A proposed algorithm for management of patients with left bundle branch block post-TAVR: 1-year follow-up

Background

Transcatheter aortic valve replacement (TAVR) has revolutionized the management of aortic stenosis and has become the standard of care across a broad spectrum of patients with aortic stenosis. However, it is still associated with high incidence of conduction abnormalities, particularly new left bundle branch block (LBBB). Management of these patients remains a challenge.

Objective

The study sought to assess the clinical outcomes of patients with post-TAVR conduction disorders managed according to a prespecified institutionally developed algorithm.

Methods

A retrospective analysis including all patients undergoing TAVR in our institute between October 2018 and December 2022 was performed. Patients with new LBBB were managed according to the algorithm comprising QRS width and electrophysiology study. In-hospital and 1-year clinical outcomes were assessed.

Results

A total of 230 patients were included in the present analysis. Seventy (30.4%) patients developed new LBBB after TAVR. Overall, 44 (19.1%) patients required permanent pacemaker (PPM) implantation: 20 (8.7%) patients with Mobitz II, complete atrioventricular block, or alternating bundle branch block; 21 (9.1%) patients with persistent new LBBB; and 3 (1.3%) patients per physician discretion. During 1-year follow-up, only 3 patients required late PPM implantation, of whom there was only 1 patient with new LBBB. There was no difference in mortality or heart failure hospitalizations between the per PPM and no PPM groups. Multivariable analysis identified atrial fibrillation, chronic kidney disease, and pre-TAVR right bundle branch block as independent predictors for PPM implantation following TAVR.

Conclusion

Our findings suggest that the presented algorithm may serve as a safe and efficacious strategy for management of patient with post-TAVR LBBB, although the PPM implantation rate may be further reduced.