Transcatheter Aortic Valve Implantation and Cardiac Conduction Abnormalities: Prevalence, Risk Factors and Management

Incidence and predictors of permanent pacemaker implantation after transcatheter aortic valve implantation with a balloon-expandable biosprosthesis in patients with bicuspid aortic valves

Introduction

There are few data on permanent pacemaker implantation (PPMI) in patients who have undergone transcatheter aortic valve implantation (TAVI) for bicuspid aortic valve (BAV) stenosis.

Aim

The purpose of this study was to evaluate the predictors and incidence of PPMI in bicuspid patients using a balloon-expandable (BE) TAVI device.

Material and methods

A total of 62 patients with bicuspid morphology who had undergone successful TAVI using a BE device without previous PPMI were included (retrospectively). Their baseline clinical, electrocardiographic (ECG), echocardiographic, and multislice computed tomography (MSCT) details were collected.

Results

The incidence of PPMI after TAVI in this BAV cohort was 12.9%. All eight patients with PPMs were found to have type 1 left-right (L-R) fusion morphology. In univariate analysis, the presence of right bundle branch block (RBBB) in preprocedural ECG (p < 0.0001), short membranous septum (MS) evaluated in MSCT (p < 0.0001), and increased annulus-left main coronary artery distance (p = 0.02) were statistically significant for PPMI. Among these parameters included in the model using multivariate Firth logistic regression analysis, the presence of preprocedural RBBB (p = 0.001) and shortness of the MS in MSCT (p = 0.004) were independent risk factors for predicting postprocedural PPMI in patients who underwent TAVI among those with BAV.

Conclusions

Preprocedural RBBB on ECG and shorter MS are independent risk factors for PPMI after TAVI in BAV patients and these parameters should be considered before the procedure to guide clinical decision making. Type 1 L-R patients may be considered at increased risk of PPMI.

A new and easy parameter to predict the requirement for permanent pacemaker implantation after transaortic valve implantation: aortic knob calcification

Introduction

One of the predictable and preventable complications that may occur after transaortic valve implantation (TAVI) is the requirement for permanent pacemaker (PPM) implantation.

Aim

To evaluate the relationship between aortic knob calcification (AKC) assessed by preoperative chest X-ray and the requirement for post-procedure PPM implantation for patients who underwent TAVI.

Material and methods

This study was conducted with 110 patients who underwent TAVI with a Myval transcatheter heart valve in our center between June 2020 and December 2022. The patients' electrocardiograms were monitored after the procedure. The patients were evaluated in two groups according to whether they required PPM. The AKC grading was performed by examining the routine posterior-anterior chest radiographs of all patients participating in the study.

Results

A PPM was placed in 17 (15.4%) patients after TAVI. The remaining 93 patients formed the control group. AKC (p = 0.002) and membranous septum (p = 0.013) statistically significantly differed between the PPM and control groups; however, no significant difference was detected in relation to the other parameters. In the univariable (p = 0.004) and multivariable (p = 0.024) regression analyses performed to identify predictors of PPM requirement after TAVI, AKC was found to be both a dependent and independent predictor.

Conclusions

AKC can be used as a cost-effective and easily accessible parameter for predicting the post-procedure PPM requirement in patients who have undergone TAVI.

Left Bundle Branch Area Pacing to Overcome Coronary Sinus Anatomy-Related Technical Problems Encountered during Implantation of Biventricular CRT-A Case Report

The results of clinical trials show that up to one-third of patients who are eligible for cardiac resynchronization therapy (CRT) do not benefit from biventricular pacing. The reasons vary, including technical problems related to left ventricle pacing lead placement in the appropriate branch of the coronary sinus. Herein, we present a case report of a patient with heart failure with reduced ejection fraction and left bundle branch block, in whom a poor coronary sinus bed made implantation of classic biventricular CRT impossible, but in whom, alternatively, rescue-performed left bundle branch area pacing allowed effective electrical and mechanical cardiac resynchronization. The report confirms that left bundle branch area pacing may be a rational alternative in such cases.

Cardiac Damage and Conduction Disorders after Transcatheter Aortic Valve Implantation

Recently, a staging system using 4 grades has been proposed to quantify the extent of cardiac damage associated with aortic stenosis (AS), namely AS-related cardiac damage staging (ASCDS). ASCDS is independently associated with all-cause mortality and important clinical outcomes. To evaluate whether it might be associated with the occurrence of conduction system disorders after TAVI, a total of 119 symptomatic patients with severe AS who underwent a TAVI were categorized according to ASCDS: group 1 (13.5%): no or LV damage; group 2 (58.8%): left atrial/mitral valve damage, atrial fibrillation (AF); group 3 (27.7%): low-flow state, pulmonary vasculature/tricuspid valve/RV damage. After TAVI, 34% of patients exhibited LBBB and 10% high-degree atrioventricular block (HD-AVB). No patient in group 1 developed HD-AVB whereas new LBBB was frequent in groups 2 and 3. Twenty-one patients presented with paroxysmal AF with a higher rate for each group increment (group 1: n = 0, 0%; group 2: n = 11, 15.7%; group 3: n = 10, 30.3%) (p = 0.012). Patients in group 3 had the higher rate of permanent pacemaker implantation (PPMI) (group 1: n = 1, 6.3%; group 2: n = 7, 10%; group 3: n = 9, 27.3%) (p = 0.012). In conclusion, ASCDS might help identify patients at higher risk of conduction disorders and PPMI requirement after TAVI.