Experts Suggest Long Term Monitoring After TAVI To Address Delayed Conduction Problem
Transcatheter aortic valve replacement (TAVR) has revolutionized the management of aortic stenosis worldwide. Recently, concerns have been raised about the increasing number of patients hospitalized for permanent pacemaker implantation (PPMI) late after TAVR. In a recent study, researchers tested two continuous ECG monitoring approaches, post-TAVR and suggested the utility of extended ECG monitoring after discharge, particularly in patients with certain high-risk features. The study findings were published in the JACC: Cardiovascular Interventions on December 27, 2021.
Although many studies have examined various predictors and mitigation strategies of immediate CHB following TAVR, data on the frequency and clinical impact of delayed conduction abnormalities after the procedure are limited. Therefore, Dr Muntané-Carol and colleagues conducted a study to determine the impact of the delayed high-degree atrioventricular block (HAVB) or complete heart block (CHB) after TAVR using a minimalist approach followed by ambulatory electrocardiographic (AECG) monitoring.
In this prospective, multi-centre study, the researchers included 459 consecutive TAVR patients without permanent pacemakers who underwent continuous AECG monitoring for 14 days (median length of hospital stay 2 days), using two devices (CardioSTAT and Zio AT). The major outcome assessed was the occurrence of HAVB or CHB.
The researchers divided the patients into the following 3 groups:
1) no right bundle branch block (RBBB) and no electrocardiographic (ECG) changes;
2) baseline RBBB with no further changes; and
3) new-onset ECG conduction disturbances.
Key findings of the study:
- Upon analysis, the researchers noted that delayed HAVB or CHB episodes occurred in 21 patients (4.6%; median 5 days post-procedure; IQR: 4-6 days), leading to permanent pacemaker implantation in 17 (81.0%).
- They further noted that HAVB or CHB events were rare in group 1 (7 of 315 [2.2%]), and the incidence increased in group 2 (5 of 38 [13.2%]) and group 3 (9 of 106 [8.5%]).
- They observed no episodes of sudden or all-cause death occurred at 30-day follow-up.
The authors concluded, "Systematic 2-week AECG monitoring following minimalist TAVR detected HAVB and CHB episodes in about 5% of cases, with no mortality at 1 month. Whereas HAVB or CHB was rare in patients without ECG changes post-TAVR, baseline RBBB and new-onset conduction disturbances determined an increased risk. These results would support tailored management using AECG monitoring and the possibility of longer hospitalization periods in patients at higher risk for delayed HAVB or CHB."
In an accompanying editorial, Dr Mohamad Alkhouli wrote, "However, futuristic innovations in smart devices, mini-sensors, and removable or dissolvable pacemakers are expected to move the field toward a 'long-term monitoring for all, prophylactic pacemaker implantation for some' strategy to address the growing concerns about delayed and very delayed conduction disturbances after the procedure."
For further information:
Muntané-Carol G, Okoh AK, Chen C, et al. Ambulatory Electrocardiographic Monitoring Following Minimalist Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2021;14:2711-2722.
