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New-Onset Persistent LBBB After TAVR
Study Questions:
What is the impact of new-onset persistent (NOP) left bundle branch block (LBBB) on long-term (>2 years) outcomes after transcatheter aortic valve replacement (TAVR)?
Methods:
A total of 1,020 consecutive patients without permanent pacemaker implantation or pre-existing LBBB who underwent either balloon-expandable (Sapien, Sapien XT, Sapien 3) or self-expanding TAVR (CoreValve, Evolut R) at nine medical centers between May 2007 and February 2015 were included in analysis. NOP-LBBB was defined as any new LBBB post-TAVR that persisted at hospital discharge. Follow-up clinical and echocardiographic data were obtained at a median of 3 years (interquartile range, 2-5 years) after TAVR.
Results:
NOP-LBBB occurred in 212 patients (20.1%) following TAVR. There were no differences between NOP-LBBB and non-LBBB groups, except for a higher rate of NOP-LBBB after self-expandable compared to balloon-expandable TAVR implantation (38% vs. 6%, respectively; p < 0.001). At follow-up, there were no differences between NOP-LBBB and non-LBBB groups in all-cause mortality (45.3% vs. 42.5%, adjusted hazard ratio [HR], 1.0; 95% confidence interval [CI], 0.82-1.47; p = 0.54), cardiovascular mortality (14.2% vs. 14.4%, adjusted HR, 1.02; 95% CI, 0.56-1.87; p = 0.95), or heart failure rehospitalization (19.8% vs. 15.6%, adjusted HR, 1.44; 95% CI, 0.85-2.46; p = 0.18). NOP-LBBB was associated with an increased risk of permanent pacemaker implantation at follow-up (15.5% vs. 5.4%, adjusted HR, 2.45; 95% CI, 1.37-4.38; p = 0.002), with the highest risk within the first 12 months. Left ventricular ejection fraction (LVEF) increased over time in patients without NOP-LBBB, but decreased slightly in patients with NOP-BBB (p < 0.001 for changes in LVEF between groups).
Conclusions:
After a median follow-up of 3 years after TAVR, NOP-LBBB was not associated with higher mortality or heart failure rehospitalization. However, NOP-LBBB increased the risk of permanent pacemaker implantation and negatively impacted LV function over time. The authors concluded that these results should inform future efforts for improving the management of patients with NOP-LBBB following TAVR.
Perspective:
TAVR is associated with a significant incidence of atrial-ventricular (AV) conduction disturbances, including LBBB and AV block. This large, multicenter study found an approximate 20% incidence of new-onset persistent LBBB following TAVR, with a substantially higher rate following self-expanding compared to balloon-expandable TAVR implantation. Clinically, about 15% of patients with NOP-LBBB required pacemaker implantation during follow-up compared to about 5% without LBBB; but there was no association with mortality or heart failure hospitalization. Because the increased bradycardic risk leading to pacemaker implantation was limited to the first year (and predominantly the first 1 month) after TAVR, closer heart rhythm monitoring in the early months after TAVR may be reasonable among patients with NOP-LBBB.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound
Keywords: Atrial Fibrillation, Arrhythmias, Cardiac, Atrioventricular Block, Bradycardia, Bundle-Branch Block, Cardiac Surgical Procedures, Echocardiography, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Pacemaker, Artificial, Stroke Volume, Transcatheter Aortic Valve Replacement
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