard ratio, 0.90; 95% CI, 0.68-1.21). In a subanalysis of 2421 patients without PPI at 30 days and with complete follow-up about the PPI, preexisting LBBB was not associated with an increased risk of PPI or sudden cardiac death. Patients with preexisting LBBB had a lower left ventricular ejection fraction (LVEF) at baseline and at 1-year follow-up ( P <0.001 for both), but those with low LVEF exhibited a similar increase in LVEF over time after TAVR compared with patients with no preexisting LBBB ( P=0.327). CONCLUSIONS:Preexisting LBBB significantly increased the risk of early (but not late) PPI after TAVR, without any significant effect on overall mortality or cardiovascular mortality. Preexisting LBBB was associated with lower LVEF pre-TAVR but did not prevent an increase in LVEF post-TAVR similar to patients without LBBB.
10.1161/CIRCINTERVENTIONS.118.006927
Risk Prediction Model for Cardiac Implantable Electronic Device Implantation After Transcatheter Aortic Valve Replacement.
Tsushima Takahiro,Nadeem Fahd,Al-Kindi Sadeer,Clevenger Joshua R,Bansal Eric J,Wheat Heather L,Kalra Ankur,Attizzani Guilherme F,Elgudin Yakov,Markowitz Alan,Costa Marco A,Simon Daniel I,Arruda Mauricio S,Mackall Judith A,Thal Sergio G
JACC. Clinical electrophysiology
OBJECTIVES:The aim of this study was to develop and validate a risk prediction model for high-grade atrioventricular block requiring cardiac implantable electronic device (CIED) implantation after transcatheter aortic valve replacement (TAVR). BACKGROUND:High-grade atrioventricular block requiring CIED remains a significant sequelae following TAVR. Although several pre-operative characteristics have been associated with the risk of post-operative CIED implantation, an accurate and validated risk prediction model is not established yet. METHODS:This was a single center, retrospective study of consecutive patients who underwent TAVR from March 10, 2011, to October 8, 2018. This cohort sample was randomly divided into a derivation cohort (group A) and a validation cohort (group B). A scoring system for risk prediction of post-TAVR CIED implantation was devised using logistic regression estimates in group A and the calibration and validation were done in group B. RESULTS:A total of 1,071 patients underwent TAVR during the study period. After excluding pre-existing CIED, a total of 888 cases were analyzed (group A: 507 and group B: 381). Independent predictive variables were as follows: self-expanding valve (1 point), hypertension (1 point), pre-existing first-degree atrioventricular block (1 point), and right bundle branch block (2 points). The resulting score was calculated from the total points. The internal validation in group B showed an ideal linear relationship in calibration plot (R = 0.933) and a good predictive accuracy (area under the curve: 0.693; 95% confidence interval: 0.627 to 0.759). CONCLUSIONS:This prediction model accurately predicts post-operative risk of CIED implantation with simple pre-operative parameters.
10.1016/j.jacep.2019.10.020
Pooled-Analysis of Association of Sievers Bicuspid Aortic Valve Morphology With New Permanent Pacemaker and Conduction Abnormalities After Transcatheter Aortic Valve Replacement.
Frontiers in cardiovascular medicine
Background:Studies on the association of Sievers bicuspid aortic valve (BAV) morphology with conduction disorders after transcatheter aortic valve replacement (TAVR) have not reached consensus. Methods:We here performed a pooled-analysis to explore whether Sievers type 1 BAV morphology increased the risk of post-TAVR conduction abnormalities and permanent pacemaker implantation (PPI) compared to type 0. Systematic literature searches through EMBASE, Medline, and Cochrane databases were concluded on 1 December 2021. The primary endpoint was post-TAVR new PPI and pooled as risk ratios (RRs) and 95% confidence intervals (CIs). Conduction abnormalities as the secondary endpoint were the composites of post-TAVR PPI and/or new-onset high-degree of atrial-ventricle node block and left-bundle branch block. Studies that reported incidence of outcomes of interest in both type 1 and type 0 BAV morphology who underwent TAVR for aortic stenosis were included. Results:Finally, nine studies were included. Baseline characteristics were generally comparable, but type 1 population was older with a higher surgical risk score compared to type 0 BAV morphology. In the pooled-analysis type 1 BAV had significantly higher risk of post-TAVR new-onset conduction abnormalities ( = 1.68, 95% 1.09-2.60, = 0.0195) and new PPI ( = 1.97, 95% 1.29-2.99, = 0.0016) compared to type 0. Random-effects univariate meta-regression indicated that no significant association between baseline characteristics and PPI. Conclusion:Sievers type 1 BAV morphology was associated with increased risk of post-TAVR PPI and conduction abnormalities compared to type 0. Dedicated cohort is warranted to further validate our hypothesis.
10.3389/fcvm.2022.884911
Predictors of high-degree atrioventricular block in patients with new-onset left bundle branch block following transcatheter aortic valve replacement.
Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing
BACKGROUND:The development of new left bundle branch block (LBBB) is frequently seen post TAVR and is a known risk factor for progression to high degree AV block. The timing and likelihood of progression into complete heart block is variable and can develop after hospital discharge. We sought to determine predictors for the development of high degree AV block in patients who developed LBBB following TAVR. METHODS:All patients between 2014 and 2019 underwent electrophysiology study after developing LBBB post TAVR. Data on these patients including baseline characteristics, echo parameters, EKG variables, HV interval, and the need for subsequent pacemaker implantation were extracted. A prolonged HV interval was defined as ≥ 65 ms. Clinically significant conduction abnormality was defined as development of high-degree AV block or clinically significant complete heart block. RESULTS:Thirty-four patients were included in our study of which 10 (29.4%) developed clinically significant heart block, while 24 (70.6%) did not. The mean HV interval for patients with clinically significant heart block was 70.1 ms vs 57.8 ms for those who did not (p = 0.022). Pre-existing first-degree heart block prior to TAVR (p = 0.026), history of AFib (p = 0.05) in addition to STS score (p = 0.037) were predictors of development of high-degree AV block in our patient population. CONCLUSIONS:In patients who develop LBBB following TAVR, HV interval, pre-existing first-degree heart block, and STS score predict progression to high-degree AV block. Performance of a routine electrophysiology study should be considered for high-risk patients who develop LBBB following TAVR.
10.1007/s10840-022-01361-3
Predictors of pacemaker dependency in patients implanted with a pacemaker after Transaortic valve replacement.
Ruiz-Hernandez Pablo M,Gonzalez-Torrecilla Esteban,Gutierrez-Ibañez Enrique,Gonzalez-Saldivar Hugo,Bruña Vanesa,Loughlin Gerard,Castellanos Evaristo,Avila Pablo,Atienza Felipe,Datino Tomas,Elizaga Jaime,Arenal Angel,Fernández-Aviles Francisco
International journal of cardiology. Heart & vasculature
Introduction and objectives:The development of complete AV block and the need for pacemaker implantation (PM) is the most frequent complication after Transaortic valve replacement (TAVR). In other PM clinical contexts, a higher percentage of ventricular stimulation has been associated with worse prognosis. The objective was to study the existence of predictors of PM dependence. Methods:We identified 96 consecutive patients who had received a PM post-TAVR (all Core-Valve). We retrospectively analyzed this cohort with the aim of identifying predictors of a high and very high percentage of ventricular pacing (VP), PM dependency and survival. Results:The mean age was 82.3 years, with a mean logistic EuroSCORE of 17.1, 53% were women and 12% of patients had LVEF < 50%. The indication was complete AV block in 40.5%, and LBBB in 59.5%. Mean survival was 62.7 months, IQR [54.4-71]. The only independent predictor of mortality was the pre-TAVR logistic Euro-SCORE (RR = 1,026, p = 0.033), but not LVEF < 50%, VP > 50%, VP > 85% or PM dependence. In 73 patients PM rhythm was documented at the end of follow-up. Of these, 14 (19.2%) were considered dependent, and 37 (50.7%) presented VP > 50%. The post-TAVR complete AV block recovery rate was 67.8%. In multivariate analysis, female sex (HR = 5.6, p = 0.005), and indication of complete AV block vs. LBBB (HR = 15.7, p = 0.017) were independently associated with PM dependency. Conclusions:Female sex and indication due to complete AV block were independent predictors of PM dependency during follow up. In our series of patients with mostly normal LVEF, a high percentage of stimulation does not influence prognosis.
10.1016/j.ijcha.2020.100654
Optimizing Care of Patients With Right Bundle Branch Block Undergoing Transcatheter Aortic Valve Replacement.
Cardiovascular revascularization medicine : including molecular interventions
OBJECTIVES:To evaluate the use of temporary-permanent pacemaker (TPP) in patients with right bundle branch block (RBBB) undergoing transcatheter aortic valve replacement (TAVR). We also sought to identify key predictors of permanent pacemaker (PPM) within 30 days of TAVR in this population. BACKGROUND:RBBB is a well-recognized risk factor for PPM post TAVR. TPP provides stable transient pacing and reduces the need for critical care beds. METHODS:This is a retrospective chart review of 371 patients who underwent TAVR at our institution. All patients with pre-existing RBBB had TPP placed prior to TAVR (n = 37). The primary outcome was the need for critical care beds. Multivariate logistic regression analysis was performed to identify predictors of PPM within 30 days of TAVR. RESULTS:67 patients required PPM within 30 days of TAVR, and 56 implanted before discharge. 51% (19 out of 37) of TPP group required PPM before discharge compared to 11% (37 out of 334) of No TPP (p < 0.001), yet TPP group spent significantly fewer hours in a critical care bed (19 vs 28 h, p = 0.01). Length of membranous septum (LMS) <8.49 mm was the strongest independent predictor of PPM within 30 days of TAVR (RAUC of 0.80, Sensitivity 0.7 and Specificity 0.8) and 98% of patients with LMS < 7 mm required PPM within 30 days. CONCLUSION:TPP-TAVR is a well-defined multidisciplinary protocol that reduces the need for critical care beds in patients with pre-existing RBBB referred for TAVR. Additionally, LMS is the strongest predictor of PPM implantation in this population. CONDENSED ABSTRACT (100 WORDS): This study evaluated the use of temporary-permanent pacemakers (TPP) in patients with right bundle branch block (RBBB) undergoing transcatheter aortic valve replacement (TAVR). TPP-TAVR provided stable pacing allowing for early mobilization and reduced the need for critical care beds. Multivariate logistic regression analysis identified length of membranous septum (LMS) <8.49 mm in patients with RBBB as the strongest independent predictor of PPM need within 30 days of TAVR. 98% of patients with RBBB and LMS < 7 mm required PPM at 30 days regardless of other characteristics including valve type and size.
10.1016/j.carrev.2022.03.018
Arrhythmias in Relation to Mortality After Transcatheter Aortic Valve Replacement.
Dhakal Bishnu P,Skinner Kristina A,Kumar Kris,Lotun Kapildeo,Shetty Ranjith,Kazui Toshinobu,Lee Kwan,Indik Julia H
The American journal of medicine
BACKGROUND:The purpose of this study was to identify predictors of mortality and potentially modifiable factors related to arrhythmias in patients that undergo transcatheter aortic valve replacement (TAVR). Patients that undergo TAVR are at risk for complete heart block requiring pacemaker implant. Additionally, other arrhythmias, specifically atrial fibrillation (AF), are common in this population. It is unclear how arrhythmias and their management contribute to mortality risk. METHODS:The study analyzed 176 patients who underwent TAVR at a single center. Factors associated with pacemaker implantation within 30 days were analyzed by logistic regression. Factors associated with mortality were analyzed by Kaplan-Meier and Cox regression analyses. RESULTS:Mean age was 80 ± 8.5 years. AF was present in 69 patients, and 39 received anticoagulation. Post-TAVR, a pacemaker was implanted in 25 patients within 30 days. Over a follow up of 566 ± 496 days, 49 patients died. In multivariable analysis, right bundle branch block remained significant (odds ratio 4.212, P = 0.012) for pacemaker implant within 30 days. The AF (hazard ratio [HR] 3.905, P = 0.001), albumin level (HR 0.316, P = 0.034), and diabetes (HR 2.323, P = 0.027) were predictors of death in a multivariate analysis, while pacemaker implant within 30 days was not. Patients with AF who were anticoagulated had improved survival in a stratified Kaplan-Meier analysis compared with those who were not anticoagulated (P = 0.0001). CONCLUSION:AF, diabetes, and low albumin levels are independently associated with mortality after TAVR. In particular, patients with AF who are not anticoagulated are at highest risk for death. Efforts to identify AF and consider anticoagulation should be emphasized.
10.1016/j.amjmed.2020.03.032
Intraprocedural high-degree atrioventricular block or complete heart block in transcatheter aortic valve replacement recipients with no prior intraventricular conduction disturbances.
Junquera Lucía,Freitas-Ferraz Afonso B,Padrón Remigio,Silva Iria,Nunes Ferreira-Neto Alfredo,Guimaraes Leonardo,Mohammadi Siamak,Morís Cesar,Philippon François,Rodés-Cabau Josep
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions
BACKGROUND:Conduction disturbances are the most frequent complication of transcatheter aortic valve replacement (TAVR). However, no data exists regarding the outcomes of intraprocedural high-degree atrioventricular block (HAVB) or complete heart block (CHB) in patients without previous conduction disturbances. OBJECTIVES:The aim of this study was to evaluate the outcomes of intraprocedural-HAVB/CHB in patients without previous intraventricular conduction disturbances. METHODS:The occurrence of intraprocedural-HAVB/CHB was assessed in 676 consecutive patients undergoing TAVR, and two groups were established according to its duration: persistent-HAVB/CHB (PHAVB/CHB) and transient-HAVB/CHB (THAVB/CHB), not present at the end of the procedure. RESULTS:Intraprocedural-HAVB/CHB occurred in 50 patients (7.4%), being persistent in 32 (64.0%), and transient in 18 (36.0%). The use of Medtronic Corevalve Revalving System (MCRS) and a greater oversizing of the valve increased the risk of intraprocedural-HAVB/CHB (p < 0.001). Permanent pacemaker implantation (PPI) was more frequent in the PHAVB/CHB than in the THAVB/CHB group (96.9% vs. 33.3%; p < 0.001). At 1-month follow-up, the PHAVB/CHB group showed a 98% ventricular pacing rate (VPR) compared to 16% in the THAVB/CHB group (p < 0.001), and similar VPR were observed at 1-year follow-up (98% vs. 37%, p < 0.001). Left ventricular ejection fraction (LVEF) decreased at 1-year follow-up in patients with PHAVB/CHB (-3.9 ± 1.8%, p = 0.003). CONCLUSIONS:In TAVR recipients with no prior intraventricular conduction disturbances, intraprocedural-HAVB/CHB occurred in 7.4% of cases. HAVB/CHB was persistent in most cases and determined a high rate of PPI post-TAVR. Very high VPR at 1- and 12-month follow-up were observed, which in turn was associated with a negative effect on LVEF. These results support early PPI and close follow-up in patients developing intraprocedural-PHAVB/CHB.
10.1002/ccd.28323
Predictors of permanent pacemaker insertion after TAVR: A systematic review and updated meta-analysis.
Mahajan Sugandhi,Gupta Rahul,Malik Aaqib H,Mahajan Pranav,Aedma Surya K,Aronow Wilbert S,Mehta Sanjay S,Lakkireddy Dhanunjaya R
Journal of cardiovascular electrophysiology
OBJECTIVES:The aim of this analysis was to evaluate the predictors associated with increased risk of permanent pacemaker implantation (PPMI) following transcatheter aortic valve replacement (TAVR). BACKGROUND:While TAVR has evolved as the standard of care for patients with severe aortic stenosis, conduction abnormalities leading to the need for PPMI is one of the most common postprocedural complications. METHODS:A systematic literature search was performed to identify relevant trials from inception to May 2020. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints. RESULTS:Thirty-seven observational studies with 71 455 patients were identified. The incidence of PPMI following TAVR was 22%. Risk was greater in men and increased with age. Patients with diabetes mellitus, presence of right bundle branch block, baseline atrioventricular conduction block, and left anterior fascicular block were noted to be at higher risk. Other significant predictors include the presence of high calcium volume in the area below the left coronary cusp and noncoronary cusp, use of self-expandable valve over balloon-expandable valve, depth of implant, valve size/annulus size, predilatation balloon valvuloplasty, and postimplant balloon dilation. CONCLUSION:Fourteen factors were found to be associated with increased risk of PPMI after TAVR, suggesting early identification of high-risk populations and targeting modifiable risk factors may aid in reducing the need for this post TAVR PPMI.
10.1111/jce.14986
His-Purkinje Conduction System Pacing Following Transcatheter Aortic Valve Replacement: Feasibility and Safety.
Vijayaraman Pugazhendhi,Cano Óscar,Koruth Jacob S,Subzposh Faiz A,Nanda Sudip,Pugliese Jessica,Ravi Venkatesh,Naperkowski Angela,Sharma Parikshit S
JACC. Clinical electrophysiology
OBJECTIVES:This study aimed to assess the feasibility and success rates of permanent His-Purkinje conduction system pacing (HPCSP) in patients requiring pacing after transcatheter aortic valve replacement (TAVR). BACKGROUND:TAVR is associated with increased risk for atrioventricular block. HPCSP has the potential to reduce electromechanical dyssynchrony associated with right ventricular pacing. The feasibility and safety of HPCSP in this population are unknown. METHODS:Consecutive patients requiring pacemakers after TAVR in whom His bundle pacing (HBP) and/or left bundle branch area pacing (LBBAP) was attempted at 5 centers were included in the study. Implant success rates, pacing characteristics, QRS duration, and left ventricular ejection fraction were assessed. Any procedure-related complications, lead revisions, heart failure hospitalizations, and deaths were documented. RESULTS:HPCSP was successful in 55 of 65 (85%) patients studied. HBP was successful in 29 of 46 patients (63%), and LBBAP was successful in 26 of 28 (93%) patients in whom it was attempted. HBP was more successful in patients with Sapien valves than in those with CoreValves (69% vs. 44%; p < 0.05). LBBAP was associated with lower pacing thresholds and higher R-wave amplitudes at implantation compared with HBP (0.64 ± 0.3 at 0.5 ms vs. 1.4 ± 0.8 at 1 ms; p < 0.001; 14 ± 8 mV vs. 5.5 ± 5.6 mV; p < 0.001). Pacing thresholds remained stable and left ventricular ejection fraction remained unchanged during a mean follow-up of 12 ± 13.7 months. CONCLUSIONS:HPCSP is feasible in the majority of patients requiring pacemakers post-TAVR. Success rates of HBP were lower in patients with CoreValves compared to Sapien valves. LBBAP was associated with higher success rates and lower pacing thresholds compared with HBP.
10.1016/j.jacep.2020.02.010
Clinical management of conduction abnormalities following transcatheter aortic valve replacement: prospective evaluation of a standardized management pathway.
Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing
PURPOSE:Limited evidence guides management of conduction abnormalities following TAVR. Standardized clinical pathways may reduce variability in care while minimizing bradyarrhythmic morbidity, length of stay (LOS), and pacemaker (PPM) implantation rates. METHODS:A multidisciplinary consensus pathway to standardize post-TAVR management was developed. We evaluated (1) pathway adherence; (2) LOS; (3) PPM implantation rates; (4) 1-month survival, and (5) late heart block. Exploratory analyses evaluated factors associated with PPM implantation. RESULTS:A total of 181 consecutive patients without prior PPM who underwent TAVR between February 2020 and February 2021 (mean age 77.9 ± 9.1, 38% women) were included. Average LOS was 3.0 days (± 2.7), and no deaths related to syncope/bradyarrhythmia were reported by 1 month. Overall, 93% of the 181 patients were managed by pathway; deviations were due to failure of discharge with a heart monitor when it was clinically indicated for either pre-existing RBBB or new PR prolongation/new LBBB. PPM implantation occurred in 19 patients by discharge, and 21 by 1-month (13%). In our exploratory analysis, pre-existing RBBB, transient peri-procedural heart block, and LOTUS valves were associated with pacemaker implantation: OR (CI) of 8.16 (3.06-21.78), 6.83 (1.94-24.03), and 8.32 (1.11-62.49), respectively. CONCLUSIONS:This report illustrates that a standardized protocol for the management of conduction abnormalities after TAVR can be implemented with high compliance, safe management of conduction disturbance, and relatively short LOS with discharge supported by ambulatory monitoring.
10.1007/s10840-022-01156-6
Novel predictors of permanent pacemaker implantation following transcatheter aortic valve replacement.
World journal of cardiology
BACKGROUND:Conduction and rhythm abnormalities requiring permanent pacemakers (PPM) are short-term complications following transcatheter aortic valve replacement (TAVR), and their clinical outcomes remain conflicting. Potential novel predictors of post-TAVR PPM, like QRS duration, QTc prolongation, and supraventricular arrhythmias, have been poorly studied. AIM:To evaluate the effects of baseline nonspecific interventricular conduction delay and supraventricular arrhythmia on post-TAVR PPM requirement and determine the impact of PPM implantation on clinical outcomes. METHODS:A retrospective cohort study that identified patients with TAVR between January 1, 2012 to December 31, 2019. The group was dichotomized into those with post-TAVR PPM and those without PPM. Both groups were followed for one year. RESULTS:Out of the 357 patients that met inclusion criteria, the mean age was 80 years, 188 (52.7%) were male, and 57 (16%) had a PPM implantation. Baseline demographics, valve type, and cardiovascular risk factors were similar except for type II diabetes mellitus (DM), which was more prevalent in the PPM cohort (59.6% 40.7%; = 0.009). The PPM cohort had a significantly higher rate of pre-procedure right bundle branch block, prolonged QRS > 120 ms, prolonged QTc > 470 ms, and supraventricular arrhythmias. There was a consistently significant increase in the odds ratio (OR) of PPM implantation for every 20 ms increase in the QRS duration above 100 ms: QRS 101-120 [OR: 2.44; confidence intervals (CI): 1.14-5.25; = 0.022], QRS 121-140 (OR: 3.25; CI: 1.32-7.98; = 0.010), QRS 141-160 (OR: 6.98; CI: 3.10-15.61; < 0.001). After model adjustment for baseline risk factors, the OR remained significant for type II DM (aOR: 2.16; CI: 1.18-3.94; = 0.012), QRS > 120 (aOR: 2.18; CI: 1.02-4.66; = 0.045) and marginally significant for supraventricular arrhythmias (aOR: 1.82; CI: 0.97-3.42; = 0.062). The PPM cohort had a higher adjusted OR of heart failure (HF) hospitalization (aOR: 2.2; CI: 1.1-4.3; = 0.022) and nonfatal myocardial infarction (MI) (aOR: 3.9; CI: 1.1-14; = 0.031) without any difference in mortality (aOR: 1.1; CI: 0.5-2.7; = 0.796) at one year. CONCLUSION:Pre-TAVR type II DM and QRS duration > 120, regardless of the presence of bundle branch blocks, are predictors of post-TAVR PPM. At 1-year post-TAVR, patients with PPM have higher odds of HF hospitalization and MI.
10.4330/wjc.v15.i11.582
How to Image and Manage Prosthesis-Related Complications After Transcatheter Aortic Valve Replacement.
Wunderlich Nina C,Honold Jörg,Swaans Martin J,Siegel Robert J
Current cardiology reports
PURPOSE OF REVIEW:In this review, we provide an overview of potential prosthesis - related complications after transcatheter aortic valve replacement, their incidences, the imaging modalities best suited for detection, and possible strategies to manage these complications. RECENT FINDINGS:Therapy for severe aortic valve stenosis requiring intervention has increasingly evolved toward transcatheter aortic valve replacement over the past decade, and the number of procedures performed has increased steadily in recent years. As more and more centers favor a minimalistic approach and largely dispense with general anesthesia and intra-procedural imaging by transesophageal echocardiography, post-procedural imaging is becoming increasingly important to promptly detect dysfunction of the transcatheter valve and potential complications. Complications after transcatheter aortic valve replacement must be detected immediately in order to initiate adequate therapeutic measures, which require a profound knowledge of possible complications that may occur after transcatheter aortic valve replacement, the imaging modalities best suited for detection, and available treatment options.
10.1007/s11886-021-01522-2
Risk Factors, Management, and Avoidance of Conduction System Disease after Transcatheter Aortic Valve Replacement.
Journal of clinical medicine
Transcatheter valve replacement (TAVR) is a rapidly developing modality to treat patients with aortic stenosis (AS). Conduction disease post TAVR is one of the most frequent and serious complications experienced by patients. Multiple factors contribute to the risk of conduction disease, including AS and the severity of valve calcification, patients' pre-existing conditions (i.e., conduction disease, anatomical variations, and short septum) in addition to procedure-related factors (e.g., self-expanding valves, implantation depth, valve-to-annulus ratio, and procedure technique). Detailed evaluation of risk profiles could allow us to better prevent, recognize, and treat this entity. Available evidence on management of conduction disease post TAVR is based on expert opinion and varies widely. Currently, conduction disease in TAVR patients is managed depending on patient risk, with minimal-to-no inpatient/outpatient observation, inpatient monitoring (24-48 h) followed by ambulatory monitoring, or either prolonged inpatient and outpatient monitoring or permanent pacemaker implantation. Herein, we review the incidence and risk factors of TAVR-associated conduction disease and discuss its management.
10.3390/jcm12134405
Can we reduce conduction disturbances following transcatheter aortic valve replacement?
Alperi Garcia Alberto,Muntané-Carol Guillem,Junquera Lucia,Del Val David,Faroux Laurent,Philippon François,Rodés-Cabau Josep
Expert review of medical devices
: Transcatheter aortic valve replacement (TAVR) has been demonstrated to be a good alternative to surgery for treating severe aortic stenosis (AS) across the whole range of surgical risk patients. Whereas most periprocedural TAVR complications have significantly decreased over time, conduction disturbances remain high. Approaches to decrease this shortcoming are under continuous investigation.: Overview of the actual evidence regarding conduction disturbances in the TAVR setting, focusing on modifiable factors. PubMed and Embase databases were used for literature search.: Several factors have been associated with an increased risk of conduction disturbances post-TAVR, and some of them may be modifiable. While some transcatheter valve systems have been associated with higher rates of conduction disturbances, additional randomized data are needed to draw definite conclusions about newer generation transcatheter valve systems. Nowadays, good hemodynamic valve function can be obtained without excessive valve oversizing, which has been associated with an increased risk of conduction disturbances in some studies. Also, contemporary data regarding valve implantation depth and new anatomical landmarks such as membranous septum length have provided valuable insights for procedural planning. Finally, homogenization of the management of conduction abnormalities post-TAVR should be emphasized to allow a better understanding and generalization of available evidence.
10.1080/17434440.2020.1741349
Management of Conduction Disturbances Associated With Transcatheter Aortic Valve Replacement: JACC Scientific Expert Panel.
Rodés-Cabau Josep,Ellenbogen Kenneth A,Krahn Andrew D,Latib Azeem,Mack Michael,Mittal Suneet,Muntané-Carol Guillem,Nazif Tamim M,Sondergaard Lars,Urena Marina,Windecker Stephan,Philippon François
Journal of the American College of Cardiology
Despite major improvements in transcatheter aortic valve replacement (TAVR) periprocedural complications in recent years, the occurrence of conduction disturbances has not decreased over time and remains the most frequent complication of the procedure. Additionally, there has been an important lack of consensus on the management of these complications, which has indeed translated into a high degree of uncertainty regarding the most appropriate treatment of a large proportion of such patients along with major differences between centers and studies in pacemaker rates post-TAVR. There is therefore an urgent need for a uniform strategy regarding the management of conduction disturbances after TAVR. The present expert consensus scientific panel document has been formulated by a multidisciplinary group of interventional cardiologists, electrophysiologists, and cardiac surgeons as an initial attempt to provide a guide for the management of conduction disturbances after TAVR based on the best available data and group expertise.
10.1016/j.jacc.2019.07.014
Early pacemaker implantation for transcatheter aortic valve implantation is safe and effective.
Pacing and clinical electrophysiology : PACE
BACKGROUND:Permanent pacemaker (PPM) implantation is a common complication of transcatheter aortic valve implantation (TAVI). The optimum timing of PPM implantation is still unclear as conduction abnormalities evolve and a balance needs to be struck between conservative delays in the hope of conduction recovery and overutilization of pacing. This study aimed to assess the safety and efficacy of early PPM implantation, without an observation period, among TAVI patients. METHODS:This is a retrospective, observational study of 1398 TAVI patients. Clinical and pacing data were collected at baseline, 30 days and at a median of 15 (4-21) months post-TAVI. Study endpoints included PPM-related complications, pacing utilization and hospital length of stay. RESULTS:One hundred five patients (8.2%) required a PPM, of which 13 were implanted pre and 92 post-TAVI. Seventy-six percent required pacing for either second- or third-degree heart block. Time to implantation for post-TAVI PPM was 1 (0-3) day. Six patients experienced a pacing-related complication- lead displacement (n = 3), hematoma (n = 2), and device infection (n = 1). Pacing utilization defined as pacing >10% of the time or a pacing requirement at the time of the pacing check was demonstrated in 83% of patients. Multivariate analysis revealed complete heart block (CHB) was the only independent predictor of pacing utilization. Hospital length of stay for the post-TAVI PPM group was longer than the group without PPM (4 [2-8] vs. 3 [2-4] days; p < .001). CONCLUSIONS:Early PPM implantation in TAVI patients is safe and majority of patients require pacing in the short and mid-term.
10.1111/pace.14397
Predictors of Early and Late Atrioventricular Block Requiring Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement: A Single-Center Experience.
Cardiovascular revascularization medicine : including molecular interventions
PURPOSE:Complete heart block requiring permanent pacemaker can occur early following transcatheter aortic valve replacement (TAVR) due to mechanical compression of the aortic valve annulus and associated atrio-ventricular (AV) conduction system. Data are limited regarding late PM implantation after TAVR. The purpose of this study was to determine predictors of early vs. late PM implantation post-TAVR procedure. METHODS:Baseline characteristics of patients who required PM <7 days following TAVR were compared with patients who required a PM >7 days to 1 year following TAVR using Chi-Square and multivariate regression analysis. RESULTS:There were 362 TAVR patients, of which 39 (10.4%) received a PM after TAVR. Of these 18 (4.6%) patients required PM within 7 days after TAVR, and 21 (5.8%) required PM after 7 days and up to 1 year later. Right bundle branch block (RBBB) (OR 6.721, CI 2.3-36.9, p < 0.005) was a positive predictor of early PM placement. Left bundle branch block (LBBB) (OR = 3.5, CI 1.19-10.80, p-value < 0.05) and atrial fibrillation (AF) (OR = 3.5, 1.36-9.4 p < 0.05) were predictors for late PM. Early and late PM were associated with a longer median hospital stay compared to no PM (4.9 ± 4.86 days vs. 10.1 ± 10.04 days vs. 6.10 ± 6.02 days). The incidence of heart failure was higher in the late PM group. The overall motility was not increased in early and late PM compared to no PM. CONCLUSION:Patients requiring PM implant after TAVR was 10.4%, of which 5.8% need PM >7 days post-TAVR. RBBB is a predictor for early PM. AF and LBBB were predictors for late PM.
10.1016/j.carrev.2022.02.002
Temporal Incidence and Predictors of High-Grade Atrioventricular Block After Transcatheter Aortic Valve Replacement.
El-Sabawi Bassim,Welle Garrett A,Cha Yong-Mei,Espinosa Raúl E,Gulati Rajiv,Sandhu Gurpreet S,Greason Kevin L,Crestanello Juan A,Friedman Paul A,Munger Thomas M,Rihal Charanjit S,Eleid Mackram F
Journal of the American Heart Association
Background The temporal incidence of high-grade atrioventricular block (HAVB) after transcatheter aortic valve replacement (TAVR) is uncertain. As a result, periprocedural monitoring and pacing strategies remain controversial. This study aimed to describe the temporal incidence of initial episode of HAVB stratified by pre- and post-TAVR conduction and identify predictors of delayed events. Methods and Results Consecutive patients undergoing TAVR at a single center between February 2012 and June 2019 were retrospectively assessed for HAVB within 30 days. Patients with prior aortic valve replacement, permanent pacemaker (PPM), or conversion to surgical replacement were excluded. Multivariable logistic regression was performed to assess predictors of delayed HAVB (initial event >24 hours post-TAVR). A total of 953 patients were included in this study. HAVB occurred in 153 (16.1%). After exclusion of those with prophylactic PPM placed post-TAVR, the incidence of delayed HAVB was 33/882 (3.7%). Variables independently associated with delayed HAVB included baseline first-degree atrioventricular block or right bundle-branch block, self-expanding valve, and new left bundle-branch block. Forty patients had intraprocedural transient HAVB, including 16 who developed HAVB recurrence and 6 who had PPM implantation without recurrence. PPM was placed for HAVB in 130 (13.6%) (self-expanding valve, 23.7% versus balloon-expandable valve, 11.9%; <0.001). Eight (0.8%) patients died by 30 days, including 1 unexplained without PPM present. Conclusions Delayed HAVB occurs with higher frequency in patients with baseline first-degree atrioventricular block or right bundle-branch block, new left bundle-branch block, and self-expanding valve. These findings provide insight into optimal monitoring and pacing strategies based on periprocedural ECG findings.
10.1161/JAHA.120.020033
Electrophysiologic Implications of Transcatheter Aortic Valve Replacement: Incidence, Outcomes, and Current Management Strategies.
Barrett Christopher,Sandhu Amneet,Tzou Wendy
Current cardiology reports
PURPOSE OF REVIEW:Transcatheter aortic valve replacement (TAVR) has changed the paradigm for management of severe aortic stenosis. Despite substantial procedural advancements, conduction system abnormalities remain a common complication following TAVR. In this review, we describe (1) incidence and risk factors for the development of conduction disturbances following TAVR, along with their prognostic significance, (2) the incidence and prognostic significance of new-onset arrhythmias following TAVR, (3) approach to management of perioperative and post-procedural conduction disturbances and arrhythmias, and (4) novel areas of research. RECENT FINDINGS:Conduction disturbances including left bundle branch block (LBBB) and high-grade atrioventricular block (HAVB) remain common issues post-TAVR despite advancements in valve technology and improvements in procedural technique. Despite data showing most conduction abnormalities resolve over time, rates of post-procedural permanent pacemaker implantation remain high. Similarly, rates of new-onset or newly detected arrhythmia, particularly atrial fibrillation, have been widely reported post-implantation of all types of TAVR valves. Recent consensus statements and decision pathway documents have been helpful in standardizing an approach to post-TAVR conduction disturbances. New areas of research show promise both for predicting which patients will develop conduction disturbances post-TAVR and for management of HAVB with novel pacing techniques. On the other hand, management of new-onset or newly detected atrial fibrillation after TAVR remains a significant challenge without standardized treatment strategy.
10.1007/s11886-021-01599-9
The incidence and impact of cardiac conduction disturbances after transcatheter aortic valve replacement.
Annals of cardiothoracic surgery
Transcatheter aortic valve replacement (TAVR) has developed into an established therapy for patients with severe aortic stenosis (AS) across the spectrum of surgical risk. Despite improvements in transcatheter heart valve (THV) technologies and procedural techniques, cardiac conduction disturbances, including high degree atrioventricular block (AVB) requiring permanent pacemaker (PPM) implantation and new-onset left bundle branch block (LBBB), remain frequent complications. TAVR-related conduction disturbances occur due to injury to the conduction system from interactions with interventional equipment and the transcatheter valve stent frame. Risk factors for post-TAVR conduction disturbances have been identified and include clinical characteristics, baseline electrocardiogram findings (right bundle branch block), anatomic factors, and potentially modifiable procedural factors (type of transcatheter valve, depth of implantation, over-sizing). New-onset LBBB and PPM implantation after TAVR have been shown to be associated with adverse long-term clinical outcomes, including mortality and heart failure hospitalization. These clinical consequences are likely to be of increasing importance as TAVR is utilized in younger and lower risk population. This review provides an updated overview of the literature regarding the incidence, predictors, and clinical outcomes of TAVR-related conduction disturbances, as well as proposed strategies for the management of this frequent clinical challenge.
10.21037/acs-2020-av-23
A Disruptive Technology: Determining Need for Permanent Pacing After TAVR.
Sandhu Amneet,Tzou Wendy S
Current cardiology reports
PURPOSE OF REVIEW:Transcatheter aortic valve replacement (TAVR) has changed the paradigm for management of severe aortic stenosis. Despite evolution of TAVR over the past 2 decades, conduction system disturbances remain a concern post-TAVR. In this review, we describe (1) permanent pacemaker (PP) implant rates associated with TAVR, (2) risk factors predicting need for PP therapy post-TAVR, (3) management of perioperative conduction abnormalities, and (4) novel areas of research. RECENT FINDINGS:Conduction disturbances remain a common issue post-TAVR, in particular, left bundle branch block (LBBB). Though newer data describes resolution of a significant fraction of these disturbances over time, rates of pacemaker therapy remain high despite improvements in valve technology and procedural technique. Recent consensus statements and guideline documents are important first steps in standardizing an approach to post-TAVR conduction disturbances. New areas of research show promise in both prediction and treatment of conduction disturbances post-TAVR.
10.1007/s11886-021-01481-8
Conduction disturbances after TAVR: Electrophysiological studies and pacemaker dependency.
Makki Nader,Dollery Jenn,Jones Danielle,Crestanello Juan,Lilly Scott
Cardiovascular revascularization medicine : including molecular interventions
BACKGROUND:Permanent pacemaker (PPM) placement occurs in 5-20% of patients after transcatheter aortic valve replacement (TAVR). Although predictors of pacemaker implantation have been established, features that predispose patients to pacemaker utilization on follow up have not been widely reported. METHODS:We performed a retrospective review of patients undergoing commercial TAVR between 2011 and 2016. We collated patients that underwent in-hospital PPM implantation and had a follow up of at least 3months. Data abstraction was performed for electrophysiological studies (EPS), pacemaker indication, timing, and device interrogation for pacemaker dependency on follow up. RESULTS:A total of 24 patients received in-hospital PPM post-TAVR (14% of total cohort), and mean follow up was 22months. Indications for PPM included resting complete heart block (CHB; 15/24, 63%), left bundle branch block and abnormal electrophysiological study (EPS; 7/24, 29%), alternating bundle branch block (1/24, 4%) and tachy-brady syndrome (1/24, 4%). Pacemaker dependency (underlying ventricular asystole, complete heart block, or >50% pacing) occurred in 8/24 patients (33%) during follow-up, 7 of whom had resting CHB, and one with CHB invoked during EPS. CONCLUSION:Pacemaker dependency after TAVR is common among those that exhibited CHB, but not among those with a prolonged HV delay during EPS. Although preliminary, these observations are relevant to management of rhythm disturbances after TAVR, and may inform the practice of EPS-based PPM implantation.
10.1016/j.carrev.2017.03.009
Evaluation and Management of Heart Block After Transcatheter Aortic Valve Replacement.
Mazzella Anthony J,Arora Sameer,Hendrickson Michael J,Sanders Mason,Vavalle John P,Gehi Anil K
Cardiac failure review
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.
10.15420/cfr.2021.05
Transcatheter aortic valve replacement and cardiac conduction.
Shreenivas Satya,Schloss Edward,Choo Joseph,Sarembock Ian,Lilly Scott,Kereiakes Dean
Expert review of cardiovascular therapy
INTRODUCTION:Conduction abnormalities after transcatheter aortic valve replacement (TAVR) account for a high percentage of post-TAVR complications. Areas covered: The etiology of conduction abnormalities is closely tied to cardiac anatomy (length of membranous septum, degree of calcification, location of left bundle within the membranous septum), baseline conduction abnormalities (preprocedure right bundle branch block), and procedural variables (type of valve, depth of implant). Management of new high-grade AV block and new left bundle branch block varies by institution in the absence of consensus guidelines. Expert opinion: Authors describe the incidence, etiology, outcomes, and management of conduction abnormalities related to aortic stenosis and TAVR.
10.1080/14779072.2019.1598264
Unmet Needs in TAVR: Conduction Disturbances and Management of Coronary Artery Disease.
Journal of clinical medicine
Over the past two decades, transcatheter aortic valve replacement (TAVR) swiftly evolved from a disrupting technology towards mainstream therapy in the field of severe symptomatic aortic stenosis. A series of randomized evaluations established its role in treating severe aortic stenosis patients across all surgical risk categories, paving the way for an extension of its indications to younger low-risk patients with a longer life expectancy. Therefore, managing comorbidities and limiting procedural complications, which may affect long-term outcomes, is of paramount importance. Among those, new-onset conduction disturbances and concomitant coronary artery disease remain two of the most debated issues. In the present review, we will discuss the incidence, prognostic impact, and unmet needs of patients with post-TAVR new-onset conduction disturbances and the ongoing challenges posed by the management of concomitant coronary artery disease.
10.3390/jcm11216256