Decision Pathway on Conduction Disturbances in TAVR: Key Points

Lilly SM, Deshmukh AJ, Epstein AE, et al.
2020 ACC Expert Consensus Decision Pathway on Management of Conduction Disturbances in Patients Undergoing Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2020;Oct 21:[Epub ahead of print].

The following are key points to remember from the 2020 American College of Cardiology (ACC) Expert Consensus Decision Pathway on Management of Conduction Disturbances in Patients Undergoing Transcatheter Aortic Valve Replacement (TAVR):

  1. There is absence of adequately powered, randomized controlled trials evaluating the optimal management of peri-TAVR conduction disturbances, and this management pathway is based on a consensus supported by existing data and experience.

Pre-TAVR management:

  1. Patients considered for TAVR should be screened for signs or symptoms of rhythm disturbances and potential indications for outpatient ambulatory electrocardiogram (ECG) monitoring.
  2. Predictors for developing a TAVR-related conduction disturbance include:
    • ECG: right bundle branch block, first-degree heart block.
    • Procedural: self-/mechanically expanding prosthesis, prosthesis/left ventricular outflow tract diameter >1, low anticipated implantation depth, anticipated pre- or post-deployment balloon valvuloplasty.
    • Computed tomography: heavy calcification below the cusp, short membranous septum.
  3. Patients at high risk for post-TAVR permanent pacemaker should be counseled about the potential need for it.
  4. Patients should continue guideline-based medications for coronary artery disease and/or heart failure despite identified risk of need for permanent pacemaker.

Intraprocedural TAVR management:

  1. If patient does not experience a new conduction disturbance, temporary pacemaker and venous sheath can be removed before the patient leaves the procedure room.
  2. If patient develops conduction disturbance (e.g., left bundle branch block, PR/QRS prolongation ≥20 milliseconds, or complete transient heart block), internal jugular venous access with a secure pacing lead is reasonable before the patient leaves the procedure room.
  3. If patient develops persistent complete heart block, internal jugular venous access with a secure pacing lead prior to leaving the procedure room is indicated.

Post-TAVR management:

  1. If patient exhibits new, progressive, or pre-existing conduction disturbance that changes post-procedure, the heart team should consider electrophysiology study and a permanent pacemaker.
  2. Patients can be considered for early discharge as long as they have no primary pacemaker indication, no new first- or second-degree atrioventricular (AV) block, no new bundle branch block, and no progression in baseline first, second-degree AV block or prolongation of the QRS ≥10%. If any of the above are present, patients should remain on telemetry until conduction is stable for ≥48 hours, and discharged with an outpatient monitor for ≥14 days.
  3. If outpatient monitoring shows new rhythm disturbance (e.g., atrial fibrillation) or progression of baseline conduction disturbance, it is suggested that the patient is discharged with the monitor for a minimum of 14 days.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease

Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Atrioventricular Block, Balloon Valvuloplasty, Bundle-Branch Block, Consensus, Coronary Artery Disease, Electrocardiography, Heart Block, Pacemaker, Artificial, Patient Discharge, Transcatheter Aortic Valve Replacement

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