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. 2021 May 18;10(10):e020033.
doi: 10.1161/JAHA.120.020033. Epub 2021 May 7.

Temporal Incidence and Predictors of High-Grade Atrioventricular Block After Transcatheter Aortic Valve Replacement

Bassim El-Sabawi  1 , Garrett A Welle  1 , Yong-Mei Cha  2 , Raúl E Espinosa  2 , Rajiv Gulati  2 , Gurpreet S Sandhu  2 , Kevin L Greason  3 , Juan A Crestanello  3 , Paul A Friedman  2 , Thomas M Munger  2 , Charanjit S Rihal  2 , Mackram F Eleid  2
Affiliations

Temporal Incidence and Predictors of High-Grade Atrioventricular Block After Transcatheter Aortic Valve Replacement

Bassim El-Sabawi et al. J Am Heart Assoc. .

Abstract

Background The temporal incidence of high-grade atrioventricular block (HAVB) after transcatheter aortic valve replacement (TAVR) is uncertain. As a result, periprocedural monitoring and pacing strategies remain controversial. This study aimed to describe the temporal incidence of initial episode of HAVB stratified by pre- and post-TAVR conduction and identify predictors of delayed events. Methods and Results Consecutive patients undergoing TAVR at a single center between February 2012 and June 2019 were retrospectively assessed for HAVB within 30 days. Patients with prior aortic valve replacement, permanent pacemaker (PPM), or conversion to surgical replacement were excluded. Multivariable logistic regression was performed to assess predictors of delayed HAVB (initial event >24 hours post-TAVR). A total of 953 patients were included in this study. HAVB occurred in 153 (16.1%). After exclusion of those with prophylactic PPM placed post-TAVR, the incidence of delayed HAVB was 33/882 (3.7%). Variables independently associated with delayed HAVB included baseline first-degree atrioventricular block or right bundle-branch block, self-expanding valve, and new left bundle-branch block. Forty patients had intraprocedural transient HAVB, including 16 who developed HAVB recurrence and 6 who had PPM implantation without recurrence. PPM was placed for HAVB in 130 (13.6%) (self-expanding valve, 23.7% versus balloon-expandable valve, 11.9%; P<0.001). Eight (0.8%) patients died by 30 days, including 1 unexplained without PPM present. Conclusions Delayed HAVB occurs with higher frequency in patients with baseline first-degree atrioventricular block or right bundle-branch block, new left bundle-branch block, and self-expanding valve. These findings provide insight into optimal monitoring and pacing strategies based on periprocedural ECG findings.

Keywords: bradycardia; bundle‐branch block; pacemaker; sudden cardiac death; transcatheter aortic valve implantation.

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Conflict of interest statement

None.

Figures

Figure 1
Figure 1. Flow chart showing the temporal incidence of initial episode of HAVB after TAVR.
*Incidence of delayed HAVB determined after exclusion of 71 patients who had prophylactic permanent pacemaker placement without early HAVB. HAVB indicates high‐grade atrioventricular block; and TAVR, transcatheter aortic valve replacement.
Figure 2
Figure 2. Temporal incidence of high‐grade atrioventricular block after TAVR.
A, Temporal incidence stratified by type of valve. B, Temporal incidence stratified by presence of pre‐TAVR RBBB, post‐TAVR new LBBB, isolated pre‐TAVR first‐degree AVB, and normal pre‐ and post‐TAVR ECG. AVB indicates atrioventricular block; LBBB, left bundle‐branch block; RBBB, right bundle‐branch block; and TAVR, transcatheter aortic valve replacement.
Figure 3
Figure 3. Temporal incidence of high‐grade atrioventricular block after TAVR in patients with baseline RBBB or new LBBB stratified by presence of concomitant conduction abnormalities.
A, Temporal incidence stratified into groups including isolated RBBB (n=55), RBBB+first‐degree AVB (n=14), bifascicular block (n=35), or bifascicular block+first‐degree AVB (n=15). B, Temporal incidence stratified into groups including new LBBB on post‐TAVR ECG with PR <200 ms (n=84), PR=200 to 239 ms (n=42), PR ≥240 ms (n=18), or incalculable PR because of AF (n=37). AF indicates atrial fibrillation; AVB, atrioventricular block; LBBB, left bundle‐branch block; RBBB, right bundle‐branch block; and TAVR, transcatheter aortic valve replacement.
Figure 4
Figure 4. Proposed algorithm of pre‐ and post‐TAVR conduction assessment and management.
*New LBBB with QRS ≥150 ms but with PR interval <200 ms are at similar risk of delayed HAVB to those with QRS <150 ms and could be managed similarly. †Incalculable PR because of atrial fibrillation. AVB indicates atrioventricular block; HAVB, high‐grade atrioventricular block; LAFB, left anterior fascicular block; LBBB, left bundle‐branch block; LPFB, left posterior fascicular block; RBBB, right bundle‐branch block; and TAVR, transcatheter aortic valve replacement.
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