Transcatheter Heart Valve Selection and Permanent Pacemaker Implantation in Patients With Pre-Existent Right Bundle Branch Block

Abstract

Background: Right bundle branch block is an established predictor for new conduction disturbances and need for a permanent pacemaker (PPM) after transcatheter aortic valve replacement. The aim of the study was to evaluate the absolute rates of transcatheter aortic valve replacement related PPM implantations in patients with pre-existent right bundle branch block and categorize for different transcatheter heart valves.

Methods and results: We pooled data on 306 transcatheter aortic valve replacement patients from 4 high-volume centers in Europe and selected those with right bundle branch block at baseline without a previously implanted PPM. Logistic regression was used to evaluate whether PPM rate differed among transcatheter heart valves after adjustment for confounders. Mean age was 83±7 years and 63% were male. Median Society of Thoracic Surgeons score was 6.3 (interquartile range, 4.1-10.2). The following transcatheter valve designs were used: Medtronic CoreValve (n=130; Medtronic, Minneapolis, MN); Edwards Sapien XT (ES-XT; n=124) and Edwards Sapien 3 (ES-3; n=32; Edwards Lifesciences, Irvine, CA); and Boston Scientific Lotus (n=20; Boston Scientific Corporation, Marlborough, MA). Overall permanent pacemaker implantation rate post-transcatheter aortic valve replacement was 41%, and per valve design: 75% with Lotus, 46% with CoreValve, 32% with ES-XT, and 34% with ES-3. The indication for PPM implantation was total atrioventricular block in 98% of the cases. Lotus was associated with a higher PPM rate than all other valves. PPM rate did not differ between ES-XT and ES-3. Ventricular paced rhythm at 30-day and 1-year follow-up was present in 81% at 89%, respectively.

Conclusions: Right bundle branch block at baseline is associated with a high incidence of PPM implantation for all transcatheter heart valves. PPM rate was highest for Lotus and lowest for ES-XT and ES-3. Pacemaker dependency remained high during follow-up.

Keywords: aortic stenosis; bundle‐branch block; pacemaker; predictors; right bundle branch block; transcatheter aortic valve implantation; transcatheter aortic valve replacement.

Figure 1

Flow chart of study inclusion. ES‐3 indicates Edwards Sapien 3; ES‐XT, Edwards Sapien XT; PPM, permanent pacemaker; RBBB, right bundle branch block; THVs, transcatheter heart valves.

Figure 2

Forest plot displaying odds ratios (OR) for permanent pacemaker implantation after multivariate analysis. The following variables were included in the multivariate model: valve type, sex, body mass index (BMI), alternative access, and an interaction term valve type×alternative access. *Odds ratio per 1 kg/m² increment of BMI. ^†An interaction term for the interaction between alternative access and valve type was included in the model to adjust for the fact that alternative access was not applied with Lotus. ES‐3 indicates Edwards Sapien 3; ES‐XT, Edwards Sapien XT; NA, not applicable; PPM, permanent pacemaker.

Figure 3

Two‐lead electrocardiogram derived from continuous rhythm monitoring within 24 hours after transcatheter aortic valve replacement, illustrating the typical cascade from RBBB to a total atrioventricular block. *Intermittent sinus beats with LBBB. BBB indicates bundle branch block; LBBB, left bundle branch block; RBBB, right bundle branch block.