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Electrophysiologic Implications of Transcatheter Aortic Valve Replacement: Incidence, Outcomes, and Current Management Strategies

  • Valvular Heart Disease (TL Kiefer, Section Editor)
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Abstract

Purpose of Review

Transcatheter aortic valve replacement (TAVR) has changed the paradigm for management of severe aortic stenosis. Despite substantial procedural advancements, conduction system abnormalities remain a common complication following TAVR. In this review, we describe (1) incidence and risk factors for the development of conduction disturbances following TAVR, along with their prognostic significance, (2) the incidence and prognostic significance of new-onset arrhythmias following TAVR, (3) approach to management of perioperative and post-procedural conduction disturbances and arrhythmias, and (4) novel areas of research.

Recent Findings

Conduction disturbances including left bundle branch block (LBBB) and high-grade atrioventricular block (HAVB) remain common issues post-TAVR despite advancements in valve technology and improvements in procedural technique. Despite data showing most conduction abnormalities resolve over time, rates of post-procedural permanent pacemaker implantation remain high. Similarly, rates of new-onset or newly detected arrhythmia, particularly atrial fibrillation, have been widely reported post-implantation of all types of TAVR valves.

Summary

Recent consensus statements and decision pathway documents have been helpful in standardizing an approach to post-TAVR conduction disturbances. New areas of research show promise both for predicting which patients will develop conduction disturbances post-TAVR and for management of HAVB with novel pacing techniques. On the other hand, management of new-onset or newly detected atrial fibrillation after TAVR remains a significant challenge without standardized treatment strategy.

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References

Papers of particular interest, published recently, have been highlighted as:

    • Of importance

      •• Of major importance

      1. Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364:2187–98.

        Article  CAS  PubMed  Google Scholar 

      2. Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med. 2014;370:1790–8.

        Article  CAS  PubMed  Google Scholar 

      3. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2016;374:1609–20.

        Article  CAS  PubMed  Google Scholar 

      4. Reardon MJ, Van Mieghem NM, Popma JJ, et al. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2017;376:1321–31.

        Article  PubMed  Google Scholar 

      5. Mack MJ, Leon MB, Thourani VH, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med. 2019;380:1695–705.

        Article  PubMed  Google Scholar 

      6. Popma JJ, Deeb GM, Yakubov SJ, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med. 2019;380:1706–15.

        Article  PubMed  Google Scholar 

      7. Mori M, Bin Mahmood SU, Geirsson A, et al. Trends in volume and risk profiles of patients undergoing isolated surgical and transcatheter aortic valve replacement. Catheter Cardiovasc Interv. 2019;93:E337–42.

        Article  PubMed  Google Scholar 

      8. Carroll JD, Mack MJ, Vemulapalli S, et al. STS-ACC TVT registry of transcatheter aortic valve replacement. J Am Coll Cardiol. 2020;76:2492–516.

        Article  CAS  PubMed  Google Scholar 

      9. Russo E, Potenza DR, Casella M, et al. Rate and predictors of permanent pacemaker implantation after transcatheter aortic valve implantation: current status. Curr Cardiol Rev. 2019;15:205–18.

        Article  PubMed  PubMed Central  Google Scholar 

      10. Thiele H, Kurz T, Feistritzer HJ, et al. Comparison of newer generation self-expandable vs. balloon-expandable valves in transcatheter aortic valve implantation: the randomized SOLVE-TAVI trial. Eur Heart J. 2020;41:1890–99.

      11. Deharo P, Bisson A, Herbert J, et al. Impact of Sapien 3 balloon-expandable versus Evolut R self-expandable transcatheter aortic valve implantation in patients with aortic stenosis: data from a nationwide analysis. Circulation. 2020;141:260–8.

        Article  PubMed  Google Scholar 

      12. Moreno R, Dobarro D, López de Sá E, et al. Cause of complete atrioventricular block after percutaneous aortic valve implantation: insights from a necropsy study. Circulation 2009;120:e29–30.

      13. Sinhal A, Altwegg L, Pasupati S, et al. Atrioventricular block after transcatheter balloon expandable aortic valve implantation. JACC Cardiovasc Interv. 2008;1:305–9.

        Article  PubMed  Google Scholar 

      14. Ream K, Sandhu A, Valle J, et al. Ambulatory rhythm monitoring to detect late high-grade atrioventricular block following transcatheter aortic valve replacement. J Am Coll Cardiol. 2019;73:2538–47.

        Article  PubMed  Google Scholar 

      15. Godin M, Eltchaninoff H, Furuta A, et al. Frequency of conduction disturbances after transcatheter implantation of an Edwards Sapien aortic valve prosthesis. Am J Cardiol. 2010;106:707–12.

        Article  PubMed  Google Scholar 

      16. Houthuizen P, van der Boon RMA, Urena M, et al. Occurrence, fate and consequences of ventricular conduction abnormalities after transcatheter aortic valve implantation. EuroIntervention. 2014;9:1142–50.

        Article  PubMed  Google Scholar 

      17. Franzoni I, Latib A, Maisano F, et al. Comparison of incidence and predictors of left bundle branch block after transcatheter aortic valve implantation using the CoreValve versus the Edwards valve. Am J Cardiol. 2013;112:554–9.

        Article  PubMed  Google Scholar 

      18. • Auffret V, Puri R, Urena M, et al. Conduction disturbances after transcatheter aortic valve replacement: current status and future perspectives. Circulation. 2017;136:1049–69. This work is a high-quality review of conduction system disturbances and risk factors associated with need for permanent pacemaker therapy post-TAVR.

        Article  PubMed  Google Scholar 

      19. Poels TT, Houthuizen P, Van Garsse LAFM, Maessen JG, de Jaegere P, Prinzen FW. Transcatheter aortic valve implantation-induced left bundle branch block: causes and consequences. J Cardiovasc Transl Res. 2014;7:395–405.

        Article  PubMed  Google Scholar 

      20. Mangieri A, Montalto C, Pagnesi M, et al. TAVI and post procedural cardiac conduction abnormalities. Front Cardiovasc Med. 2018;5:85.

        Article  PubMed  PubMed Central  Google Scholar 

      21. Nazif TM, Chen S, George I, et al. New-onset left bundle branch block after transcatheter aortic valve replacement is associated with adverse long-term clinical outcomes in intermediate-risk patients: an analysis from the PARTNER II trial. Eur Heart J. 2019;40:2218–27.

        Article  PubMed  Google Scholar 

      22. Regueiro A, Abdul-Jawad Altisent O, Del Trigo M, et al. Impact of new-onset left bundle branch block and periprocedural permanent pacemaker implantation on clinical outcomes in patients undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis. Circ Cardiovasc Interv. 2016;9:e003635.

      23. Urena M, Mok M, Serra V, et al. Predictive factors and long-term clinical consequences of persistent left bundle branch block following transcatheter aortic valve implantation with a balloon-expandable valve. J Am Coll Cardiol. 2012;60:1743–52.

        Article  PubMed  Google Scholar 

      24. Tzikas A, van Dalen BM, Van Mieghem NM, et al. Frequency of conduction abnormalities after transcatheter aortic valve implantation with the Medtronic-CoreValve and the effect on left ventricular ejection fraction. Am J Cardiol. 2011;107:285–9.

        Article  PubMed  Google Scholar 

      25. Nazif TM, Williams MR, Hahn RT, et al. Clinical implications of new-onset left bundle branch block after transcatheter aortic valve replacement: analysis of the PARTNER experience. Eur Heart J. 2014;35:1599–607.

        Article  PubMed  Google Scholar 

      26. Abdel-Wahab M, Mehilli J, Frerker C, et al. Comparison of balloon-expandable vs self-expandable valves in patients undergoing transcatheter aortic valve replacement: the CHOICE randomized clinical trial. JAMA. 2014;311:1503–14.

        Article  PubMed  CAS  Google Scholar 

      27. Husser O, Kim WK, Pellegrini C, et al. Multicenter comparison of novel self-expanding versus balloon-expandable transcatheter heart valves. JACC: Cardiovasc Interv 2017;10:2078–87.

      28. De Torres-Alba F, Kaleschke G, Diller GP, et al. Changes in the pacemaker rate after transition from Edwards SAPIEN XT to SAPIEN 3 transcatheter aortic valve implantation. JACC: Cardiovasc Interv 2016;9:805–13.

      29. Nazif TM, Dizon JM, Hahn RT, et al. Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement: the PARTNER (Placement of AoRtic TraNscathetER Valves) trial and registry. JACC Cardiovasc Interv. 2015;8:60–9.

        Article  PubMed  Google Scholar 

      30. Fadahunsi OO, Olowoyeye A, Ukaigwe A, et al. Incidence, predictors, and outcomes of permanent pacemaker implantation following transcatheter aortic valve replacement: analysis from the U.S. Society of Thoracic Surgeons/American College of Cardiology TVT Registry. JACC Cardiovasc Interv 2016;9:2189–99.

      31. Siontis GCM, Jüni P, Pilgrim T, et al. Predictors of permanent pacemaker implantation in patients with severe aortic stenosis undergoing TAVR: a meta-analysis. J Am Coll Cardiol. 2014;64:129–40.

        Article  PubMed  Google Scholar 

      32. Koos R, Mahnken AH, Aktug O, et al. Electrocardiographic and imaging predictors for permanent pacemaker requirement after transcatheter aortic valve implantation. J Heart Valve Dis. 2011;20:83–90.

        PubMed  Google Scholar 

      33. Maan A, Refaat MM, Heist EK, et al. Incidence and predictors of pacemaker implantation in patients undergoing transcatheter aortic valve replacement. Pacing Clin Electrophysiol. 2015;38:878–86.

        Article  PubMed  Google Scholar 

      34. Kiani S, Kamioka N, Black GB, et al. Development of a risk score to predict new pacemaker implantation after transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2019;12:2133–42.

        Article  PubMed  Google Scholar 

      35. Hamdan A, Guetta V, Klempfner R, et al. Inverse relationship between membranous septal length and the risk of atrioventricular block in patients undergoing transcatheter aortic valve implantation. JACC Cardiovasc Interv. 2015;8:1218–28.

        Article  PubMed  Google Scholar 

      36. Maeno Y, Abramowitz Y, Kawamori H, et al. A highly predictive risk model for pacemaker implantation after TAVR. JACC Cardiovasc Imaging. 2017;10:1139–47.

        Article  PubMed  Google Scholar 

      37. Lenders GD, Collas V, Hernandez JM, et al. Depth of valve implantation, conduction disturbances and pacemaker implantation with CoreValve and CoreValve Accutrak system for Transcatheter Aortic Valve Implantation, a multi-center study. Int J Cardiol. 2014;176:771–5.

        Article  PubMed  Google Scholar 

      38. Petronio AS, Sinning J-M, Van Mieghem N, et al. Optimal implantation depth and adherence to guidelines on permanent pacing to improve the results of transcatheter aortic valve replacement with the Medtronic CoreValve system: the CoreValve prospective, international, post-market ADVANCE-II study. JACC Cardiovasc Interv. 2015;8:837–46.

        Article  PubMed  Google Scholar 

      39. Chevreul K, Brunn M, Cadier B, et al. Cost of transcatheter aortic valve implantation and factors associated with higher hospital stay cost in patients of the FRANCE (FRench Aortic National CoreValve and Edwards) registry. Arch Cardiovasc Dis. 2013;106:209–19.

        Article  PubMed  Google Scholar 

      40. Gutmann A, Kaier K, Sorg S, et al. Analysis of the additional costs of clinical complications in patients undergoing transcatheter aortic valve replacement in the German health care system. Int J Cardiol. 2015;179:231–7.

        Article  PubMed  Google Scholar 

      41. Weber M, Sinning JM, Hammerstingl C, Werner N, Grube E, Nickenig G. Permanent pacemaker implantation after TAVR—predictors and impact on outcomes. Interv Cardiol. 2015;10:98–102.

        Article  PubMed  PubMed Central  Google Scholar 

      42. Siontis GCM, Praz F, Lanz J, et al. New-onset arrhythmias following transcatheter aortic valve implantation: a systematic review and meta-analysis. Heart. 2018;104:1208–15.

        Article  PubMed  Google Scholar 

      43. Chopard R, Teiger E, Meneveau N, et al. Baseline characteristics and prognostic implications of pre-existing and new-onset atrial fibrillation after transcatheter aortic valve implantation: results from the FRANCE-2 registry. JACC Cardiovasc Interv. 2015;8:1346–55.

        Article  PubMed  Google Scholar 

      44. Tarantini G, Mojoli M, Windecker S, et al. Prevalence and impact of atrial fibrillation in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement: an analysis from the SOURCE XT prospective multicenter registry. JACC Cardiovasc Interv. 2016;9:937–46.

        Article  PubMed  Google Scholar 

      45. Biviano AB, Nazif T, Dizon J, et al. Atrial fibrillation is associated with increased mortality in patients undergoing transcatheter aortic valve replacement: insights from the placement of aortic transcatheter valve (PARTNER) trial. Circ Cardiovasc Interv. 2016;9. Available at: https://www.ahajournals.org/doi/10.1161/CIRCINTERVENTIONS.115.002766. Accessed 1 Mar 2021.

      46. van Rosendael PJ, Delgado V, Bax JJ. Pacemaker implantation rate after transcatheter aortic valve implantation with early and new-generation devices: a systematic review. Eur Heart J. 2018;39:2003–13.

        Article  PubMed  Google Scholar 

      47. Khawaja MZ, Rajani R, Cook A, et al. Permanent pacemaker insertion after CoreValve transcatheter aortic valve implantation: incidence and contributing factors (the UK CoreValve Collaborative). Circulation. 2011;123:951–60.

        Article  CAS  PubMed  Google Scholar 

      48. •• 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: a report of the American college of cardiology solution set oversight committee. J Am Coll Cardiol. 2020;76:2391–411. This document outlines strategies for the management of conduction disturbances post-TAVR. It puts forth an organized method to approach such disturbances.

        Article  PubMed  Google Scholar 

      49. Rodés-Cabau J, Ellenbogen KA, Krahn AD, et al. Management of conduction disturbances associated with transcatheter aortic valve replacement: JACC scientific expert panel. J Am Coll Cardiol. 2019;74:1086–106.

        Article  PubMed  Google Scholar 

      50. Sandhu A, Tzou W, Ream K, et al. Heart block after discharge in patients undergoing TAVR with latest-generation valves. J Am Coll Cardiol. 2018;71:577–8.

        Article  PubMed  Google Scholar 

      51. Nazif TM, Chen S, Codner P, et al. The initial U.S. experience with the tempo active fixation temporary pacing lead in structural heart interventions. Catheter Cardiovasc Interv 2020;95:1051–56.

      52. Rivard L, Schram G, Asgar A, et al. Electrocardiographic and electrophysiological predictors of atrioventricular block after transcatheter aortic valve replacement. Heart Rhythm. 2015;12:321–9.

        Article  PubMed  Google Scholar 

      53. Tovia-Brodie O, Ben-Haim Y, Joffe E, et al. The value of electrophysiologic study in decision-making regarding the need for pacemaker implantation after TAVI. J Interv Card Electrophysiol. 2017;48:121–30.

        Article  PubMed  Google Scholar 

      54. Rogers T, Devraj M, Thomaides A, et al. Utility of invasive electrophysiology studies in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation. Am J Cardiol. 2018;121:1351–7.

        Article  PubMed  Google Scholar 

      55. Krishnaswamy A, Sammour Y, Mangieri A, et al. The utility of rapid atrial pacing immediately post-TAVR to predict the need for pacemaker implantation. JACC Cardiovasc Interv. 2020;13:1046–54.

        Article  PubMed  Google Scholar 

      56. Vijayaraman P, Cano Ó, Koruth JS, et al. His-Purkinje conduction system pacing following transcatheter aortic valve replacement: feasibility and safety. JACC Clin Electrophysiol. 2020;6:649–57.

        Article  PubMed  Google Scholar 

      57. Guo J, Li L, Xiao G, et al. Feasibility and stability of left bundle branch pacing in patients after prosthetic valve implantation. Clin Cardiol. 2020;43:1110–8.

        Article  PubMed  PubMed Central  Google Scholar 

      58. De Pooter J, Gauthey A, Calle S, et al. Feasibility of His-bundle pacing in patients with conduction disorders following transcatheter aortic valve replacement. J Cardiovasc Electrophysiol. 2020;31:813–21.

        Article  PubMed  Google Scholar 

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      Authors and Affiliations

      1. Division of Cardiology, Section of Electrophysiology, University of Colorado, 12401 E. 17th Ave., MS B-136, Aurora, CO, 80045, USA

        Christopher Barrett, Amneet Sandhu & Wendy Tzou

      2. Denver VA Medical Center, Denver, USA

        Amneet Sandhu

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      1. Christopher Barrett
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      Correspondence to Amneet Sandhu or Wendy Tzou.

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      Barrett, C., Sandhu, A. & Tzou, W. Electrophysiologic Implications of Transcatheter Aortic Valve Replacement: Incidence, Outcomes, and Current Management Strategies. Curr Cardiol Rep 23, 167 (2021). https://doi.org/10.1007/s11886-021-01599-9

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