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New-onset persistent left bundle branch block led to no change in long-term post-TAVR mortality
New-onset persistent left bundle branch block was not linked to increased mortality rates 3 years after transcatheter aortic valve replacement, according to findings presented at EuroPCR.
But despite no association between increased mortality, new-onset persistent left bundle branch block increased permanent pacemaker implantation and negatively affected left ventricular function over time.
In the study, which was simultaneously published in JACC: Cardiovascular Interventions, Chekrallah Chamandi, MD, and colleagues assessed the impact of new-onset persistent left bundle branch block on outcomes more than 2 years after TAVR.
“Although variable in its incidence (5-65%), new-onset left bundle branch block is one of the most common complications post-TAVR, which depends on the study, type of device used, implantation methods and patient comorbidities,” Chamandi, a cardiologist at Quebec Heart and Lung Institute at Laval University in Canada, and colleagues wrote.
The data of 1,020 consecutive patients without pre-existing left bundle branch block or permanent pacemaker implantation undergoing TAVR were analyzed. Clinical follow-up and echocardiographic data were gathered at a median of 3 years post-TAVR, the researchers wrote.
Post-TAVR complications
New-onset persistent left bundle branch block occurred in 20.1% of patients after TAVR, Chamandi and colleagues reported.
The researchers noted no differences between the new-onset persistent left bundle branch block and no new-onset persistent left bundle branch block, except for a higher use of the self-expandable CoreValve system (Medtronic) in the no new-onset persistent left bundle branch block group (P < .001).
At follow-up, Chamandi and colleagues discerned there were no differences between the new-onset persistent left bundle branch block and the no new-onset persistent left bundle branch block in all-cause (45.3% vs. 42.5%; adjusted HR = 1.09; 95% CI, 0.82-1.47) and CV (14.2% vs 14.4%; aHR = 1.02, 95% CI, 0.56-1.87) mortality, respectively. There was also no difference in HF rehospitalization (19.8% vs. 15.6%, aHR = 1.02; 95% CI, 0.85-2.46).
New-onset persistent left bundle branch block was associated with an increased risk for permanent pacemaker implantation at follow-up (15.5% vs. 5.4%, aHR = 2.45; 95% CI, 1.37-4.38), with greater risk within the first 12 months, the researchers wrote. Left ventricular ejection fraction had an increase over time in patients with no new-onset persistent left bundle branch block while decreasing in new-onset persistent bundle branch block patients (P < .001), Chamandi and colleagues wrote.
The results should inform future efforts for improving the management of patients with new-onset persistent left bundle branch block post-TAVR, the researchers wrote.
“As TAVR is inevitably expanding toward the treatment of most patients with aortic stenosis, caution should be raised to prevent conduction disturbances and implement specific protocols regarding the follow-up of such patients,” Chamandi and colleagues wrote.
Evidence-based strategy needed
In a related editorial, Ron Waksman, MD, an interventional cardiologist at MedStar Washington Hospital Center in Washington, D.C., and Jaffar M. Khan, MD, a staff clinician at the NHLBI, wrote: “The need for pacing requires rigorous assessment to avoid unnecessary [permanent pacemaker] implantation, which is imperative in younger populations. An evidence-based strategy is needed to monitor and manage these patients, particularly in the first month and potentially up to the first year after TAVR.” – by Earl Holland Jr.
References:
Chamandi C, et al. TAVI-induced conduction abnormalities – Predictors and prognosis. Presented at: EuroPCR; May 21-24, 2019; Paris.
Chamandi C, et al. JACC Cardiovasc Interv. 2019;doi:10.1016/j.jcin.2019.03.025.
Waksman R, et al. JACC Cardiovasc Interv. 2019;doi:10.1016/j.jcin.2019.04.008.
Disclosures: Chamandi reports receiving a fellowship grant from Edwards Lifesciences. Waksman reports he serves on advisory boards for Abbott Vascular, Amgen, Boston Scientific, Cardioset, Cardiovascular Systems Inc., Medtronic, Philips Volcano, Pi-Cardia Ltd., and received consultant fees from Abbott Vascular, Amgen, Biosensors, Biotronik, Boston Scientific, Cardioset, Cardiovascular Systems Inc., Medtronic, Philips Volcano and Pi-Cardia Ltd. Khan reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.