Contributor: Taylor Lynch, MD
Educational Pearls:
Conduction abnormalities are a common and clinically significant complication in patients who undergo transcatheter aortic valve replacement (TAVR)
Clinical Features
- The most common abnormalities include high grade AV block and new onset LBBB
- Due to the close proximity of the aortic annulus to the AV node and His-Purkinje system
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More common in males, the elderly, and those with pre-existing conduction disease (RBBB or LBBB)
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Sinus pauses and sinus arrest are a rare post-TAVR rhythm disturbances
- Temporary failure of sinus node firing with absent P waves, followed by return of sinus rhythm
- Sinus Pauses: Typically last
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Sinus Arrest: Typically last > 3 seconds
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Not due to direct mechanical injury from the valve, but may occur in patients as a result of pre-existing disease or other external factors:
- Medications
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Beta blockers, calcium channel blockers, digoxin
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Pre-existing damage to the SA node
- Fibrosis from a previous MI
Treatment
- If the patient is asymptomatic, provide ongoing surveillance
- If the patient is symptomatic, treatment should be aimed at the underlying cause:
- For medication-induced abnormalities, stop the offending medication
- For acute, unstable bradycardia:
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Medications: Atropine, Dopamine Infusion, Epinephrine Infusion
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If cardiology is not immediately available, initiate transcutaneous pacing or insert a temporary transvenous pacemaker
- Definitive treatment: Pacemaker
- ~10–15% of patients may develop a bradyarrhythmia post TAVR, with ~8-15% later requiring a pacemaker
Due to the risk of conduction abnormalities post TAVR, many patients are discharged with ambulatory rhythm monitoring such as a ZioPatch or Holter monitor, and may present to the emergency department for evaluation of rhythm disturbances.
References:
- Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. Heart Rhythm. 2019;16(9):e128-e226.
- Lilly, S, Deshmukh, A, Epstein, A. et al. 2020 ACC Expert Consensus Decision Pathway on Management of Conduction Disturbances in Patients Undergoing Transcatheter Aortic Valve Replacement: A Report of the American College of Cardiology Solution Set Oversight Committee. JACC. 2020 Nov, 76 (20) 2391–2411.
https://doi.org/10.1016/j.jacc.2020.08.050
- Sammour, Y, Krishnaswamy, A, Kumar, A. et al. Incidence, Predictors, and Implications of Permanent Pacemaker Requirement After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol Intv. 2021 Jan, 14 (2) 115–134.
https://doi.org/10.1016/j.jcin.2020.09.063
- Tarakji KG, Patel D, Krishnaswamy A, et al. Bradyarrhythmias detected by extended rhythm recording in patients undergoing transcatheter aortic valve replacement (Brady-TAVR Study). Heart Rhythm. 2022;19(3):381-388.
Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P
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