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Kusumoto et al 2018 Bradycardia Clinical Practice Guidelines

August 20, 2019 Circulation. 2019;140:e382–e482. DOI: 10.1161/CIR.0000000000000628 e442

CLINICAL STATEMENTS AND GUIDELINES IIa B-NR 2.  In patients with new persistent bundle branch block after transcatheter aortic valve replacement, careful surveillance for bradycardia is reasonable.S8.1.2.4-5,S8.1.2.4-6

IIb B-NR 3.  In patients with new persistent LBBB after transcatheter aortic valve replacement, implantation of a PPM may be considered.S8.1.2.4-4,S8.1.2.4-7–S8.1.2.4-10

Synopsis

At time of writing, the literature on conduction disturbance after transcatheter aortic valve replacement (TAVR) is replete with thousands of case series, multiple reports from larger registries, a few meta-analyses, and no prospective RCTs of PPM implantation. Before TAVR predictors for PPM implant include preexisting RBBB, increased prosthesis to left ventricular outflow tract ratio, and increased left ventricular end-diastolic diameter.S8.1.2.4-8 After TAVR, new LBBB occurs in 19% to 55% of patientsS8.1.2.4-1,S8.1.2.4-3,S8.1.2.4-11 and new high-degree atrioventricular block in approximately 10% of patients.S8.1.2.4-12 Up to half of new bundle branch blockS8.1.2.4-1 and complete heart blockS8.1.2.4-7 can be expected to resolve before discharge. Further, only half of patients with a new PPM after TAVR will be pacer dependent at follow-up although that does not necessarily imply that pacing is not needed, as intermittent atrioventricular block may be present.S8.1.2.4-13 The likelihood of new conduction disturbances depends on patient and procedural factors.S8.1.2.4-7,S8.1.2.4-8 After TAVR, new RBBB is associated with increased risk of PPM implantation and increased late all-cause mortality and cardiac mortality independent on whether a new PPM was implanted.S8.1.2.4-5,S8.1.2.4-8,S8.1.2.4-14,S8.1.2.4-15 Although most studies show that new LBBB after TAVRS8.1.2.4-4,S8.1.2.4-9,S8.1.2.4-10 is associated with a higher risk of new PPM, studies are mixed as to whether new LBBB is a predictor of late mortality. What is clear is that early PPM for new LBBB is not protective against the increased mortality.S8.1.2.4-4,S8.1.2.4-16,S8.1.2.4-17 Although it may be considered, at the time of this writing, it is unclear whether patients with new bundle branch block that persists when the patient is ready for discharge will benefit from pacer implantation during the index hospitalization.S8.1.2.4-4,S8.1.2.4-7–S8.1.2.4-10

Recommendation-Specific Supportive Text

1.	 High-degree atrioventricular block is most commonly observed in the immediate periprocedural period but will persist beyond 48 hours in 2% to 20% of patients.S8.1.2.4-1,S8.1.2.4-7,S8.1.2.4-8 In older studies, rates of PPM implant after TAVR ranged from 2% 51%, but with rapidly evolving technology and newer implant strategies, there has been a general decrease in the requirements for pacemaker implantation after TAVR.S8.1.2.4-2–S8.1.2.4-

4,S8.1.2.4-7 In 1 study, at follow-up, 52% of patients were continuously paced, but 22% of patients had recovery of atrioventricular conduction and no longer required pacing for rate support.S8.1.2.4-3 Specific timing of pacemaker implant has not been formally studied and will always depend on the individual clinical situation. In published reports, the range for pacemaker implantation after TAVR has varied from 2 days to several weeks with a median of approximately 3 days.S8.1.2.4-2–S8.1.2.4-4,S8.1.2.4-7 2.	 Patients with new bundle branch block after TAVR may be at risk for syncope and development of atrioventricular block. In 29% of patients with new LBBB the first episode of high-degree atrioventricular block occurs after discharge with associated potential risk for syncope.S8.1.2.4-6 Careful surveillance for bradycardia is appropriate. Although different monitoring modalities, durations and intervals are available, to date no specific method or protocol has been proven to be superior. Further investigation in this area is needed. Institutions should choose the monitoring modality and protocol according to availability and expertise at the individual institution. 3.	 New LBBB occurs in approximately 10% of patients after TAVR and will resolve in approximately 50% at 6 to 12 months.S8.1.2.4-8 Patients with new persistent LBBB after TAVR are at increased risk for needing a PPM both perioperatively and after discharge.S8.1.2.4-4,S8.1.2.4-10 Studies have been inconsistent on the implications of new LBBB after TAVR with some studies showing lower survival and others reporting no increased risk of death or repeat hospitalization.S8.1.2.4-4,S8.1.2.4-18 Preprocedural conduction abnormalities, particularly RBBB, are associated with increased risk of PPM after TAVR.S8.1.2.4-19,S8.1.2.4-20 In 1 study an HV interval ≥65 ms after TAVR was modestly predictive for the development of high-grade atrioventricular block in the setting of new LBBB after TAVR (sensitivity, 80%; specificity, 79%).S8.1.2.4-21 8.1.2.5. Heart Transplant, Surgical Myectomy, and Alcohol Septal Ablation 8.1.2.5.1. After Heart Transplant.  With the adoption of bicaval heart transplant anastomoses rather than biatrial anastomoses the pacemaker rate has decreased from 10% to 14% to 2% to 4%.S8.1.2.5.1-1–S8.1.2.5.1-4 SND remains the most common cause for bradycardia accounting

Recommendations for Conduction Disturbances After Transcatheter Aortic Valve Replacement (Continued)

COR LOE Recommendations

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