The following are key points to remember from the JACC Scientific Expert Panel opinion on the management of conduction disturbances associated with transcatheter aortic valve replacement (TAVR):

1. The occurrence of high-degree atrioventricular block or complete heart block requiring permanent pacemaker implantation (PPM) and new-onset left bundle branch block (LBBB) remain the most frequent complication of the TAVR procedure. Nonetheless, there is a lack of consensus on the management of conduction disturbances and there are significant differences among centers in PPM implantation rates post-TAVR.
2. Multiple observational studies are currently evaluating the usefulness of both electrophysiologic studies (EPS) and continuous electrocardiographic (ECG) monitoring post-TAVR, particularly focusing on those patients with new-onset LBBB. In one study, almost one-third of the patients requiring PPM post-TAVR exhibited episodes of high-degree atrioventricular block, complete heart block, or severe bradycardia on 24-hour continuous ECG monitoring pre-TAVR.
3. Valve pre-dilation before the implantation of the transcatheter heart valve may be associated with an increased risk of conduction disturbances. Valve implantation depth, higher degree of valve oversizing, or the use of larger valves also appears to be an important risk factor for post-TAVR conduction disturbances.
4. The authors provide the following suggestions for the management of patients according to ECG changes after TAVR:
• GROUP 1: Patients without RBBB pre-procedure and with no ECG changes following TAVR. In this scenario, temporary pacemaker should be removed at the end of the procedure and the patient should be on overnight telemetry.
• GROUP 2: Patients with pre-existing RBBB. This is a group at highest risk of high-degree atrioventricular block or complete heart block and the need for PPM following TAVR. The highest risk is during the procedure and the initial 2-3 days post-procedure. Temporary pacing wire is recommended overnight in all patients with pre-existing RBBB.
• GROUP 3: Patients with pre-existing conduction disturbances (QRS ≥120 ms, first-degree atrioventricular block) who develop persistent increase of PR or QRS duration ≥20 ms. These patients should have temporary pacemaker wire overnight. If there is regression of the ECG changes to baseline, QRS ≤150 ms, and PR ≤240 ms, the patient should be monitored for another day before discharge. If there is further increase ≥20 ms PR or QRS, or QRS >150 ms, or PR >240 ms, an invasive EPS should be considered to guide the decision about PPM.
• GROUP 4: Patients with new-onset LBBB. If LBBB persists post-procedure but there is no progression of the duration of the QRS or PR interval, temporary pacing wire can be discontinued. If there is a change in PR and/or QRS duration, the clinician should consider EPS, ambulatory ECG monitoring at hospital discharge, or a PPM. Likewise, for patients with LBBB and QRS >150 ms or PR >240 ms, the clinician should consider EPS, ambulatory ECG monitoring at hospital discharge, or a PPM. In patients with LBBB, QRS ≤150 ms, and PR ≤240 ms, ambulatory ECG monitoring should be considered.
• GROUP 5: Patients with transient or persistent high-degree atrioventricular block during the procedure should have a temporary pacemaker wire overnight, and if the abnormality persists, PPM should be implanted.
5. For all patients post-TAVR, a 12-lead ECG is recommended at 1- and 12-month follow-up and yearly thereafter. Patients with low left ventricular ejection fraction and LBBB post-TAVR can be evaluated at 3- to 6-month follow-up (with ECG and echocardiography examinations) to determine a potential indication for resynchronization therapy and/or implantable cardioverter-defibrillator therapy.
6. The role of EPS and ambulatory ECG monitors in the risk assessment of delayed life-threatening arrhythmias and sudden death post-TAVR in patients with conduction disturbances following TAVR is the subject of ongoing investigations.

Keywords: Arrhythmias, Cardiac, Atrioventricular Block, Bradycardia, Bundle-Branch Block, Death, Sudden, Defibrillators, Implantable, Dilatation, Echocardiography, Electrocardiography, Electrocardiography, Ambulatory, Electrophysiology, Heart Valve Diseases, Heart Valves, Pacemaker, Artificial, Risk Factors, Stroke Volume, Telemetry, Transcatheter Aortic Valve Replacement

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