Left bundle branch pacing after transcatheter aortic valve implantation. Initial experience of a center

Introduction

Permanent pacing is often needed in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) due to new onset conduction disorders. Nevertheless, continuous right ventricular pacing may deteriorate left ventricular ejection fraction (LVEF) and lead to poor outcomes. Thus, in last years, more physiological forms of pacing, such as left bundle branch pacing (LBBP) have been developed to prevent pacing induced cardiomyopathy.

Purpose

The aim of our study is to describe the initial experience in our center, evaluate the safety and feasibility of LBBP after TAVI and describe electrophysiological outcomes in the first months of follow-up.

Methods

We designed a prospective registry that collected all patients from the TAVI program of our center who developed conduction abnormalities in the immediate postoperative and received LBBP. We analyzed baseline characteristics, complications and procedure time, electrophysiological parameters after the procedure and final QRS interval. During follow-up LVEF, electrophysiological parameters and adverse clinical events (readmissions for heart failure, cardiovascular mortality and all-cause of mortality) were also evaluated at 3rd, 6th and 12th month.

Results

Between January 2020 and January 2022, twenty patients who developed conduction abnormalities after TAVI underwent LBBP. Seven patients (35%) had a complete atrioventricular block, two patients (10%) alternating bundle branch block and 11 (55%) had a new left bundle branch block. HV electrophysiology study was performed in 8 patients, with a median value of 68ms (66–72).

Of the 20 patients, 3 out of 4 patients were male and had history of hypertension. 40% had previous ischemic heart disease and one patient had transthyretin cardiac amyloidosis. Median age was 79 years-old (76–83.5). Balloon-expandable prosthesis was implanted in 11 patients while 9 received a self-expandable prosthesis. Median basal LVEF was 59% (41.5–60) and median NTproBNP was 1722pg/ml (535–5848).

LBBP was successful in all of the 20 patients. The median time of the procedure was 60 minutes (45–80) without suffering any complications. The median QRS interval before the procedure was 155ms (140–158) and 116ms (105–125) post-implant.

To date, two patients have died of non-cardiac cause 3 and 8 months after LBBP. There have been no readmissions for heart failure. LVEF (pre and post-LBBP) and electrophysiological parameters post-implant and three-month follow-up are shown in Table 1.

Conclusions

In our experience, LBBP after TAVI is a safe and feasible procedure. Despite the small sample size and short follow-up period, our first results indicate stability of LVEF and pacemaker parameters.

Funding Acknowledgement

Type of funding sources: None.

Clinical outcomes of percutaneous coronary intervention in coronary allograft vasculopathy from single center experience

Background/Introduction

Cardiac allograft vasculopathy (CAV) is a leading cause of morbidity and mortality of heart transplant recipients. Percutaneous coronary intervention (PCI) is an alternative to medical treatment, however long-term data from large multicenter studies are scarce.

Purpose

To review clinical characteristics and outcomes of CAV undergoing PCI in our heart transplant series.

Methods

We analysed retrospectively 52 heart transplant recipients with CAV who underwent PCI from 2004 to 2020. Surveillance angiography was performed in 90% of stents. Stent restenosis (SR), stent thrombosis (ST), target lesion revascularization (TLR) and patient survival are reported.

Results

During study period, 124 lesions were treated. Primary success was obtained in 99% of lesions. Mean angiographic follow up was 37±47 months. A total of 31 (25%) stents presented events during follow-up: 24 SR, 7 ST. There were no differences between bare-metal stent (BMS) and drug-eluting stent (DES). We performed 16 (12.9%) TLR. There was no association between clinical and lesion-related features and TLR. Post-PCI survival was 75.3% at 5 and 55.7% at 10 years.. Cytomegalovirus (CMV) infection before development of CAV decreased survival in univariable analysis (p<0.016).

Conclusions

PCI with stent in CAV can be performed with high rates of primary success and low rate of complications, similar to non-transplant patients. Our series suggest that CMV infection can have negative impact in post-PCI survival, but further studies are needed.

Funding Acknowledgement

Type of funding source: None

Usefulness of strain imaging to determine prognosis in pulmonary hypertension

Introduction

Pulmonary hypertension (PH) is defined as mean pulmonary arterial pressure (mPAP) ≥25 mmHg at rest, measured by right heart catheterization (RHC).

Purpose

To describe classical and myocardial deformation echocardiographic parameters in patients with established PH and to identify prognostic variables

Methods

We prospectively enrolled 76 patients with mPAP ≥25 mmHg undergoing RHC between 2017 and 2018. All subjects underwent transthoracic echocardiography (TTE) according to the latest ASE/EACVI guidelines the same day of the RHC. Strain analysis was carried out by speckle-tracking echocardiography (QLAB 10.7, Philips). Clinical events during the follow-up were: acute heart failure hospitalization, cardiac transplant and all-cause mortality.

Results

Mean age was 59±12, 43.4% were women and 49 patients (64.5%) belonged to group 2 of PH. The median follow-up was 288 (ICR 92–534) days. Total number of events was 42 (55.3%, 9 deaths). Variables associated to events are shown in Table 1. All classic LV and RV systolic function and strain parameters were associated with a worse prognosis, being free-wall RV longitudinal strain (RVLS) the only one that remained as a prognostic factor in mutivariate analysis. Other variables associated with a worse prognosis were PCP>15 mmHg and NT-proBNP>1800, the latter being independent predictor of events. The attached figure shows event-free survival curves for the global population divided according to whether or not they belong to group II PH.

Conclusions

Our data highlight the prognostic value of free-wall RVLS and NT-proBNP in patients with established PH. NT-ProBNP was only useful in group II PH while free-wall RVLS identified patients with a higher risk of events in both groups, mainly in patients with heart disease

Free event survival Curves

Funding Acknowledgement

Type of funding source: None