Ambulatory Rhythm Monitoring to Detect Late High-Grade Atrioventricular Block Following Transcatheter Aortic Valve Replacement

• Published in: Journal of the American College of Cardiology Vol. 73; no. 20; pp. 2538 - 2547
• Main Authors: Ream, Karen, Sandhu, Amneet, Valle, Javier, Weber, Rachel, Kaizer, Alexander, Wiktor, Dominik M., Borne, Ryan T., Tumolo, Alexis Z., Kunkel, Megan, Zipse, Matthew M., Schuller, Joseph, Tompkins, Christine, Rosenberg, Michael, Nguyen, Duy T., Cleveland, Joseph C., Fullerton, David, Carroll, John D., Messenger, John, Sauer, William H., Aleong, Ryan G., Tzou, Wendy S.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 28-05-2019; Elsevier Limited
• Subjects: Aged; ambulatory event monitoring; Aortic valve; Aortic Valve - surgery; Aortic Valve Stenosis - surgery; Atrioventricular Block - diagnosis; Atrioventricular Block - epidemiology; Atrioventricular Block - physiopathology; Cardiac arrhythmia; Cardiology; Cardiomyopathy; Colorado - epidemiology; complete heart block; Diabetes; Discharge; Electrocardiography; Electrocardiography, Ambulatory - methods; Female; Follow-Up Studies; Heart; Hospitals; Humans; Hypertension; Identification methods; Implantation; Incidence; Kidney diseases; Male; Monitoring; Mortality; pacemaker; Patients; Postoperative Complications; Prospective Studies; Reproducibility of Results; Risk analysis; Risk Factors; Sensitivity; Sensitivity analysis; Survival Rate - trends; Telemetry; Time Factors; transcatheter aortic valve replacement; Transcatheter Aortic Valve Replacement - adverse effects; Colorado; United States > US; DH-AVB; pacemaker; H-AVB; ambulatory event monitoring; RBBB; transcatheter aortic valve replacement; AEM; ICD; complete heart block; PPM; AVB; TAVR
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2019.02.068

High-grade atrioventricular block (H-AVB) is a well-described in-hospital complication of transcatheter aortic valve replacement (TAVR). Delayed high-grade atrioventricular block (DH-AVB) has not been systematically studied among outpatients post-TAVR, using latest-generation TAVR technology and in the early post-TAVR discharge era.
The purpose of this study was to assess utility of ambulatory event monitoring (AEM) in identifying post-TAVR DH-AVB and associated risk factors.
Patients without pre-existing pacing device undergoing TAVR at the University of Colorado Hospital from October 2016 to March 2018, and who did not require permanent pacemaker implantation pre-discharge, were discharged with 30-day AEM to assess for DH-AVB (≥2 days post-TAVR). Clinical and follow-up data were collected and compared among those without incident H-AVB.
Among 150 consecutive TAVR patients without a prior pacing device, 18 (12%) developed H-AVB necessitating permanent pacemaker <2 days post-TAVR, 1 died pre-discharge, and 13 declined AEM; 118 had 30-day AEM data. DH-AVB occurred in 12 (10% of AEM patients, 8% of total cohort) a median of 6 days (range 3 to 24 days) post-TAVR. DH-AVB versus non-AVB patients were more likely to have hypertension and right bundle branch block (RBBB). Sensitivity and specificity of RBBB in predicting DH-AVB was 27% and 94%, respectively.
DH-AVB is an underappreciated complication of TAVR among patients without pre-procedure pacing devices, occurring at rates similar to in-hospital, acute post-TAVR H-AVB. RBBB is a risk factor for DH-AVB but has poor sensitivity, and other predictors remain unclear. In this single-center analysis, AEM was helpful in expeditious identification and treatment of 10% of post-TAVR outpatients. Prospective study is needed to clarify incidence, risk factors, and patient selection for outpatient monitoring.
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