In some cases, full atrioventricular (AV) block occurs beyond two days after transcatheter aortic valve replacement (TAVR). This highlights the usefulness of extending monitoring after discharge, particularly in patients who tolerated the procedure well, but meet high-risk criteria.
We have made great progress regarding conduction disorders in TAVR, especially after the publication of the consensus that unified criteria. However, all blocks that occur beyond 2 days continue to be a challenge.
Two studies recently published in JACC Interventions analyzed the usefulness of electrocardiographic monitoring after discharge.
In one of the papers, up to 4.6% of cases of complete or high-grade AV block within 14 days were diagnosed using ambulatory monitoring. The other study went further in time: after one year of monitoring, 11.9% of cases of complete or high-grade block were identified. In the latter, the device was implantable, with everything that entails.
Post-TAVR ambulatory electrocardiographic monitoring is the most conservative and minimalist option.
The first study included almost 500 patients with no permanent pacemaker who were monitored continuously for 14 days after discharge. Monitoring was performed using two leads, as suggested by the consensus.
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High-grade or complete block was observed in approximately 1 in 20 patients in the monitored population. Of these, 81% ended up with a permanent pacemaker.
These new disorders were relatively rare (2.2%) in the lower-risk group as defined by the consensus (no changes from the baseline ECG). For those at higher risk (previous right bundle branch block), the rate of block in those 14 days was 13.2%. Finally, the intermediate group (new conduction disorder) reached 8.5%.
No sudden death was recorded within 30 days of implantation.
The other study included 59 patients who underwent an invasive electrophysiological study and, after remaining the first 48 hours of the procedure without conduction disorders, had a recorder implanted for one year.
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This type of monitoring identified 11.9% of patients with delayed blocks. Of the seven patients who presented conduction disorders, five did so within 8 days of the procedure, while the remaining two developed conduction disorders beyond 3 months.
It is important to note that, in 5 patients, the block could only be diagnosed by the implantable device and not by the surface ECG. The electrophysiological study and the implantable recorder are not cost-effective in the general population undergoing TAVR.
Whether ambulatory monitoring in post-TAVR patients yields protection against events such as sudden death remains to be proven.
Original Title: Ambulatory electrocardiographic monitoring following minimalist transcatheter aortic valve replacement.
Reference: Guillem Muntané-Carol et al. JACC Cardiovasc Interv. 2021 Dec 27;14(24):2711-2722. doi: 10.1016/j.jcin.2021.08.039.
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