Electrophysiology-guided algorithm for patients with conduction abnormalities post TAVR: one-year follow-up
Authors: Bar-Moshe A , Abu-Salman A , Cafri C , Merkin M , Bereza S , Kezerle L , Haim M , Konstantino Y 
Published: May 2024

Abstract

Introduction
Transcatheter aortic valve replacement (TAVR) revolutionized the treatment of aortic stenosis [1]. Although TAVR is an effective treatment for AS patients, it is associated with high incidence of new-onset conduction disturbances and pacemaker implantations. The two most common conduction disturbances after TAVR are new onset left bundle branch block (LBBB) and high-degree atrioventricular block (HDAVB) [2]. While patients with HDAVB require a permanent pacemaker implantation (PPM), the management of LBBB is not completely established yet. According to the ESC 2021 guidelines, a PPM is indicated in patients with persistent HDAVB or new onset alternating BBB after TAVR. Yet, the recommendations regarding other conduction abnormalities are not well defined. In patients with persistent new onset LBBB, ambulatory continuous ECG monitoring or electrophysiology study (EPS) are recommended [3].

Purpose
To evaluate the clinical outcomes of patients with conduction disorders after TAVR who were managed according to electrophysiology-guided algorithm (Figure 1), including mortality, late pacemaker’s implantations, and heart failure hospitalizations. Predictors of periprocedural LBBB and HDAVB were also assessed.

Methods
Retrospective population-based cohort study including all patients who developed new onset LBBB after TAVR at a tertiary University Medical Center from October 1, 2018, to December 31, 2022, and were managed according to specific electrophysiology-guided algorithm.

Results
The study cohort included 230 consecutive patients who underwent TAVR. Mean age was 80.3 and 56.5% were females (Figure 2). Twenty patients (8.7%) developed HDAVB and required a PPM, whereas 40 patients (17.4%) developed persistent LBBB. According to the algorithm, 8 patients (20%) with a QRS&lt;130ms were discharged without PPM [group A], 20 patients (50%) with a QRS of 130-160ms underwent EPS, and 12 patients (30%) with a QRS&gt;160ms [Group C] received a PPM. Among the EPS group: 9 patients (22.5%) with HV&gt;65ms underwent PPM [group B2], while 11 patients with HV&lt;65ms (27.5%) were discharged without PPM [group B1]. During a one-year follow-up only one patient required late PPM [group B1]. Mortality was higher among the subgroups with PPM [B2 and C] compared to the subgroups without a PPM [A and B1]: 4 vs. 1 patient accordingly.

Conclusions
The presented electrophysiology-guided algorithm for patients with persistent LBBB after TAVR appears safe and efficient, with a modest incidence of PPM (17.6% of the total cohort) during hospitalization and a minimal need for late PPM at one year follow-up. Importantly, there was no excess of mortality among patients who were discharged without a pacemaker implantation. Thus, we suggest that the presented algorithm may serve as a reliable strategy to distinguish between individuals with new onset persistent LBBB after TAVR who require PPM compared to those in whom a PPM can be safely avoided.