Arrhythmic Burden in Patients With New-Onset LBBB Post-TAVR
Study Questions:
What is the global arrhythmic burden, the rate of arrhythmias leading to a treatment change, and 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)?
Methods:
The MARE study investigators conducted 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 (3-6) days post-TAVR, and patients had continuous electrocardiogram monitoring for 12 months. All arrhythmic events were adjudicated in a central electrocardiography core laboratory. Primary endpoints were the incidence of arrhythmias leading to a treatment change, and the incidence of HAVB at 12-month follow-up.
Results:
A total of 1,553 new arrhythmic events were detected in 44 patients (1,443 episodes of tachyarrhythmia in 26 patients [atrial fibrillation/flutter/atrial tachycardia, 1,427; ventricular tachycardia, 16]; 110 episodes of bradyarrhythmia in 21 patients [HAVB, 54; severe bradycardia, 56]). All arrhythmic events were silent in 34 patients (77%), the arrhythmic event led to a treatment change in 19 patients (18%), and 11 patients (11%) required pacemaker or implantable cardioverter-defibrillator implantation (due to HAVB, severe bradycardia, or ventricular tachycardia episodes in nine, one, and one patient, respectively). A total of 12 patients died at 1-year follow-up, one from sudden death.
Conclusions:
The authors concluded that a high incidence of arrhythmic events was observed at 1-year follow-up in close to one-half of the patients with LBBB post-TAVR.
Perspective:
This study reports a high burden of arrhythmic events at 1-year follow-up in nearly one-half of patients, leading to a treatment change in more than one-third of them. Significant bradyarrhythmias were detected in 20% of the patients, with a permanent pacemaker required in nearly one-half of them. Episodes of new-onset atrial fibrillation/flutter occurred in close to one-fifth of the patients, leading to a therapy change in approximately one-half of them. Finally, in about three-quarters of the patients with new arrhythmias, all arrhythmic events were silent. Future prospective studies are needed to evaluate the impact of treatment of these silent arrhythmias on hard clinical endpoints before advocating routine cardiac device monitoring of all patients with LBBB post-TAVR.
Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Atrioventricular Block, Bradycardia, Bundle-Branch Block, Death, Sudden, Defibrillators, Implantable, Electrocardiography, Heart Valve Diseases, Pacemaker, Artificial, Secondary Prevention, Tachycardia, Ventricular, Transcatheter Aortic Valve Replacement
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