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Published on: May 29, 2015
Role of Routine Electrophysiological Study Performed During Transcatheter Aortic Valve Replacement to Predict AV
Mattia Pagnoni1, David Meier1, Adrian Luca1
1Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland.
Insights
Electrophysiological (EP) testing during transcatheter aortic valve replacement (TAVR) has limited ability to predict high-degree atrioventricular block (HAVB). However, specific ECG findings, like post-TAVR PR interval ≤180 ms, can identify low-risk patients, especially those with new-onset LBBB.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Transcatheter aortic valve replacement (TAVR) is increasingly used for aortic stenosis.
- Periprocedural electrophysiological (EP) testing is being explored to predict risks associated with TAVR.
- High-degree atrioventricular block (HAVB) is a significant complication post-TAVR.
Purpose of the Study:
- To evaluate the predictive value of pre- and immediate post-TAVR electrocardiogram (ECG) and HV interval measurements for HAVB.
- To identify specific electrophysiological parameters that can stratify HAVB risk in TAVR patients.
Main Methods:
- Consecutive TAVR patients without prior pacemakers were included.
- Standardized ECG and HV interval measurements were performed pre- and post-TAVR.
- The primary outcome was HAVB or need for ventricular pacing >24 hours post-TAVR.
Main Results:
- A Delta-HV interval ≥18 ms predicted HAVB with 50% sensitivity and 90% specificity.
- An HV interval ≥60 ms post-TAVR showed 63% sensitivity and 79% specificity for HAVB.
- A post-TAVR PR interval ≤180 ms identified patients at very low risk of HAVB.
Conclusions:
- Periprocedural EP assessment during TAVR has limited yield in identifying all at-risk patients for HAVB.
- Early risk stratification is more useful in TAVR patients who develop new-onset LBBB.
- Post-TAVR PR interval ≤180 ms is a reliable indicator of low HAVB risk, irrespective of QRS characteristics.
Background:
Periprocedural electrophysiological (EP) testing may be useful to predict high degree atrioventricular block (HAVB) risk in patients undergoing transcatheter aortic valve replacement (TAVR).
Objective:
To determine whether pre- and immediate post-TAVR ECG and HV interval findings are predictive of HAVB.
Methods:
Consecutive TAVR patients without prior pacemaker (PM) implantation underwent ECG and standardized HV interval measurements pre- and post-TAVR using the quadripolar catheter for rapid pacing. The primary outcome was HAVB >24 h after TAVR or ventricular pacing need RESULTS: Out of 97 included patients, 8 experienced the primary outcome (7 with HAVB and 1 with PM need). On univariate analysis, pre- and post-TAVR PR, post-TAVR HV, and Delta-HV intervals were predictors of the primary outcome. A Delta-HV interval ≥18 ms predicted HAVB with sensitivity = 50% and specificity = 90% (AUC = 0.708, PPV = 31%), while an HV interval ≥60 ms after TAVR had sensitivity = 63% and specificity = 79% (AUC = 0.681, PPV = 21%). None of the patients with a PR interval ≤180 ms post-TAVR experienced the primary outcome. Among patients with new-onset LBBB, an HV interval post-TAVR >65 ms was the only predictor of HAVB (AUC = 0.776, PPV = 33%, and NPV = 97%).
Conclusion:
The yield of periprocedural EP assessment during TAVR is limited considering that about half of the at-risk patients fail to be identified. However, early periprocedural risk stratification may be more useful in the subset of patients with new-onset LBBB. Among ECG findings, a post-TAVR PR interval ≤180 ms identifies a subgroup at very low risk, independently of QRS interval and morphology.
