What percentage of patients develop heart block after Transcatheter Aortic Valve Replacement (TAVR)?

From the Guidelines

Approximately 15% of patients develop heart block after Transcatheter Aortic Valve Replacement (TAVR), with permanent pacemaker implantation required in a significant portion of these cases. The risk of heart block after TAVR is influenced by several factors, including the type of valve used, pre-existing conduction abnormalities, and anatomical considerations.

• The type of valve used plays a significant role, with self-expanding valves like CoreValve having higher rates of heart block compared to balloon-expandable valves like SAPIEN 1.
• Patients with pre-existing right bundle branch block (RBBB) are at particularly high risk, with rates of complete heart block approaching 24% 1.
• The mechanism involves mechanical trauma to the conduction system, as the aortic valve sits in close proximity to the bundle of His and left bundle branch.
• Heart block typically develops within 24-48 hours post-procedure, though delayed conduction disturbances can occur up to 7 days later 1.
• This risk necessitates careful ECG monitoring after TAVR, with some centers implementing extended monitoring protocols for high-risk patients.
• The majority of conduction disturbances occur early, which is why close monitoring in the immediate post-procedural period is essential.
• A recent study found that patients who did not develop pacing-induced Wenckebach AV block have a very low need for permanent pacing, highlighting the importance of individualized monitoring and management strategies 1.

From the Research

Incidence of Heart Block after TAVR

• The incidence of heart block after Transcatheter Aortic Valve Replacement (TAVR) varies, with studies reporting different percentages of patients developing this condition.
• According to a study published in 2017 2, approximately 9% of patients (54 out of 578) required permanent pacemakers for high-degree atrioventricular block (HD-AVB) after TAVR.
• Another study published in 2021 3 reported an incidence of 16.1% (153 out of 953 patients) of high-grade atrioventricular block (HAVB) after TAVR.
• A more recent study published in 2022 4 found that 29.4% (10 out of 34 patients) with new-onset left bundle branch block (LBBB) after TAVR developed clinically significant heart block.

Predictors of Heart Block after TAVR

• Several studies have identified predictors of heart block after TAVR, including:

• Age 2
• Right bundle branch block 2
• Atrial fibrillation 2, 4
• Self-expanding valves 2, 3
• New left bundle branch block 3, 4
• Pre-existing first-degree heart block 4
• STS score 4

• These predictors can help identify patients at high risk of developing heart block after TAVR and inform management strategies.

Management of Heart Block after TAVR

• The management of heart block after TAVR typically involves the implantation of a permanent pacemaker.
• According to a study published in 2021 5, the need for permanent pacemaker implantation for post-TAVR high-degree atrioventricular block (HAVB) has persisted despite advances in TAVR technology and techniques.
• The study also notes that most HAVB occurs within 48 hours of the procedure, but there is a growing number of patients developing HAVB after initial hospitalization for TAVR due to early discharge trends.