Intraprocedural dynamics of cardiac conduction during transcatheter aortic valve implantation: Assessment by simultaneous electrophysiological testing

doi:10.1016/j.hrthm.2020.10.018

Heart Rhythm

Volume 18, Issue 3, March 2021, Pages 419-425

https://doi.org/10.1016/j.hrthm.2020.10.018 Get rights and content

Background

Transcatheter aortic valve implantation (TAVI) is an established treatment for patients with severe aortic stenosis and high to intermediate surgical risk. However, the proximity of the conduction system to the prosthesis landing zone bears the risk of atrioventricular conduction disorders. The underlying pathophysiology is not fully understood.

Objective

The purpose of this study was to characterize the impact of TAVI on the conduction system as assessed by simultaneous electrophysiological testing.

Methods

AH and HV intervals and QRS duration were measured using a quadripolar His catheter and surface electrocardiogram in 108 patients at baseline (BL), after balloon predilation (timepoint 1 [T1]), after implantation of the valve prosthesis (T2), and after postdilation, if deemed necessary (T3).

Results

Between BL and T2, significant increases of HV interval and QRS duration were observed, with a mean delta of +12.4 ms and +32.7 ms, respectively. Both balloon predilation and valve implantation had an impact on infranodal conduction. No significant increase of AH intervals was documented. The increase of QRS duration led to left bundle branch block (LBBB) in 57 patients (52.8%). Implantation depth positively correlated with QRS prolongation (ρ = 0.21, P = .042) but not with changes of AH or HV interval (ρ = –0.03, P = .762; and ρ = 0.15, P = .130, respectively).

Conclusion

Electrophysiological testing during TAVI shows impairment of infranodal atrioventricular conduction by balloon predilation and valve implantation. This impairment is positively correlated with valve implantation depth and results in an increase of QRS duration with mainly LBBB pattern on surface electrocardiogram.

Introduction

Transcatheter aortic valve implantation (TAVI) is an established treatment method for patients with severe aortic stenosis and high to intermediate surgical risk.1, 2, 3 However, the proximity of the cardiac conduction system to the prosthesis landing zone bears the risk of conduction abnormalities, such as atrioventricular (AV) block and/or left bundle branch block (LBBB).⁴^,⁵ The pathophysiological mechanisms behind the impairment of the conduction system are not fully understood.

The rate of conduction disorders requiring pacemaker implantation is higher after TAVI compared to surgical aortic valve replacement (7%–43% vs 7%) and in self-expandable compared to balloon-expandable valve prostheses (median 28% vs 6%).6, 7, 8, 9

Total AV block is a class I indication for pacemaker implantation, whereas other conduction disturbances such as first-degree AV block or its combination with right bundle branch block (RBBB) or LBBB are not.¹⁰ However, these disorders have a certain risk of progression to total AV block, especially when they occur after structural cardiac interventions such as TAVI. Recommendations for the duration of rhythm monitoring or uniform indications for prophylactic pacemaker implantation after TAVI are not available. Although different predictors of the development of total AV block have been described, including peri-interventional increase of PR interval >40 ms,¹¹ pre-existing or new-onset RBBB or LBBB,⁹^,¹¹^,¹² aortic annular or left ventricular outflow tract (LVOT) calcification,¹³ type of valve prosthesis, depth of implantation, and oversizing,12, 13, 14 data are too scarce to draw clinically relevant conclusions.

Three clinical trials that included electrophysiological (EP) testing before and after TAVI showed distinct prolongations of AV conduction.15, 16, 17 However, to our knowledge, a simultaneous intraprocedural evaluation has never been performed before.

The aim of our study was to characterize the impact of each key procedural step (predilation, valve implantation, postdilation) of TAVI on AH and HV intervals as well as QRS duration by simultaneous EP testing and 12-lead electrocardiographic tracings.

Section snippets

Methods

The study was designed as a prospective, nonrandomized, single-center, single-cohort pilot trial and was conducted in accordance with the Declaration of Helsinki. The study protocol was approved by the Ethics Committee of the Federal State of Upper Austria. Before enrollment in the study, all subjects provided written informed consent.

Baseline characteristics

Baseline characteristics of 108 consecutive study patients are listed in Table 1, and the rates of conduction disorders at baseline are listed in Table 2. According to the inclusion criteria, all patients were in sinus rhythm at baseline.

EP testing was successfully conducted in all 108 individuals. The AH interval could be measured in all but 1 patient, in whom sudden onset of persistent atrial fibrillation occurred before EP testing. Ten patients developed total AV block (1 after balloon

Discussion

The present study aimed to evaluate the impact of major interventional steps of TAVI on AH and HV intervals and QRS duration as assessed by intraprocedural EP testing. Three main findings emerged from this study. First, simultaneous measurement of AH and HV intervals via a quadripolar His catheter during TAVI is a feasible, safe, and effective option for assessment of its impact on the cardiac conduction system. Second, both balloon dilation of the native calcified aortic valve as well as

Conclusion

As assessed by simultaneous EP testing, TAVI procedures with self-expandable valve prostheses significantly affect the infranodal conduction system but not the AV node itself. Implantation depth correlates with new-onset LBBB but not total AV block during TAVI. The significant increases in HV intervals and QRS duration place patients at risk for delayed occurrence of total AV block and/or bundle branch block–related deterioration of ventricular function, which both result in worse long-term

Acknowledgments

The authors thank EP technicians Martin Patrasso and Roman Kneidinger for their support in performing EP testing during TAVI.

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Cited by (7)

Impact of implantation depth and calcium burden on infranodal conduction delay after transcatheter aortic valve replacement
2024, Heart Rhythm O2
Infranodal conduction disorders are common after transcatheter aortic valve replacement (TAVR). Risk factors are incompletely understood.
The purpose of this study was to assess the impact of valve implantation depth and calcium burden of the device landing zone on infranodal conduction intraprocedure pre- and post-TAVR.
In all patients undergoing TAVR between June 2020 and June 2021, the His-ventricle (HV) interval was measured pre- and post-valve deployment. The difference between the 2 measurements defined delta HV, whereas infranodal conduction delay was defined as HV interval >55 ms. Valve implantation depth was measured as the distance between the aortic annular plane and the ventricular prosthesis end. Calcium burden was quantified as the volume of calcium in 6 regions of interest: the non-, right, and left coronary cusps (NCC, RCC, and LCC, respectively) and the corresponding regions of the left ventricular outflow tract (LVOT) underlying each cusp (LVOT_NCC, LVOT_RCC, LVOT_LCC, respectively).
Of 101 patients (mean age 81 ± 5.7 years; 47% women), 37 demonstrated infranodal conduction delay intraprocedure post-TAVR. Overall, mean implantation depth was 5 ± 3.1 mm, median calcium volume was 2080 mm³ [interquartile range 632–2400]. Delta HV showed no correlation with implantation depth or calcium burden (r = –0.08 and r = 0.12, respectively). However, LVOT_NCC calcification was a significant predictor for infranodal conduction delay post-valve deployment in a multivariable logistic regression model (odds ratio 1.62 per 100-mm³ increase (95% confidence interval 1.06–2.69; P = .04).
Assessment of LVOT_NCC calcification may identify patients at risk for infranodal conduction delay after TAVR, whereas implantation depth did not predict infranodal conduction delay.
Invasive electrophysiological testing to predict and guide permanent pacemaker implantation after transcatheter aortic valve implantation: A meta-analysis
2023, Heart Rhythm O2
Citation Excerpt :
The literature search identified 657 potentially eligible studies, of which 24 were further evaluated in full text. A total of 18 studies21–38 with 1230 patients (mean 68 patients per study) reporting on nonoverlapping patient populations were considered eligible (Supplemental Material Section 2). The characteristics of the included studies and patients are summarized in Tables 1 and 2.
Atrioventricular conduction abnormalities after transcatheter aortic valve implantation (TAVI) are common. The value of electrophysiological study (EPS) for risk stratification of high-grade atrioventricular block (HG-AVB) and guidance of permanent pacemaker (PPM) implantation is poorly defined.
The purpose of this study was to identify EPS parameters associated with HG-AVB and determine the value of EPS-guided PPM implantation after TAVI.
We performed a systematic review and meta-analysis of studies investigating the value of EPS parameters for risk stratification of TAVI-related HG-AVB and for guidance of PPM implantation among patients with equivocal PPM indications after TAVI.
Eighteen studies (1230 patients) were eligible. In 7 studies, EPS was performed only after TAVI, whereas in 11 studies EPS was performed both before and after TAVI. Overall PPM implantation rate for HG-AVB was 16%. AV conduction intervals prolonged after TAVI, with the AH and HV intervals showing the largest magnitude of changes. Pre-TAVI HV >70 ms and the absolute value of the post-TAVI HV interval were associated with subsequent HG-AVB and PPM implantation with odds ratios of 2.53 (95% confidence interval [CI] 1.11–5.81; P = .04) and 1.10 (95% CI 1.03–1.17; P = .02; per 1-ms increase), respectively. In 10 studies, PPM was also implanted due to abnormal EPS findings in patients with equivocal PPM indications post-TAVI (typically new left bundle branch block or transient HG-AVB). Among them, the rate of long-term PPM dependency was 57%.
Selective EPS testing may assist in the risk stratification of post-TAVI HG-AVB and in the guidance of PPM implantation, especially in patients with equivocal PPM indications post-TAVI.
Delayed Total Atrioventricular Block After Transcatheter Aortic Valve Replacement Assessed by Implantable Loop Recorders
2021, JACC: Cardiovascular Interventions
Citation Excerpt :
These conduction system structures are prone to damage from mechanical impact caused by balloon predilation, valve implantation, and, in the case of self-expanding protheses, Nitinol cage–derived radial force. In contrast to the His bundle and the left bundle branch, the compact AV node seems not to be affected by TAVR, as we previously demonstrated by simultaneous EP testing (16). Total AVB requiring PPM implantation often occurs within 1 to 2 days after TAVR but can have an even later onset in up to 30% of all cases (19,20).
The aims of this study were to evaluate the rate and time course of delayed total atrioventricular block (DT-AVB) after transcatheter aortic valve replacement (TAVR) using continuous electrocardiographic monitoring by implantable loop recorders and to identify potential predictors.
DT-AVB has been defined as onset more than 2 days after TAVR or after hospital discharge and is reported in 10% to 15% of patients at 30-day follow-up. To date, there is no standardized diagnostic and therapeutic algorithm to manage TAVR patients at risk for DT-AVB.
Consecutive patients undergoing TAVR and simultaneous electrophysiologic testing without persistent or recurrent total atrioventricular block within 48 hours after the procedure underwent loop recorder implantation for full disclosure of atrioventricular conduction during 12-month follow-up.
DT-AVB occurred in 7 of 59 patients (11.9%), with onset between 2 days and 3 months after the procedure. Both prolongation of the PQ interval between baseline and day 2 after TAVR (OR: 1.04; 95% CI: 1.01-1.09); P = 0.032) and prolongation of the HV interval during the procedure (OR: 1.07; 95% CI: 1.02-1.14; P = 0.015) significantly predicted the onset of DT-AVB.
TAVR was associated with a considerable rate of DT-AVB of nearly 12% in this series. Prolongation of the PQ interval between baseline and day 2 and intraprocedural prolongation of the HV interval were significant predictors of DT-AVB.
The QRS frontal plane axis changes during left bundle branch block after transcatheter aortic valve replacement
2023, PACE - Pacing and Clinical Electrophysiology
The R-wave amplitude in V1 on baseline electrocardiogram correlates with the occurrence of high-degree atrioventricular block following left bundle branch block after transcatheter aortic valve replacement
2023, Europace
Evaluation of the 2021 European Society of Cardiology guidelines in pre-existing right bundle branch block patients undergoing transcatheter aortic valve implantation with a balloon-expandable valve
2022, European Heart Journal Open

View all citing articles on Scopus

: Funding sources: The authors have no funding sources to disclose. Disclosures: The authors have no conflicts of interest or relationships relevant to the contents of this paper to disclose.

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ClinicalGeneralIntraprocedural dynamics of cardiac conduction during transcatheter aortic valve implantation: Assessment by simultaneous electrophysiological testing

Background

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Baseline characteristics

Discussion

Conclusion

Acknowledgments

JACC Cardiovasc Interv

JACC Cardiovasc Interv

J Am Coll Cardiol

JACC Cardiovasc Interv

JACC Cardiovasc Interv

Heart Rhythm

Int J Cardiol

J Am Coll Cardiol Interv

J Cardiol

Can J Cardiol

JACC Cardiovasc Interv

Am J Cardiol

Interv Cardiol Clin

J Am Coll Cardiol Intv

Transcatheter aortic valve-implantation for aortic stenosis in patients who cannot undergo surgery

N Engl J Med

Transcatheter or surgical aortic-valve replacement in intermediate-risk patients

N Engl J Med

Clinical
General
Intraprocedural dynamics of cardiac conduction during transcatheter aortic valve implantation: Assessment by simultaneous electrophysiological testing