As TAVR is increasingly used as an alternative to surgical aortic valve replacement (SAVR), conduction abnormalities, such as new onset left bundle branch block (LBBB) and high-grade atrioventricular block (AVB), requiring permanent pacemaker (PPM) implantation remain common following TAVR, according to a state-of-the-art review published Jan. 18 in JACC: Cardiovascular Interventions.

Yasser Sammour, MD, et al., summarize findings of a systematic computerized search to identify randomized clinical trials, observational studies, multicenter registries, systematic reviews and meta-analyses through June 2020 that reported incidence, predictors and outcomes of conduction abnormalities requiring PPM after TAVR.

According to the results, there are multiple preprocedural and procedural factors that impact the risk for PPM implantation after TAVR. Preprocedural conduction abnormalities, such as right bundle branch block and LBBB are associated with increased PPM implantation and mortality following TAVR. In addition, demographic predictors associated with new onset LBBB after TAVR include female sex, diabetes mellitus, prior CABG, first-degree AVB, prolonged QRS duration, aortic annulus calcification, and larger left ventricular end-diastolic volume. Procedural factors include CoreValve implantation, transapical access, pre-dilation, oversizing and lower implantation depth. Patients receiving self-expanding valves may have a higher risk of PPM implantation.

The researchers found a lack of consensus on the duration of post-TAVR telemetry monitoring and indications for PPM implantation, but note that high-grade AVB and new onset LBBB are the most frequent indications. In addition, the researchers found that PPM implantation and new onset LBBB may be associated with adverse effects on post-TAVR morbidity and mortality.

According to the researchers, as TAVR adoption continues to increase as safe, effective alternative to SAVR, new onset LBBB and high-grade AVB requiring PPM implantation remain common, although the rate of PPM implantation is variable and dependent upon preexisting and procedural factors. Current evidence shows increased mortality with new onset LBBB and PPM implantation in TAVR patients, they note. They add that TAVR sites should be “cognizant of specific anatomic, electrical, and clinical risk factors while screening patients for TAVR” and that “operators must be vigilant when weighing different considerations for valve choice and in performing the implantation to minimize the risk of PPM.” In addition, immediate post-TAVR atrial pacing can help risk-stratify patients and their need for PPM implantation, they conclude.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, EP Basic Science, Aortic Surgery, Cardiac Surgery and Arrhythmias

Keywords: Bundle-Branch Block, Atrioventricular Block, Transcatheter Aortic Valve Replacement, Aortic Valve, Dilatation, Stroke Volume, Heart Valve Prosthesis, Risk Factors, Pacemaker, Artificial, Telemetry, Registries, Diabetes Mellitus, Coronary Artery Bypass, National Cardiovascular Data Registries, STS/ACC TVT Registry

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