Delayed AV Block in Post-TAVR Patients

May 20, 2019
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Authors:
Ream K, Sandhu A, Valle J, et al.
Citation:
Ambulatory Rhythm Monitoring to Detect Late High-Grade Atrioventricular Block Following Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2019;73:2538-2547.
Summary By:
Thomas C. Crawford, MD, FACC

Study Questions:

What is the utility of ambulatory event monitoring (AEM) in identifying post-transcatheter aortic valve replacement (TAVR) delayed high-grade atrioventricular block (DH-AVB)?

Methods:

This was a retrospective analysis of patients undergoing TAVR at a single academic center. None of the patients had a pre-existing pacing device or required permanent pacemaker implantation predischarge. Patients were discharged with 30-day AEM to assess for DH-AVB (≥2 days post-TAVR). Clinical and follow-up data were collected and analyzed.

Results:

Among 150 consecutive TAVR patients without a prior pacing device, 18 (12%) developed H-AVB necessitating permanent pacemaker <2 days post-TAVR, 1 died predischarge, and 13 declined AEM; 118 had 30-day AEM data. DH-AVB occurred in 12 (10% of AEM patients, 8% of total cohort) a median of 6 days (range 3-24 days) post-TAVR. DH-AVB versus non-AVB patients were more likely to have hypertension and right bundle branch block (RBBB). Sensitivity and specificity of RBBB in predicting DH-AVB was 27% and 94%, respectively.

Conclusions:

DH-AVB is a relatively common complication of TAVR among patients without preprocedure pacing devices. RBBB is a risk factor for DH-AVB, but has poor sensitivity. In this single-center analysis, AEM was helpful in expeditious identification and treatment of 10% of post-TAVR outpatients.

Perspective:

TAVR represents a major advance in the treatment of structural heart disease. Yet, unexplained post-TAVR 30-day mortality is significant. Syncope and sudden cardiac death post-TAVR may be related to undiagnosed incident H-AVB occurring after hospital discharge. The results of this study suggest that routine AEM following TAVR offers the ability to better refine management by rapid detection and treatment of AVB, and potentially reduce the morbidity and mortality associated with H-AVB occurring in the outpatient setting. Patients with RBBB were 26 times more likely to develop H-AVB than those without RBBB, yet the sensitivity of RBBB to predict the need for a pacemaker was only 27%. It is clear that we need a better method for risk stratification post-TAVR. AEM, if confirmed in future prospective studies, may become part of the routine follow-up post-TAVR.

Keywords: Arrhythmias, Cardiac, Atrioventricular Block, Cardiac Surgical Procedures, Bundle-Branch Block, Death, Sudden, Cardiac, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Hypertension, Monitoring, Ambulatory, Outpatients, Pacemaker, Artificial, Risk Factors, Syncope, Transcatheter Aortic Valve Replacement


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