Expert Panel Algorithm for Post-TAVR Conduction Disturbances

Batya Swift Yasgur MA, LSW

August 29, 2019

An expert panel has issued an algorithm strategy for managing conduction disturbances associated with transcatheter aortic valve replacement (TAVR).

The panel included a multidisciplinary group of interventional cardiologists, electrophysiologists, and cardiac surgeons, and the document covers the gamut of clinical decisions in TAVR, from preprocedural risk assessment to postprocedural monitoring and management.

Based on preprocedural electrocardiogram (ECG), ECG changes and arrhythmias during the procedure, and analysis of the ECG at the end of the procedure, patients were categorized into five groups, with a management algorithm specific to each group.

"This expert report document represents an initial effort to provide a comprehensive and structured guide for managing patients with conduction disturbances post-TAVR and a framework for future research," lead author Josep Rodés-Cabau, MD, director, Catheterization and Interventional Laboratories, Quebec Heart and Lung Institute, Quebec City, Canada, told | Medscape Cardiology.

"We hope this document may help to implement a more uniform practice regarding the management of conduction disturbances post-TAVR," said Rodés-Cabau, who is associate professor of medicine, Laval University, Quebec City.

The statement was published in the August 27 issue of the Journal of the American College of Cardiology.

Uniform Strategy

"The occurrence of conduction disturbances remains the most important drawback of TAVR, and there has been an important lack of consensus on the management of these complications," Rodés-Cabau pointed out.

"This has translated into major differences between centers and studies in pacemaker rates post-TAVR," he said.

Differences in managing conduction disturbances "can have major consequences in the hospitalization length and costs of the TAVR procedure and may also affect clinical outcomes."

Moreover, this "large variability also prevented appropriate evaluation of the safety and efficacy of different strategies for managing conduction disturbances in a large cohort of patients from multiple centers."

For this reason, there was "a need for a uniform strategy regarding the management of conduction disturbances post-TAVR," he said.

Preprocedural Risk Evaluation

Prior to the procedure, an evaluation of the risk for conduction disturbances should be performed, the panel notes.

The strongest and most consistent risk factor is the presence of right bundle branch block (RBBB) at baseline, which increases the risk for permanent pacemaker implantation (PPM) 3- to 47-fold (odds ratio [OR], 2.8 - 46.7).

Baseline RBBB is also associated with increased risk for early and late mortality after TAVR.

The authors recommend preprocedural ECG monitoring for at least 24 hours, because some conduction issues may be "silent" and detected only after the procedure.

Detecting baseline arrhythmias pre-TAVR enables treatment (i.e., PPM or changes in medical therapy) prior to the procedure, which can reduce the post-TAVR risk for PPM and hospitalization length.

Procedural Considerations

"Certain modifiable aspects of the TAVR procedure have been implicated in the occurrence of conduction disturbances and PPM post-TAVR," and should be taken into consideration when planning the procedure, particularly in patients with an intrinsic increased risk, the authors note.

Newer-generation transcatheter heart valve (THV) devices may be associated with lower PPM rates after TAVR. However, "no definite data exist to date on the potential differences among newer-generation transcatheter valves regarding the pattern of evolution (progression-regression) of conduction disturbances over time; thus, the recommendations provided in this document apply to all transcatheter valves, with no specific differentiation according to valve type," they emphasize.

The authors summarize their procedural recommendations:

  • Continuous ECG monitoring during the procedure

  • A temporary pacing wire is usually implanted in the right ventricle at the beginning of the procedure or may be placed in the left ventricle

  • Central venous access is recommended in case there is an urgent need for temporary pacing wire

  • Consider avoiding prevalve dilation before the transcatheter heart valve, because increased risk for conduction disturbances is associated with balloon valvuloplasty

  • Consider a valve type with a lower risk for conduction disturbances in high-risk patients

  • Aim to minimize the depth of valve implantation; a higher (more aortic) valve positioning is associated with lower risk.

A 12-lead ECG should ideally be obtained at the end of the procedure. If that is not feasible in the procedure room, a 6-lead ECG can be obtained through the continuous ECG monitoring system and a 12-lead ECG can be obtained as soon as possible once the patient has left the procedure room.

"Compromise" Position

Based on ECG changes/arrhythmias during the procedure and analysis of the ECG at the end of procedure, the authors divide patients into five groups, each with its own unique algorithm.

"A compromise between the increasing pressure toward a minimalist approach, including early discharge of TAVR recipients, and the potential risks associated with a too-precipitous clinical decision in this context was taken into consideration in each management algorithm proposal," Rodés-Cabau said.

Group 1: No ECG changes in patients without preprocedure RBBB

These patients have a "very low risk of developing high-degree atrioventricular block/complete heart block (HAVB/CHB) or any conduction disturbance within the hours and days following the procedure."

Temporary pacing can be safely discontinued at the end of the procedure, although continuous EC monitoring until hospital discharge is "recommended."

Group 2: No ECG changes in patients with pre-existing RBBB

"The presence of RBBB remains the most important risk factor for HABV/CHB and need for PPM following TAVR," the authors write.

The increased risk for HABV starts at the time of the procedure, but persists afterward, especially within the initial 2 to 3 days after the procedure.

A temporary pacing wire is recommended for 24 hours (or at least overnight), along with telemetry and daily ECG during the whole hospitalization.

If ECG changes occur during this period, the authors advise adopting the management strategies of groups 3 and 5, depending on the presentation.

Patients without ECG changes of significant bradyarrhythmias during this period can "probably be safely discharged," although continuous ECG monitoring (from 48 hours to 4 weeks) may be considered.

Group 3: ECG changes (increase in PR or QRS interval ≥20 ms) in patients with pre-existing conduction disturbances (RBBB, LBBB, intraventricular conduction delay [ IVCD] with QRS ≥120 ms, first-degree atrioventricular block [AVB])

These patients have prior conduction disturbances and exhibit postprocedure ECG changes (but not HAVB/CHB) and represent "the most challenging group regarding temporary and permanent pacemaker recommendations," according to the authors.

They propose that any significant increase in PR or QRS interval duration, compared with pre-TAVR ECG, may lead to continuing the temporary pacing wire for 24 hours or at least overnight.

The wire may be removed earlier if the changes regress in less than 24 hours, and multiple ECGs may facilitate the clinical decision-making process.

When the patient can be safely discharged is based on a complex variety of factors, informed by potential arrhythmic changes pre- and postremoval of the temporary pacemaker; the extent of regression of the ECG changes to baseline value; and the level of risk for HAVB/CHB.

The authors note that their recommendations for this "complex" group of patients are based on "little evidence" but "the risk of advanced conduction disturbances…may justify additional measures (including PPM before hospital discharge) to prevent life-threatening arrhythmias and sudden cardiac death."

Group 4: New-onset LBBB

New-onset LBBB after TAVR "remains the most frequent complication of the procedure," the authors note.

They recommend maintaining the temporary pacing wire for 24 hours, along with daily ECG and telemetry for at least 1 to 2 days — although earlier removal of the temporary pacing wire can be considered if LBBB resolves in less than 24 hours, and the patient can be discharged on day 1 after TAVR.

In contrast, if LBBB persists without further progression of QRS or PR interval duration at day 1, temporary pacing can be discontinued and, if no further ECG changes are observed up to day 2 to 3 after TAVR, the patient can be discharged.

Because these patients remain at increased risk for delayed HAVB/CHB requiring PPM, clinicians may consider continuous ECG monitoring (>2–4 weeks) and/or electrophysiology studies.

Group 5: HAVB/CHB — transient or persistent — during the procedure

Most episodes of HAVB/CHB occur during the TAVR procedure, with less than 20% occurring during the initial postprocedural days.

"This information provides the rationale for avoiding an excessive hospitalization length post-TAVR based on the possible occurrence of delayed HAVB/CHB," the authors comment.

Additionally, the vast majority of delayed (postprocedural) HAVB/CHB episodes occur in patients with either previous or new-onset conduction disturbances (RBBB, LBBB, first-degree AVB).

Multiple Gaps

The statement includes a list of ongoing studies in the field of TAVR and conduction disturbances, including those that investigate different types of transcatheter valves and different types of ECG monitoring.

The authors also offer guidance regarding long-term follow-up of patients, based on their ECG findings.

"There are still multiple gaps in the field that need to be addressed," Rodés-Cabau said.

Future studies are needed "regarding the detection of arrhythmias pre-TAVR, accurate evaluation of the risk and timing of life-threatening arrhythmias and sudden death post-TAVR, and continuous ECG monitoring in the management of patients with conduction disturbances," he said.

Rodés-Cabau has received institutional research grants from Edwards Lifesciences, Boston Scientific, and Medtronic, and holds the Research Chair "Fondation Famille Jacques Larivière" for the Development of Structural Heart Disease Interventions. The other authors' disclosures are listed in the publication.

J Am Coll Cardiol. 2019;74:1086-1106. Abstract

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