Conduction Disturbances After Transcatheter Aortic Valve Replacement

Abstract

Transcatheter aortic valve replacement (TAVR) has become a well-accepted option for treating patients with aortic stenosis at intermediate to high or prohibitive surgical risk. TAVR-related conduction disturbances, mainly new-onset left bundle-branch block and advanced atrioventricular block requiring permanent pacemaker implantation, remain the most common complication of this procedure. Furthermore, improvements in TAVR technology, akin to the increasing experience of operators/centers, have translated to a major reduction in periprocedural complications, yet the incidence of conduction disturbances has remained relatively high, with perhaps an increasing trend over time. Several factors have been associated with a heightened risk of conduction disturbances and permanent pacemaker implantation after TAVR, with prior right bundle-branch block and transcatheter valve type and implantation depth being the most commonly reported. New-onset left bundle-branch block and the need for permanent pacemaker implantation may have a significant detrimental association with patients' prognosis. Consequently, strategies intended to reduce the risk and to improve the management of such complications are of paramount importance, particularly in an era when TAVR expansion toward treating lower-risk patients is considered inevitable. In this article, we review the available evidence on the incidence, predictive factors, and clinical association of conduction disturbances after TAVR and propose a strategy for the management of these complications.

Variations in rotation of the aortic root and membranous septum with implications for transcatheter valve implantation

“…New, or worsened, conduction abnormalities following transcatheter implantation of the aortic valve (TAVI) remain a common morbidity 1. This limits the use of TAVI to intermediate-risk and high-risk elderly patients with symptomatic severe aortic stenosis 2–4.…”

“…This limits the use of TAVI to intermediate-risk and high-risk elderly patients with symptomatic severe aortic stenosis 2–4. The precise anatomical basis for this occurrence is not well understood 1. Structural variation in the aortic root, and its supporting structures, has yet to be taken into account in this regard.…”

Association of Clinical and Economic Outcomes With Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement

“…5 A large series of 1556 patients undergoing TAVR by Urena and colleagues 24 showed no association of new PPM implantation after TAVR with overall or cardiovascular mortality or repeated hospitalization after a mean follow-up of approximately 2 years. Similarly, a German registry of 1147 patients showed no association of new PPM implantation with 30-day mortality, but did not examine long-term outcomes.…”

Transcatheter aortic valve implantation in low-risk patients: is it too early?

“…Indeed, implantation of a new permanent pacemaker is associated with poorer evolution of LV ejection fraction over time and is an independent predictor of lower ejection fraction at 12 months’ follow-up 17. The reported rate of PPMI varies according to the implanted TAVI valve, ranging from 18%–49% after self-expanding CoreValve implantation to 0%–12% after balloon expandable Edwards Sapien valve implantation 18. Although these PPMI rates have decreased with the latest generation self-expanding Medtronic Evolut R valve, they have actually increased with the balloon expandable Edwards Sapien 3 valve.…”