Risk Stratification of New Persistent Left Bundle Branch Block After Transcatheter Aortic Valve Implantation

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Previous studies reported that new-onset persistent left bundle branch block (NOP-LBBB) was related to worse outcomes after transcatheter aortic valve implantation (TAVI). However, these results can be confounded by the presence of permanent pacemaker (PPM) implantation before and after TAVI. Long-term outcomes and the risk stratification of NOP-LBBB not having PPM implantation before and after TAVI have not been fully investigated. This is an international, multicenter, retrospective study of patients who underwent TAVI from July 31, 2007, to May 8, 2020. A total of 2,240 patients were included, and 17.5% of patients developed NOP-LBBB. NOP-LBBB was associated with cardiac mortality (adjusted hazard ratio [aHR] 1.419, 95% confidence interval [CI] 1.014 to 1.985, p = 0.041) and the composite outcomes of cardiac mortality and/or heart failure readmission (aHR 1.313, 95% CI 1.027 to 1.678, p = 0.030). Patients who developed NOP-LBBB with pre-TAVI left ventricular ejection fraction (LVEF) <40% were significantly associated with cardiac mortality (aHR 2.049, 95% CI 1.039 to 4.041, p = 0.038), heart failure (aHR 3.990, 95% CI 2.362 to 6.741, p <0.001), and the composite outcome (aHR 2.729, 95% CI 1.703 to 4.374, p <0.001). Although NOP-LBBB with pre-TAVI LVEF >40% had a significant decrease in LVEF 6 to 12 months after TAVI (−1.8 ± 9.7% vs +0.6 ± 8.1%, p = 0.003), NOP-LBBB with pre-TAVI LVEF <40% had a significant increase in LVEF 6 to 12 months after TAVI (+9.7 ± 13.6% vs +13.0 ± 11.7%, p = 0.157). In conclusion, patients with NOP-LBBB without pre-TAVI and post-TAVI PPM developed significantly worse long-term outcomes, especially in patients with pre-TAVI LVEF <40%. Further prospective investigation should be undertaken.

Section snippets

Methods

This is an international, multicenter, retrospective study of consecutive patients who underwent TAVI from July 31, 2007, to May 8, 2020, at the participating hospitals. All patients with preexisting LBBB and cardiac implantable electronic devices (CIEDs) such as PPM, implantable cardioverter-defibrillator, or cardiac resynchronization therapy were excluded from this study, and all CIED implantations after the index TAVI procedure. We collected patient characteristics, pre-TAVI and post-TAVI

Results

At the participating 5 centers during the study duration, 2,240 patients were ultimately included in our analysis (Supplementary Figure 1). The median of the observational period was 1.8 (interquartile range 0.8 to 3.2) years after TAVI, and 393 patients (17.5%) developed NOP-LBBB. The baseline characteristics are listed in Table 1. During the study period, the development of NOP-LBBB was significantly associated with cardiac mortality and the composite outcome of cardiac mortality and/or HF

Discussion

The main findings of the present international, multicenter study are summarized as follows: (1) the development of NOP-LBBB was significantly associated with cardiac mortality and the composite of cardiac mortality and/or HF readmission without cofounding effects from the presence of pre-TAVI and post-TAVI PPM, (2) pre-TAVI LVEF <40% can help stratify the risk of post-TAVI long-term outcomes, and (3) the association of NOP-LBBB and pre-TAVI LVEF <40% was significantly related to worse outcomes.

Disclosures

Dr. Attizzani is a consultant and is on the advisory board of Medtronic. Dr. Mackall has received consulting honoraria from Abbott. Dr. Ohno is a consultant and is on the advisory board of Medtronic. Dr. Kaneko is a consultant/speaker for Edwards Lifesciences, Medtronic, Abbott, Baylis, Cook Medical, 4C medical, and CardioMech. Dr. Barbanti is a consultant for Edwards Lifesciences and an advisory board member for Medtronic. The remaining authors have no conflicts of interest to declare.

References (30)

  • GF Attizzani et al.

    Impact of repositioning on outcomes following transcatheter aortic valve replacement with a self-expandable valve

    JACC Cardiovasc Interv

    (2020)
  • P Vijayaraman et al.

    His-Purkinje conduction system pacing following transcatheter aortic valve replacement: feasibility and safety

    JACC Clin Electrophysiol

    (2020)
  • CR Smith et al.

    PARTNER Trial Investigators. Transcatheter versus surgical 1 replacement in high-risk patients

    N Engl J Med

    (2011)
  • DH Adams et al.

    Transcatheter aortic-valve replacement with a self-expanding prosthesis

    N Engl J Med

    (2014)
  • MB Leon et al.

    PARTNER 2 Investigators. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients

    N Engl J Med

    (2016)
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