Risk Stratification and Management of Advanced Conduction Disturbances Following TAVI in Patients With Pre-Existing RBBB

Toshiaki Isogai, MD, MPH; Iryna Dykun, MD; Ankit Agrawal, MD; Shashank Shekhar, MD; Anas M. Saad, MD; Beni Rai Verma, MD; Omar M. Abdelfattah, MD; Ankur Kalra, MD; Amar Krishnaswamy, MD; Grant W. Reed, MD, MSc; Samir R. Kapadia, MD; Rishi Puri, MBBS, PhD

Structural Heart (Apr 2022)

Risk Stratification and Management of Advanced Conduction Disturbances Following TAVI in Patients With Pre-Existing RBBB

Toshiaki Isogai, MD, MPH,
Iryna Dykun, MD,
Ankit Agrawal, MD,
Shashank Shekhar, MD,
Anas M. Saad, MD,
Beni Rai Verma, MD,
Omar M. Abdelfattah, MD,
Ankur Kalra, MD,
Amar Krishnaswamy, MD,
Grant W. Reed, MD, MSc,
Samir R. Kapadia, MD,
Rishi Puri, MBBS, PhD

Affiliations

Toshiaki Isogai, MD, MPH: Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
Iryna Dykun, MD: Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
Ankit Agrawal, MD: Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
Shashank Shekhar, MD: Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
Anas M. Saad, MD: Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
Beni Rai Verma, MD: Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
Omar M. Abdelfattah, MD: Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
Ankur Kalra, MD: Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
Amar Krishnaswamy, MD: Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
Grant W. Reed, MD, MSc: Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
Samir R. Kapadia, MD: Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
Rishi Puri, MBBS, PhD: Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Address correspondence to: Rishi Puri, MBBS, PhD, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, J2-3, Cleveland, OH 44195

Journal volume & issue: Vol. 6, no. 1
p. 100006

Abstract

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Background: Pre-existing right bundle branch block (RBBB) is a strong predictor of increased need for a permanent pacemaker (PPM) following transcatheter aortic valve implantation (TAVI). Yet, further risk stratification and management remain challenging in patients with pre-existing RBBB owing to limited data. Therefore, we sought to investigate the incidence, predictors, and management of advanced conduction disturbances after TAVI in patients with pre-existing RBBB. Methods: We retrospectively reviewed 261 consecutive patients with pre-existing RBBB (median age 81 years; 28.0% female; 95.0% received a balloon-expandable valve) without a pre-existing PPM who underwent TAVI at our institution in 2015-2019. Outcomes were high-degree atrioventricular block/complete heart block (HAVB/CHB) and PPM requirement. Results: Overall, the 30-day HAVB/CHB rate was 28.0%, of which 76.7% occurred during the TAVI procedure. The delayed HAVB/CHB rate was 8.3%. Implantation depth below aortic annulus (per 1-mm increase) was significantly associated with increased risk of procedural HAVB/CHB (adjusted odds ratio = 1.25, 95% confidence interval = 1.07-1.46), delayed HAVB/CHB (1.34 [1.01-1.79]), and 30-day PPM (1.32 [1.11-1.55]). Predilation was associated with delayed HAVB/CHB (4.02 [1.22-13.23]). The combination of no predilation and implantation depth of ≤2.0 mm had lower rates of procedural HAVB/CHB (11.2% vs. 26.7%-30.4%, p = 0.011), delayed HAVB/CHB (2.1% vs. 7.6%-28.1%, p < 0.001), and 30-day PPM (10.3% vs. 20.0%-43.5%, p < 0.001) than the other strategies of valve deployment. Complete HAVB/CHB recovery after PPM implantation was uncommon at 7.1%. Conclusions: In patients with pre-existing RBBB, the majority of HAVB/CHB events occurred during the TAVI procedure. Avoidance of predilation coupled with high valve deployment may result in relatively low rates of procedural and delayed HAVB/CHB, along with 30-day PPM rates.

Published in Structural Heart

ISSN: 2474-8706 (Print); 2474-8714 (Online)
Publisher: Elsevier
Country of publisher: United States
LCC subjects: Medicine: Internal medicine: Specialties of internal medicine: Diseases of the circulatory (Cardiovascular) system
Website: https://www.sciencedirect.com/journal/structural-heart

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