How to manage a new Left Bundle Branch Block (LBBB) in a patient scheduled for Transcatheter Aortic Valve Replacement (TAVR)?

From the Guidelines

Managing a new Left Bundle Branch Block (LBBB) in a patient scheduled for Transcatheter Aortic Valve Replacement (TAVR) requires careful monitoring and consideration for prophylactic pacemaker implantation, with a focus on minimizing manipulation of the conduction system during TAVR and implementing enhanced cardiac monitoring for at least 48-72 hours post-procedure, as recommended by the 2020 ACC expert consensus decision pathway on management of conduction disturbances in patients undergoing TAVR 1.

Key Considerations

• For patients who develop new LBBB prior to TAVR, proceed with the scheduled procedure but implement enhanced cardiac monitoring for at least 48-72 hours post-procedure.
• During TAVR, minimize manipulation of the conduction system by careful valve positioning and appropriate valve sizing.
• After TAVR, if the patient has a new LBBB, continuous electrocardiographic monitoring is essential for at least 48 hours to detect progression to higher-degree atrioventricular block.
• Patients with persistent LBBB after TAVR, especially with a PR interval >240 ms, QRS duration >150 ms, or first-degree AV block, should be considered for prophylactic permanent pacemaker implantation before discharge, as suggested by the 2020 ACC expert consensus decision pathway on management of conduction disturbances in patients undergoing TAVR 1.

Rationale

The development of LBBB after TAVR indicates damage to the conduction system, which can progress to complete heart block due to the proximity of the aortic valve to the conduction system, as noted in the 2020 ACC expert consensus decision pathway on management of conduction disturbances in patients undergoing TAVR 1. The mechanical pressure from valve deployment can further compromise conduction, particularly in patients with pre-existing conduction abnormalities, making vigilant monitoring and timely intervention crucial for preventing sudden cardiac events, as highlighted in the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1.

Monitoring and Pacemaker Implantation

• The 2020 ACC expert consensus decision pathway on management of conduction disturbances in patients undergoing TAVR recommends that patients with new LBBB after TAVR should be monitored for at least 48 hours to detect progression to higher-degree atrioventricular block 1.
• The decision to implant a permanent pacemaker should be based on the presence of symptoms that correlate with atrioventricular block, as well as the presence of high-degree atrioventricular block or symptomatic bradycardia, as recommended by the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1.
• The use of ambulatory event monitoring (AEM) or implantable loop recorders may be considered for patients with new LBBB after TAVR, as suggested by the 2020 ACC expert consensus decision pathway on management of conduction disturbances in patients undergoing TAVR 1.

Conclusion is not allowed, so the response ends here.

From the Research

Management of New Left Bundle Branch Block (LBBB) in TAVR Patients

• The development of new-onset LBBB after Transcatheter Aortic Valve Replacement (TAVR) is associated with worse clinical outcomes, including higher rates of permanent pacemaker (PPM) requirement, heart failure hospitalizations, and decreased left ventricular ejection fraction (LVEF) 2, 3.
• Patients with new-onset LBBB after TAVR have a longer length of stay and higher rates of 30-day PPM requirement and 1-year heart failure hospitalizations compared to those without LBBB 2.
• The presence of new-onset LBBB after TAVR is also associated with adverse long-term clinical outcomes, including increased rates of all-cause mortality, cardiovascular mortality, and rehospitalization 3.
• The management of LBBB after TAVR is currently not defined by international societies, resulting in individual centers developing their own management strategy 4.
• Prompt postprocedural recognition and management of patients with new-onset LBBB, including permanent pacemaker implantation, may prevent potential complications and constitute the preferred approach in this frail and elderly population 4.

Risk Stratification and Outcomes

• New-onset persistent LBBB (NOP-LBBB) after TAVR is associated with cardiac mortality and the composite outcomes of cardiac mortality and/or heart failure readmission 5.
• Patients who develop NOP-LBBB with pre-TAVR LVEF <40% are significantly associated with cardiac mortality, heart failure, and the composite outcome 5.
• The development of new conduction abnormalities, such as LBBB or the need for PPM, induces a decline in LVEF post-TAVR, emphasizing the importance of long-term monitoring of left ventricular function in these patients 6.

Clinical Implications

• The presence of new-onset LBBB after TAVR should prompt close monitoring and management to prevent potential complications and improve clinical outcomes 2, 3, 4.
• Further prospective investigation is needed to fully understand the long-term outcomes and risk stratification of patients with new-onset LBBB after TAVR 5.