What is the management of heart block after Transcatheter Aortic Valve Replacement (TAVR)?

Management of Heart Block After TAVR

Patients who develop persistent high-grade AV block after TAVR should receive permanent pacemaker implantation, while those with transient heart block require careful monitoring and risk stratification to determine the need for permanent pacing. 1

Risk Assessment and Initial Management

Pre-existing Risk Factors

• High-risk patients:
  • Pre-existing right bundle branch block (RBBB) - highest risk, up to 24% chance of developing high-degree AV block 1
  • First-degree heart block
  • Self-expanding valve prosthesis (higher risk than balloon-expandable)
  • Heavy calcification below the cusp
  • Short membranous septum

Immediate Post-TAVR Management

1. For patients with persistent complete heart block:

   • Maintain temporary pacemaker for at least 24 hours to assess for conduction recovery
   • Proceed with permanent pacemaker implantation if heart block persists 1

2. For patients with transient complete heart block during valve deployment:

   • Maintain temporary pacemaker and continuous cardiac monitoring for at least 24 hours
   • If recurrent episodes of transient high-grade AV block occur, consider permanent pacemaker implantation prior to discharge 1

3. For patients with pre-existing RBBB who develop transient or persistent high-grade AV block:

   • Permanent pacemaker implantation is indicated in the vast majority of cases
   • Consider a durable transvenous pacing lead prior to leaving the procedure suite 1

Monitoring Strategy Based on Conduction Status

No New Conduction Disturbances

• For patients with normal sinus rhythm and no new conduction disturbances post-procedure:
  • Risk of delayed AV block is <1%
  • Temporary pacemaker can be removed immediately post-procedure
  • Continue cardiac monitoring for 24 hours
  • Obtain repeat 12-lead ECG the following day 1

New LBBB or PR/QRS Prolongation

• For patients who develop new LBBB or PR/QRS prolongation ≥20 ms:
  • Continue transvenous pacing for at least 24 hours
  • Maintain continuous cardiac monitoring during hospitalization
  • Obtain daily ECGs
  • If temporary pacemaker is removed, ensure recovery location has capability for emergent pacing 1

Predictive Testing

• Consider rapid atrial pacing test (up to 120 beats per minute):
  • If Wenckebach AV block does not develop: very low risk of needing permanent pacing (1.3%)
  • If Wenckebach AV block develops: higher risk of needing permanent pacing (13.1%) 1

Post-Discharge Monitoring

Delayed High-Grade AV Block (DH-AVB)

• DH-AVB occurs in approximately 10% of patients, typically within the first 7-8 days post-TAVR 1
• Risk factors include pre-existing RBBB and new-onset LBBB

Monitoring Recommendations

1. For patients with new or worsened conduction disturbance (PR or QRS interval increase ≥10%):

   • Inpatient monitoring with telemetry for at least 2 days if the rhythm disturbance does not progress
   • Consider extended monitoring up to 7 days if ambulatory electrocardiographic monitoring (AEM) will not be used
   • Provide AEM for at least 14 days post-discharge 1

2. For patients with new-onset persistent LBBB:

   • Consider extended monitoring (up to 30 days)
   • Higher risk of developing delayed high-grade AV block (approximately 10%) 1

Permanent Pacemaker Implantation

Timing of Implantation

• Preferably separate the PPM implantation from TAVR procedure to allow for:
  • Proper informed consent
  • Appropriate equipment and staff availability
  • Same-day implantation may be reasonable in cases of persistent complete heart block, especially with pre-existing RBBB 1

Device Selection

• Consider the need for:
  • Standard pacemaker vs. implantable cardioverter-defibrillator (ICD)
  • Cardiac resynchronization therapy in patients with reduced left ventricular ejection fraction
  • His-bundle pacing may be considered to avoid pacing-induced cardiomyopathy 2

Special Considerations

Late-Onset Heart Block

• Cases of very late-onset complete heart block have been reported, suggesting potential benefit of longer monitoring in high-risk patients 2

Monitoring Limitations

• Current monitoring strategies may not capture all cases of delayed heart block
• Bradyarrhythmias are common before and after TAVR but may not predict the need for permanent pacemaker 3

Response Protocol

• The heart team and AEM monitor should have capacity to:
  • Receive and respond to DH-AVB within an hour
  • Dispatch appropriate emergency medical services if needed 1

Pitfalls to Avoid

• Do not discharge high-risk patients (especially those with new LBBB or pre-existing RBBB) without adequate monitoring plans
• Do not assume transient heart block is benign, as recurrence can occur with devastating consequences
• Do not delay permanent pacemaker implantation in patients with persistent high-grade AV block, as this can lead to syncope and potential fatal outcomes 1
• Do not rely solely on in-hospital monitoring, as delayed heart block can occur after discharge