The safety and efficacy of transcatheter aortic valve replacement (TAVR) is already established. However, it still poses a challenge for conduction disturbances, such as the need for pacemaker or new onset left bundle branch block (LBBB). The current rate for the latter ranges from approximately 11% to 19%.
In most cases, 50% of LBBB reverses in the first 24 to 48 hours after implantation, but if it is definitive, plenty of evidence suggests that it would have a deleterious effect, increasing morbidity and deteriorating ventricular function.
This study included 612 patients who received a SAPIEN 3 (S3) valve between 2015 and 2018 at the Cleveland Clinic. Among them, 70 had LBBB (11.4%).
Patient mean age was 80 years; 54% of patients were men, 89% had hypertension, 3% had diabetes, 2% required dialysis, 28% had undergone PCI, 20% had undergone CRM, 12.9% had a stroke, and 37% had COPD. Ejection fraction was preserved.
The Society of Thoracic Surgeons mortality score was 5.7%.
Those who developed new onset LBBB had a higher QRS (97.3 ± 9.9 vs.93.5 ± 10.9 ms; p = 0.005), and greater implant depth (3.5 ± 2 vs. 2.2 ± 1.8 mm; p < 0.001), and more frequently received a 29-mm valve (41.4% vs. 22.3%; p = 0.003).
The rates of in-hospital stay were higher for those with new onset LBBB.
At 30 days and at 1 year, the need for a permanent pacemaker was greater in those who experienced new onset LBBB (18.6% vs. 5.4%; p < 0.001 and 23.2% vs. 7%; p = 0.030, respectively).
There were no differences in mortality at 30 days, a year, and 3 years of follow-up.
At 12 months, hospitalizations for heart failure were higher in those with new onset LBBB (10.7% vs. 4.4%; p = 0.033).
Left ventricular ejection fraction at 30 days and at 1 year was lower in those who developed new onset LBBB (55.9 ± 11.4% vs. 9%; p = 0.026 and 12% vs. 60.1 ± 8.9%; p = 0.002 respectively), regardless of whether they had an ejection fraction > or < 50%, as well as end-diastolic indexed volume (51.4 ± 18.6 vs. 46.4 ± 15.1 ml/ M2; p = 0.036) and end-systole indexed volume (23.2 ± 14.1 vs. 18.9 ± 9.7 ml/m2; p = 0.009).
Read also: Resistant Obstructive Hypertrophic Cardiomyopathy: Myomectomy or Septal Ablation?
In a multivariate regression analysis, implant depth was the only predictor of new onset LBBB.
Conclusion
New onset LBBB after TAVR with SAPIEN 3 was associated with increased need for permanent pacemaker, worse left ventricular function, larger ventricular volumes, and increased rates of hospitalization due to heart failure, with no difference in mortality.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Clinical and echocardiographic outcomes with new‐onset left bundle branch block after SAPIEN‐3 transcatheter aortic valve replacement.
Reference: Yasser M. Sammour, et al. Catheter Cardiovasc Interv. 2023;101:187–196.
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