What is the management approach for a patient who develops heart block after undergoing a Transcatheter Aortic Valve Implantation (TAVI)?

Management of Heart Block After TAVI

Patients who develop heart block after Transcatheter Aortic Valve Implantation (TAVI) require a structured management approach with permanent pacemaker implantation for persistent high-grade AV block, while temporary pacing with observation is appropriate for transient conduction disturbances. 1

Immediate Post-TAVI Management

Assessment Based on Conduction Status

• For patients with normal sinus rhythm and no new conduction disturbances immediately post-procedure:

  • Temporary pacemaker and central venous sheath can be removed immediately 1
  • Continue cardiac monitoring for 24 hours 1
  • Obtain repeat 12-lead ECG the following day 1
  • Risk of developing delayed AV block is <1% in these patients 1

• For patients with pre-existing RBBB:

  • Maintain transvenous pacing capability with continuous cardiac monitoring for at least 24 hours 1
  • Higher risk (up to 24%) of developing high-degree AV block during hospitalization 1
  • This risk exists for up to 7 days and is greater with self-expanding valves 1
  • If temporary pacemaker is removed, ensure capability for emergent pacing 1

• For patients who develop new LBBB or PR/QRS prolongation ≥20 ms:

  • Continue transvenous pacing for at least 24 hours 1
  • Maintain continuous cardiac monitoring and obtain daily ECGs 1
  • These patients have increased risk of PPM implantation (RR: 1.89) 1

Management of Transient or Persistent High-Grade AV Block

• For transient high-grade AV block during valve deployment:

  • Maintain transvenous pacemaker and continuous cardiac monitoring for at least 24 hours 1

• For persistent high-grade AV block:

  • Permanent pacemaker implantation is indicated 1
  • Leave temporary pacemaker in place for at least 24 hours to assess for conduction recovery 1

• For recurrent episodes of transient high-grade AV block:

  • Consider permanent pacemaker implantation prior to hospital discharge regardless of symptoms 1

Predictive Testing

• Atrial pacing test can help predict need for permanent pacing:

  • If Wenckebach AV block does not occur with right atrial pacing up to 120 bpm, only 1.3% require PPM by 30 days 1
  • If Wenckebach AV block does occur, 13.1% require PPM by 30 days 1
  • Higher PPM rates with self-expanding valves (15.9%) compared to balloon-expandable valves (3.7%) 1

• Electrophysiology study for patients with new LBBB:

  • HV interval >55 ms predicts high risk of developing high-grade AV block (53% vs 10%) 2
  • Negative predictive value of 90% for HV interval ≤55 ms 2

Timing of Permanent Pacemaker Implantation

• For patients with persistent complete heart block:

  • Permanent pacemaker implantation is indicated 1
  • Preferably separate the PPM procedure from TAVI to allow for informed consent 1
  • Same-day PPM implantation may be reasonable in select cases (e.g., persistent complete heart block with pre-existing RBBB) 1

• For patients with pre-existing RBBB who develop high-grade AV block:

  • Consider durable transvenous pacing lead prior to leaving the procedure suite 1
  • High requirement for ventricular pacing at follow-up in these patients 1

• Timing considerations:

  • Early PPM implantation after TAVI is an independent predictor of persistent AV block 3
  • Consider postponing PPM implantation for a few days as long-term persistence of AV block is generally low 3
  • PPM implantation can be safely performed immediately after TAVI without increased complication rates 4

Extended Monitoring for Delayed Heart Block

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

  • Early discharge after TAVI is less likely to be safe 1
  • Recommend inpatient monitoring with telemetry for at least 2 days if the rhythm disturbance does not progress 1
  • Consider up to 7 days of monitoring if ambulatory electrocardiographic monitoring (AEM) is not planned 1

• Ambulatory monitoring recommendations:

  • Provide AEM to patients with PR or QRS interval that is new or extended by ≥10% 1
  • Monitoring should occur for at least 14 days post-discharge 1
  • Ensure capability to receive and respond to delayed high-grade AV block within an hour 1

Risk Factors for Permanent Pacemaker Requirement

• Pre-procedural risk factors:

  • Pre-existing right bundle branch block 1, 3, 5
  • Higher mean aortic valve gradient prior to implantation 3

• Procedural risk factors:

  • Self-expanding valve prosthesis (CoreValve) vs balloon-expandable valve (Edwards) 3, 5
  • Post-dilatation of the prosthesis 3

Common Pitfalls and Caveats

• Delayed high-grade AV block (DH-AVB) occurs in approximately 10% of patients and can lead to syncope or sudden cardiac death 1
• DH-AVB has been identified in patients with normal ECGs pre- and post-TAVI, so monitoring is important even in low-risk patients 1
• 14-30 days of monitoring may not capture all occurrences of DH-AVB 1
• Atropine can be used for temporary management of bradycardia but is not a substitute for appropriate pacing in high-grade AV block 6
• Atropine may lessen the degree of partial heart block when vagal activity is an etiologic factor, but in some patients with complete heart block, it may cause atrioventricular block and nodal rhythm 6