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Left bundle branch block, permanent pacing common after TAVR with repositionable valve
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Many patients implanted with a repositionable bioprosthesis during transcatheter aortic valve replacement experienced left bundle branch block and required permanent pacemaker implantation, according to new data published in JACC: Cardiovascular Interventions.
“TAVR is now a well-established treatment for aortic stenosis in patients deemed to be at high surgical risk,” Rajiv Rampat, MD, from the department of cardiology at Brighton and Sussex University Hospitals in Brighton, United Kingdom, and colleagues wrote. “However, with the growing adoption of this new technology, the complications of this procedure have become apparent.”
Researchers conducted a retrospective study in 228 patients who underwent TAVR with the repositionable valve (Lotus, Boston Scientific) between March 2013 and February 2015 across 10 U.K. medical centers. The valve is not yet approved for use in the United States.
The study excluded 12% of patients (n = 27) due to preprocedural pacemaker implantation.
Conduction disturbances
After the procedure, 111 of the patients (55%) developed new left bundle branch block, and 64 patients (32%) received permanent pacemakers with a median time to insertion of 3 ± 3.4 days, according to the researchers.
Of those who required a permanent pacemaker, the most common causes were presentation with atrioventricular block (n = 46; 72%), or left bundle branch block with first-degree atrioventricular block (n = 11; 17%).
The preprocedural ECG findings for study participants who received post-TAVR pacing included no conduction disturbance in 64%, first-degree atrioventricular block in 16%; right bundle branch block in 9% and left bundle branch block in 8%, Rampat and colleagues wrote.
Patients who had balloon aortic valvuloplasty before TAVR had a higher rate of left bundle branch block (OR = 1.25; P = .03).
There was an independent association between the need for permanent pacing and preprocedural conduction abnormality (OR = 2.54; P = .048).
Additionally, there was a link between the absence of aortic valve calcification and higher pacemaker implantation rate (OR = 0.55; P = .031).
There was no independent association between depth of implant, valve oversizing, balloon postdilatation, and the need for pacing after the procedure according to a multivariate regression analysis.
Room for improvement
In a related editorial, Philippe Généreux, MD, from the Gagnon Cardiovascular Institute, Morristown Medical Center, New Jersey; the Cardiovascular Research Foundation, New York; and the Hospital du Sacré-Couer de Montréal, wrote the results were “surprising” and “we can easily agree that there is room for improvement.”
“Today, vascular, bleeding and [paravalvular leak] complications have been marginalized. With this procedure potentially expanding to the low-risk population, conduction disorders, coronary access and [transcatheter heart valve] durability seem to be the remaining issues,” Généreux wrote. “Whether upcoming Lotus iterations and implantation optimization techniques will keep the Lotus valve in the race of contemporary [transcatheter heart valve] devices remains to be seen.” – by Dave Quaile
Disclosures: Rampat reports no relevant financial disclosures. Please see the full study for a list of the other researchers’ relevant financial disclosures. Généreux reports receiving speaker fees from Cardiovascular Systems, Edwards Lifesciences, Medtronic and Tryton Medical; consultant fees from Boston Scientific, Cardiovascular Systems and Pi-Cardia; an institutional research grant from Boston Scientific; and holding equity in Pi-Cardia, Saranas, SIG.NUM and Soundbite Medical Solutions.
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