TAVI is associated with a relevant incidence of conduction system disturbances and the development of atrioventricular block that may require permanent pacemaker implantation. Many patients receive negative chronotropic drugs (beta blockers, non-dihydropyridine calcium channel blockers, or digoxin) due to cardiovascular comorbidities; however, there is concern that their early administration could promote the occurrence of high-grade conduction block. The aim of this study was to evaluate the safety of using negative chronotropic drugs within the first 48 hours after TAVI.
Study characteristics
A retrospective cohort study was conducted at the University of North Carolina Medical Center, including adults who underwent TAVI between January 1, 2016, and April 2, 2024. Patients with a prior pacemaker, baseline second-degree or higher atrioventricular block (AVB), immediate use of a transvenous pacemaker, or the need for inotropes or vasopressors during the first 48 hours were excluded.
The cohort was divided according to whether or not negative chronotropic drugs were administered within the first 48 hours. Although the analysis accounted for baseline conduction disturbances (right bundle branch block, first-degree AVB, among others), prescription of negative chronotropic drugs was not based on a specific protocol in response to new post-TAVI conduction abnormalities, but rather on the clinical judgment of the treating team.
The primary endpoint was the incidence of second-degree or higher AVB at 30 days. Secondary endpoints included the need for permanent pacemaker implantation (at discharge and at 30 days), significant AVB at discharge, all-cause mortality at 30 days, and length of hospital stay.
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Results: Safety of early use of negative chronotropic drugs after transcatheter aortic valve implantation
Of the 990 patients who underwent TAVI, 756 met inclusion criteria; 381 (50.4%) received negative chronotropic drugs within the first 48 hours and 375 (49.6%) did not. The median age was 78 years, and 45.5% were women. Most patients received a balloon-expandable SAPIEN 3 valve (≈82%). Second-degree or higher AVB at 30 days occurred in 2.7% of patients who did not receive negative chronotropic drugs and in 1.6% of those who did (p = 0.297).
No significant differences were observed in AVB at discharge or in pacemaker implantation at 30 days, although there was a trend toward a higher rate of pacemaker implantation at discharge in the group not receiving negative chronotropic drugs (2.7% vs. 0.8%; p = 0.054). There were no differences in 30-day mortality between the two groups. In multivariable analysis, the use of negative chronotropic drugs was associated with a lower likelihood of significant AVB at 30 days (p = 0.048) and a lower need for pacemaker implantation both at 30 days (p = 0.030) and at discharge (p = 0.032).
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Conclusion: Impact of negative chronotropic drugs
In summary, early use of negative chronotropic drugs within the first 48 hours after TAVI was not associated with an increased risk of high-grade AVB or a higher need for pacemaker implantation, and may be considered a reasonable strategy in selected patients, provided that individual risk assessment and appropriate monitoring are ensured.
Original Title: Impact of Early Atrioventricular Nodal Blocker Use Post-Transcatheter Aortic Valve Replacement.
Reference: Jocelyn Edwards, Zachary Carroll, Mikayla Lovelace, Jorden Mandel, Lindsay Carter, Theresa Kline. Catheterization and Cardiovascular Interventions, 2025.
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