Conduction System Abnormalities After Transcatheter Aortic Valve Replacement: Mechanism, Prediction, and Management

Key points

Mechanisms of conduction abnormalities following transcatheter aortic valve replacement

A detailed explanation of the mechanisms that underlie post-TAVR conduction abnormalities requires a brief overview of the anatomic structures in and around the aortic root and the LVOT, because the conduction system of the heart lies in close proximity to these structures. The aortic root is made up of the sinuses of Valsalva, the fibrous interleaflet triangles, and the valvar leaflets themselves.¹⁶ It is a direct extension of the LVOT, which is itself composed of muscular components (the

Prediction of conduction system abnormalities posttranscatheter aortic valve replacement

Preprocedural patient characteristics and peri-procedural considerations are important predictors for conduction system abnormalities following TAVR. In a large meta-analysis that included a mix of balloon-expandable and self-expanding systems implanted predominantly via the transfemoral approach, male sex, preprocedural electrocardiographic abnormalities including first-degree AV block, left-anterior hemiblock, and RBBB were significantly associated with the need for PPM. The presence of AV

Management and clinical implications

The long-term deleterious consequences of ventricular pacing are well known. In TAVR, PPM implantation has been associated with an increased risk for heart failure hospitalization, all-cause readmission, emergency department visits, days spent in the intensive care unit, overall length of stay, maintenance of a persistently reduced ejection fraction, and overall mortality.29, 30, 31 This risk may be particularly increased among patients with already reduced ejection fraction.³²

One of the

Summary

Conduction disturbances are frequent following TAVR given the location of the cardiac conduction system relative to the site of transcatheter heart valve implantation. Several clinical, anatomic, electrocardiographic, and procedural characteristics are predictors for the need for PPM following TAVR. Care should be taken to limit the use of PPM given the deleterious consequences of pacing post-TAVR, and input from electrophysiology specialists should be undertaken to ensure the appropriate use

Acknowledgments

Dr V.S. Mahadevan is a Principal investigator for research studies with Edwards Life Sciences.