Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm: rationale and design of the multicentre LBBB-TAVI Study (original) (raw)
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The American Journal of Cardiology, 2013
Conduction disorders and permanent pacemaker implantation are common complications in patients who undergo transcatheter aortic valve implantation (TAVI). The aim of this study was to assess the incidence and clinical significance of new bundle branch block in patients who underwent TAVI with the Medtronic CoreValve Revalving System (MCRS) or the Edwards SAPIEN valve (ESV). Data from 238 patients with no previous pacemaker implantation, left bundle branch block (LBBB) or right bundle branch block at baseline electrocardiography who underwent TAVI with either MCRS (n [ 87) or ESV (n [ 151) bioprostheses from 2007 to 2011 were analyzed. New-onset LBBB occurred in 26.5% patients (n [ 63): 13.5% with the ESV (n [ 20) and 50.0% with the MCRS (n [ 43) (p [ 0.001). Permanent pacemaker implantation was required in 12.7% of patients (n [ 8) because of complete atrioventricular block (ESV n [ 2, MCRS n [ 4), LBBB and first degree atrioventricular block (MCRS n [ 1) and new-onset LBBB associated with sinus bradycardia (MCRS n [ 1). At discharge, LBBB persisted in 8.6% of ESV patients (n [ 13) and 32.2% of MCRS patients (n [ 28) (p [ 0.001).
Europace, 2017
Transcatheter aortic valve implantation (TAVI) is frequently associated with cardiac conduction defects (CCD) requiring permanent pacemaker implantation (PPI). Although new-onset left bundle branch block (LBBB) is often seen, the rate of progression to severe CCD is unclear. We aimed to find clinical and electrocardiographic (ECG) parameters associated with severe CCD requiring PPI in patients with a new-onset LBBB after TAVI and assess its effect on clinical outcome. Methods and results All consecutive patients undergoing TAVI who developed a new-onset LBBB were retrospectively analysed. We excluded patients with pre-existing bundle branch block or pacemaker. Patients were divided into two groups: with or without PPI after TAVI. We included 155 patients (50% female, 80 + 7 years), of which 37 (24%) developed CCD requiring PPI, mainly due to a total atrioventricular block (n ¼ 17; 46%). Cardiac conduction defects requiring PPI were associated with the following pre-existing parameters: atrial fibrillation (AF), the use of digoxin, CoreValve implantation, and left heart axis. Furthermore, it was associated with the following post-procedural parameters: left heart axis, lower mean heart rate, and prolonged PQ and QRS times. During follow-up, patients with PPI showed a lower mortality rate (11 vs. 29%, P ¼ 0.03). In patients without PPI, mortality was lower in those with narrower QRS complex and transient LBBB. Conclusion The severity and persistence of a new-onset LBBB after TAVI is associated with mortality. Cardiac conduction defects requiring PPI are associated with prior AF, the use of digoxin, CoreValve implantation, and a left heart axis. In these patients, PPI portends a better prognosis than no PPI.
Journal of Cardiac Arrhythmias
Introduction: Data on the impact of left bundle-branch block after transcatheter aortic valve implantation (TAVI) are scarce, and treatment has been individualized. Based on this, the electrophysiological study (EPS) concomitant with TAVI may be a strategy for the early stratification of patients needing permanent pacemaker implantation (PPM). Objective: To describe the use of EPS in risk stratification of a definitive pacemaker in patients undergoing TAVI. Materials and methods: Data from seven patients with indications for TAVI due to critical aortic stenosis were retrospectively evaluated. The EPS was performed with a quadripolar diagnostic catheter in His bundle to measure the His-ventricle (HV) interval. Measurement of HV at 70 ms or above was used for discussion on PPM implant indication. Results: Four analyzed patients evolved with left bundle-branch block after TAVI. PPM implantation was indicated for one patient, and the surgery was performed uneventfully during the same ho...
Journal of the American College of Cardiology, 2012
Objectives This study evaluated the predictive factors and prognostic value of new-onset persistent left bundle branch block (LBBB) in patients undergoing transcatheter aortic valve implantation (TAVI) with a balloon-expandable valve. Background The predictors of persistent (vs. transient or absent) LBBB after TAVI with a balloon-expandable valve and its clinical consequences are unknown. Methods A total of 202 consecutive patients with no baseline ventricular conduction disturbances or previous permanent pacemaker implantation (PPI) who underwent TAVI with a balloon-expandable valve were included. Patients were on continuous electrocardiographic (ECG) monitoring during hospitalization and 12-lead ECG was performed daily until hospital discharge. No patient was lost at a median follow-up of 12 (range: 6 to 24) months, and ECG tracing was available in 97% of patients. The criteria for PPI were limited to the occurrence of highdegree atrioventricular block (AVB) or severe symptomatic bradycardia. Results New-onset LBBB was observed in 61 patients (30.2%) after TAVI, and had resolved in 37.7% and 57.3% at hospital discharge and 6-to 12-month follow-up, respectively. Baseline QRS duration (p ϭ 0.037) and ventricular depth of the prosthesis (p ϭ 0.017) were independent predictors of persistent LBBB. Persistent LBBB at hospital discharge was associated with a decrease in left ventricular ejection fraction (p ϭ 0.001) and poorer functional status (p ϭ 0.034) at 1-year follow-up. Patients with persistent LBBB and no PPI at hospital discharge had a higher incidence of syncope (16.0% vs. 0.7%; p ϭ 0.001) and complete AVB requiring PPI (20.0% vs. 0.7%; p Ͻ 0.001), but not of global mortality or cardiac mortality during the follow-up period (all, p Ͼ 0.20). New-onset LBBB was the only factor associated with PPI following TAVI (p Ͻ 0.001). Conclusions Up to 30% of patients with no prior conduction disturbances developed new LBBB following TAVI with a balloonexpandable valve, although it was transient in more than one third. Longer baseline QRS duration and a more ventricular positioning of the prosthesis were associated with a higher rate of persistent LBBB, which in turn determined higher risks for complete AVB and PPI, but not mortality, at 1-year follow-up.
JACC. Cardiovascular interventions, 2018
The authors sought to determine: 1) the global arrhythmic burden; 2) the rate of arrhythmias leading to a treatment change; and 3) the incidence of high-degree atrioventricular block (HAVB) at 12-month follow-up in patients with new-onset persistent left bundle branch block (LBBB) following transcatheter aortic valve replacement (TAVR). Controversial data exist on the occurrence of significant arrhythmias in patients with LBBB post-TAVR. This was a multicenter prospective study including 103 consecutive patients with new-onset persistent LBBB post-TAVR with the balloon-expandable SAPIEN XT/3 valve (n = 53), or the self-expanding CoreValve/Evolut R system (n = 50). An implantable cardiac monitor (Reveal XT, Reveal Linq) was implanted at 4 (3 to 6) days post-TAVR, and patients had continuous electrocardiogram monitoring for 12 months. All arrhythmic events were adjudicated in a central electrocardiography core lab. Primary endpoints were the incidence of arrhythmias leading to a treat...
Left Bundle Branch Block After Transcatheter Aortic Valve Implantation
JACC: Cardiovascular Interventions, 2014
Transcatheter aortic valve implantation (TAVI) has experienced unprecedented growth since its first description by Alain Cribier in 2002 (1) and is now routinely performed in many institutions worldwide. New-onset left bundle branch block (LBBB) or atrioventricular (AV) block necessitating permanent pacemaker implantation (PPI) are among the most frequent complications of TAVI (2-5). Case reports describing late occurrence of complete AV block and the fact that LBBB has been associated with a worse outcome after surgical aortic valve implantation led clinicians to adopt a generous strategy of pacemaker implantation after TAVI. This strategy was further enhanced by the urge to ambulate patients early after TAVI instead of prolonged monitoring for resolution of AV conduction impairment. Improvement
Frontiers in Cardiovascular Medicine
BackgroundStudies suggest that performing an electrophysiological study (EPS) may be useful to identify patients with new-onset left bundle branch block (LBBB) post-TAVR at risk of atrioventricular block. However, tools to optimize the yield of such strategy are needed. We therefore aimed to investigate whether 12-lead ECG changes post-TAVR may help identify patients with abnormal EPS findings.Materials and methodsConsecutive patients with new-onset LBBB post-TAVR who underwent EPS were included. PR and QRS intervals were measured on 12-lead ECG pre-TAVR and during EPS. Abnormal EPS was defined as an HV interval > 55 ms.ResultsAmong 61 patients, 28 (46%) had an HV interval > 55 ms after TAVR. Post-TAVR PR interval and ΔPR (PR-post–pre-TAVR) were significantly longer in patients with prolonged HV (PR: 188 ± 38 vs. 228 ± 34 ms, p < 0.001, ΔPR: 10 ± 30 vs. 34 ± 23 ms, p = 0.001), while no difference was found in QRS duration. PR and ΔPR intervals both effectively discriminated...
International Journal of Cardiology, 2017
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 ≥80 ms at the last recording. High degree AVB after discharge was evaluated from the pacemaker memories and ECG at 1 and 6 months. 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 b 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.
American Journal of Cardiology, 2016
New-onset conduction disturbances are common after transcatheter aortic valve implantation (TAVI). The most common complication is left bundle branch block (LBBB). The clinical impact of new-onset LBBB after TAVI remains controversial. The aim of this study was to analyze the clinical impact of new-onset LBBB in terms of mortality and morbidity (need for pacemakers and admissions for heart failure) at long-term follow-up. From April 2008 to December 2014, 220 patients who had severe aortic stenosis were treated with the implantation of a CoreValve prosthesis. Sixty-seven of these patients were excluded from the analysis, including 22 patients with pre-existing LBBB and 45 with a permanent pacemaker, implanted previously or within 72 hours of implantation. The remaining 153 patients were divided into 2 groups: group 1 (n [ 80), those with persistent new-onset LBBB, and group 2 (n [ 73), those without conduction disturbances after treatment. Both groups were followed up at 1 month, 6 months, 12 months, and yearly thereafter. Persistent new-onset LBBB occurred in 80 patients (36%) immediately after TAVI; 73 patients (33%) did not develop conduction disturbances. The mean follow-up time of both groups was 32-22 months (range 3 to 82 months), and there were no differences in time between the groups. There were no differences in mortality between the groups (39% vs 48%, p [ 0.58). No differences were observed between the groups in re-hospitalizations for heart failure (11% vs 16%, p [ 0.55). Group 1 did not require pacemaker implantation more often at follow-up (10% vs 13%, p [ 0.38) than group 2. In conclusion, new-onset LBBB was not associated with a higher incidence of late need for a permanent pacemaker after CoreValve implantation. In addition, it was not associated with a higher risk of late mortality or re-hospitalization.