Does RBBB Impact Long-Term Outcomes of TAVR Patients?

Pre-existing right bundle branch block (RBBB) in transcatheter aortic valve replacement (TAVR) patients is associated with higher 30-day rates of permanent pacemaker implantation (PPI) and mortality, according to a study published July 19 in JACC: Cardiovascular Interventions.

Led by Vincent Auffret, MD, et al., the multicenter study analyzed 3,527 patients who underwent TAVR and had a baseline electrocardiogram (ECG) to evaluate for RBBB. Of those patients, 10 percent had pre-existing RBBB and subsequently higher 30-day rates of PPI (40.1 percent vs. 13.5 percent, p < 0.001) and death (10 percent vs. 6 percent, p = 0.024). However, of all the patients analyzed, those with pre-existing RBBB and without PPI had the highest two-year risk of cardiovascular death (27.8 percent).

Long-term follow-up (mean 20±18 months) showed pre-existing RBBB was individually associated with all-cause mortality (31 percent vs. 25 percent) and cardiovascular mortality (23 percent vs. 17 percent). Interestingly, RBBB did not have a similar effect on sudden cardiac death (1 percent vs. 2 percent).

The study authors conclude, "Future studies are required to elucidate the optimal management of TAVR recipient[s] with RBBB especially by evaluating the optimal pre- and post-TAVR monitoring strategies as well as invasive strategies such as systematic electrophysiological studies, implantable monitoring devices, or 'prophylactic' PPI in selected cases."

"Baseline RBBB before TAVR may eventually become a bad omen, one that signifies trouble ahead and can be used to alert physicians to prepare in advance for the possible adverse events following the procedure," state Ron Waksman, MD, FACC, and Arie Steinvil, MD. In an editorial comment, they highlight leadless pacemakers, which "may be a safer, short-term option for patients with trauma-related, temporary conduction disorders following TAVR."

"Given that recent reports have shown an association of RBBB with mortality in large general population cohorts, post myocardial infarction patients, and those with systolic heart failure, it's possible the results presented here merely reflect an already known association in a specific population subset." As such, they conclude that, "In current practice, RBBB, although associated presently with PPI and long-term mortality, should be regarded as a poor prognostic marker."

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Chronic Heart Failure

Keywords: Bundle-Branch Block, Transcatheter Aortic Valve Replacement, Heart Failure, Systolic, Follow-Up Studies, Electrocardiography, Arrhythmias, Cardiac, Heart Conduction System, Death, Sudden, Cardiac, Myocardial Infarction

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