Post-TAVR conduction abnormalities tied to worse outcomes

A prospective, single-center study from Denmark suggests nearly half of patients develop a new conduction abnormality after transcatheter aortic valve replacement (TAVR), impacting their short-term and long-term prognosis.

The study, based at Copenhagen University Hospital, enrolled 816 consecutive TAVR patients without pre-procedural bundle branch block (BBB) or permanent pacemakers (PPMs). Thirty percent of patients developed new BBB and another 16.2 percent required a PPM within 30 days of TAVR, leaving 53.6 percent without conduction abnormalities.

And while previous studies were inconsistent in whether BBB or PPM implantation were associated with adverse outcomes, lead author Troels H. Jorgensen, MD, and colleagues found that both increased the risk for heart failure hospitalizations and mortality during the median 2.5 years of follow-up.

  • Compared to no conduction abnormalities, BBB was associated with 2.8 times the risk of all-cause mortality at one year and 1.79 times the risk of death after one year.
  • PPM wasn’t significantly associated with all-cause mortality at one year but was linked to a 58 percent greater risk beyond one year.
  • New BBB (hazard ratio: 1.47) and PPM (HR: 1.66) were each associated with a higher risk for heart failure hospitalization during follow-up.
  • Both indications of conduction abnormalities (CAs) were associated with reduced left ventricular ejection fraction (LVEF).

“In the present study, PPM implantation seemed beneficial in case of new CAs, maybe protecting from early sudden cardiac death,” Jorgensen and co-authors wrote in JACC: Cardiovascular Interventions. “However, the increased risk for heart failure hospitalization and low LVEF at follow-up for both patients with new BBB and new PPM could be a cofactor in the increased risk for late mortality observed in these patients compared with those with no CAs.

“Thus, neither new BBB nor new PPM appears benign in the long term, indicating that prevention is the best long-term treatment of TAVR-induced CAs and that these patients may benefit from closer follow-up.”

The authors said their findings may be discordant with previous studies because prior reports included different patient populations, including individuals with more comorbidities or left BBB (LBBB) in the comparator group.

These results are also important to analyze in relation to paravalvular regurgitation (PVR) after TAVR, which was previously termed the “Achilles’ heel” of the procedure.

“Both manufacturers and operators have had a strong focus on reducing the rate of PVR. However, preventive measures against PVR, such as the introduction of sealing skirts, more liberal THV (transcatheter heart valve) oversizing, and post-dilation, are risk factors for the development of conduction abnormalities after TAVR,” Jorgensen and colleagues wrote.

Future large-scale studies should further investigate the associations between CAs and downstream clinical outcomes, the authors recommended.

“Furthermore, procedural planning and selection of THV may reduce the risk for the development of CAs without increasing the risk for PVR, which might be of significant value for long-term outcome after TAVR,” Jorgensen et al. wrote.