Right bundle branch block is not associated with worse short- and mid-term outcome after transcatheter aortic valve implantation

Risk Stratification for Pacemaker Implantation after Transcatheter Aortic Valve Implantation in Patients with Right Bundle Branch Block

Background: Permanent pacemaker implantation (PPI) after transcatheter valve implantation (TAVI) is a common complication. Pre-existing right bundle branch block (RBBB) is a strong risk factor for PPI after TAVI. However, a patient-specific approach for risk stratification in this subgroup has not yet been established. Methods: We investigated TAVI patients with pre-existing RBBB to stratify risk factors for PPI and 1-year-mortality by detailed analysis of ECG data, RBBB morphology and degree of calcification in the implantation area assessed by computed tomography angiography. Results: Between 2010 and 2018, 2129 patients underwent TAVI at our institution. Among these, 98 pacemaker-naïve patients with pre-existing RBBB underwent a TAVI procedure. PPI, because of relevant conduction disturbances (CD), was necessary in 43 (43.9%) patients. PPI was more frequently indicated in women vs. men (62.1% vs. 32.8%, p = 0.004) and in men treated with a self-expandable vs. a balloon-expandable valve (58.3% vs. 26.5%, p = 0.035). ECG data (heart rhythm, PQ, QRS, QT) and RBBB morphology had no influence on PPI rate, whereas risk for PPI increased with the degree of calcification in the left septal His-/left bundle branch-area to a 9.375-fold odds for the 3rd tertile of calcification (1.639–53.621; p = 0.012). Overall, 1-year-mortality was comparable among patients with or without PPI (14.0% vs. 16.4%; p = 0.697). Conclusions: Patients with RBBB undergoing TAVI have a high risk of PPI. Among this subgroup, female patients, male patients treated with self-expandable valve types, patients with high load/degree of non-coronary LVOT calcification and patients with atrial fibrillation need enhanced surveillance for CD after procedure.

Mid- to Long-Term Clinical and Echocardiographic Effects of Post-procedural Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Aims

To date, the prognostic effects of permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR) remain controversial. The purpose of this meta-analysis was to investigate the mid- (1 year) to long-term (> 1 year) clinical and echocardiographic effects of post-procedural PPI in patients after TAVR.

Methods

PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched from the establishment of databases up to 1 December 2021. Studies comparing clinical and echocardiographic outcomes between patients with and without post-TAVR PPI of ≥ 1-year follow-up were collected for further meta-analysis.

Results

A total of 39 studies comprising of 83,082 patients were included in this meta-analysis. At mid-term follow-up (1 year), the pooled results demonstrated a higher risk of all-cause mortality in patients with post-procedural PPI than those without following TAVR (relative risk (RR), 1.17; 95% CI, 1.10–1.24; P < 0.00001). No significant differences were observed in cardiovascular mortality (RR, 0.86; 95% CI, 0.71–1.03; P = 0.10) or heart failure rehospitalization (RR, 0.91; 95% CI, 0.58–1.44; P = 0.69) at 1-year follow-up. At long-term follow-up (> 1 year), post-TAVR PPI had negative effects on all-cause mortality (RR, 1.18; 95% CI, 1.09–1.28; P < 0.0001) and heart failure rehospitalization (RR, 1.42; 95% CI, 1.18–1.71; P = 0.0002). There was no difference in long-term cardiovascular mortality between the two groups (RR, 1.15; 95% CI, 0.97–1.36; P = 0.11). Left ventricular ejection fraction (LVEF) was not significantly different at baseline (mean difference, 1.40; 95% CI, –0.13–2.93; P = 0.07), but was significantly lower in the PPI group at 1-year follow-up (mean difference, –3.57; 95% CI, –4.88 to –2.26; P < 0.00001).

Conclusion

Our meta-analysis provides evidence that post-TAVR PPI has negative clinical and echocardiographic effects on patients at mid- to long-term follow-up. Further studies are urgently needed to explore the cause of these complications and optimize the treatment and management of patients requiring permanent pacing after TAVR.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289935], identifier [CRD42021289935].

Impact of Pre-Existing Right Bundle Branch Block on In-Hospital Outcomes Following Transcatheter Aortic Valve Replacement: Insight from National Inpatient Sample Database, 2016-2019

BACKGROUND

Right bundle branch block (RBBB) is a common finding in older adults and may have higher complications following the transcutaneous aortic valve replacement (TAVR) procedure.

METHODS

The National Inpatient Sample (NIS) was queried for all hospitalizations undergoing percutaneous TAVR from 2016 to 2019. Cohorts with RBBB were compared to hospitalized patients without RBBB. Weighted multivariable logistic regression was used to assess the association between RBBB and in-hospital outcomes.

RESULTS

Out of 203,900 procedures performed, 5.05% had RBBB, and 94.95% didn't have RBBB. The primary outcome of in-hospital mortality was not statistically different between patients with and without RBBB (0.92% vs. 1.41%, OR: 0.65, 95% CI: 0.41-1.03, p=0.07), a finding that did not change when adjusted for comorbidities in multivariate analysis (adjusted OR: 0.65, 95% CI: 0.41-1.05, p=0.08). In the RBBB group, total complication rates were higher (adjusted OR: 3.67, 95% CI: 3.32-4.06, p<0.001), driven primarily by pacemaker implantation (adjusted OR: 4.18, 95% CI: 3.77-4.63, p<0.001). We also found higher cardiac arrest (adjusted OR: 2.46, 95% CI: 1.08-23.99, p=0.001) and post-procedural heart failure (adjusted OR: 2.75, 95% CI: 1.07-7.08, p=0.036).

CONCLUSION

Patients with a history of RBBB who undergo TAVR have an increased need for permanent pacemaker implantation compared to those without a right bundle branch block. Whether extended monitoring post TAVR would reduce complications is a matter of further study.