Incidence and Predictors of High-Grade AV Block in Patients With Initially Unchanged Electrocardiogram After TAVR
Mohamed Elhadi1, Mohamad S Alabdaljabar1, Conor Lane1
1Division of Interventional Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
Insights
High-grade atrioventricular block (HAVB) is common after transcatheter aortic valve replacement (TAVR). Patients with right bundle branch block (RBBB) require 24-hour monitoring, while others may be suitable for earlier discharge.
Area of Science:
- Cardiology
- Cardiac Electrophysiology
- Interventional Cardiology
Background:
- High-grade atrioventricular block (HAVB) is a known complication following transcatheter aortic valve replacement (TAVR).
- Understanding conduction abnormalities pre- and post-TAVR is crucial for patient management.
- This study compares outcomes in patients with pre-existing conduction disease versus those with normal baseline electrocardiograms (ECGs).
Purpose of the Study:
- To compare the incidence of HAVB in patients with different baseline conduction abnormalities undergoing TAVR.
- To identify specific conduction diseases that predict a higher risk of HAVB post-TAVR.
- To inform post-procedure monitoring strategies based on pre-existing ECG findings.
Main Methods:
- Retrospective review of 1069 patients who underwent TAVR at Mayo Clinic between February 2012 and December 2021.
- Patients were categorized into groups based on baseline ECG: normal (control), isolated PR prolongation (>240 ms), left bundle branch block (LBBB), and right bundle branch block (RBBB).
- Incidence of early (<24 hours) and delayed (>24 hours) HAVB was compared across groups.
Main Results:
- Right bundle branch block (RBBB) was associated with a significantly higher incidence of early HAVB (11.2%) compared to controls (0.6%).
- Delayed HAVB was also more frequent in the RBBB group (6.5%) and showed a trend towards higher incidence in PR >240 ms (4.5%) and LBBB (4.3%) groups compared to controls (1.5%).
- Patients with isolated PR >240 ms and LBBB had a combined HAVB incidence of approximately 5%, with most events occurring after 24 hours.
Conclusions:
- Despite no immediate ECG changes, 17.8% of patients with pre-existing RBBB developed HAVB post-TAVR, necessitating at least 24 hours of inpatient monitoring.
- For patients with isolated PR >240 ms and LBBB, a lower incidence of HAVB (5%) was observed, with most events occurring later.
- Same-day discharge with ambulatory ECG monitoring may be a viable option for patients with isolated PR >240 ms and LBBB, warranting further investigation.
Background:
High-grade atrioventricular block (HAVB) is common after transcatheter aortic valve replacement (TAVR). We compared patients with baseline conduction disease that is unchanged on the immediate post-TAVR echocardiogram (ECG) to patients with normal baseline and post-TAVR ECG (control group).
Methods:
Consecutive patients who underwent TAVR at Mayo Clinic (Rochester, Minnesota) between February 2012 and December 2021 were retrospectively reviewed.
Results:
In total, 1069 patients were included in the study: 825 controls, 44 with isolated PR of >240 milliseconds, 93 with left bundle branch block (LBBB), and 107 with right bundle branch block (RBBB). Early HAVB (<24 hours post-TAVR) occurred more frequently in the RBBB group compared with controls (11.2% vs 0.6%; P < .001). Early HAVB incidence was similar between the control, isolated PR >240, and LBBB groups (0.6%, 0%, and 1.1%, respectively). Delayed HAVB (>24 hours post-TAVR) was most frequent in the RBBB group (6.5% vs 1.5%; P < .001), with higher incidence also observed in PR >240 and LBBB groups compared with that in control (4.5% vs 1.5%; P = .14; and 4.3% vs 1.5%; P = .06, respectivley). Most of HAVB events in the control, isolated PR >240 and LBBB groups were delayed.
Conclusions:
Despite no immediate change in post-TAVR ECG, 17.8% of patients with preexisting RBBB developed HAVB, mostly within 24 hours. This emphasizes the need for inpatient monitoring for at least 24 hours in this group. Conversely, in patients with isolated PR >240 milliseconds and LBBB, the incidence of HAVB was relatively low (5%), with the majority occurring after 24 hours. Potentially, same-day discharge with ambulatory ECG monitoring may be suitable for these patients.
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