Ambulatory rhythm monitoring detects heart block after transcatheter aortic valve replacement
1. The routine use of ambulatory event monitoring (AEM) commonly detects high grade atrioventricular block (H-AVB) after discharge following Transcatheter Aortic Valve Replacement (TAVR).
2. The presence of a right bundle branch block (RBBB) is a specific but not sensitive predictor of H-AVB in patients following TAVR.
Evidence Rating Level: 2 (Good)
Study Rundown: Transcatheter Aortic Valve Replacement (TAVR) for management of aortic valve disease is preferred in patients who may be higher risk for surgical repair. The development of high grade AV block following TAVR is a common complication necessitating the implantation of a pacemaker in many patients. Though more commonly diagnosed in hospital, the streamlining of procedures and reduced recovery time has led to shorter admissions for TAVR and more patients may develop H-AVB at home following discharge. This study evaluated the utility of routine ambulatory event monitoring (AEM) following discharge after TAVR for the detection of H-AVB. The study found that development of delayed H-AVB was common, occurring in up to 10% of monitored patients. The presence of RBBB following TAVR was a specific, but not sensitive, finding in predicting the development of delayed H-AVB.
The main strength of this study was the recruitment of consecutive patients agreeing to long-term rhythm monitoring allowing for initial evaluation of risk of delayed H-AVB. The main limitations of the study included the small size, and lack of data on important procedural risk factors that may influence risk of AV block.
Click to read the study in JACC
In-Depth [retrospective cohort]: This was a retrospective cohort study of patients undergoing TAVR at the University of Colorado Hospital between October 2016 and March 2018. Participants were excluded if they had pre-existing pacemarker or implanted cardioverter-defibrillator, or if they developed high grade AV block following TAVR prior to discharge from hospital. Ambulatory event monitoring for up to 30 days was performed in patients who consented.
The study included 150 consecutive patients, of whom 13 refused participation in the trial and 18 developed H-AVB prior to discharge. Of the 118 patients who underwent AEM following discharge, 12 (10%) developed H-AVB after a median of 6 days (range 3-24 days). The presence of a RBBB on electrocardiogram was 27% sensitive and 94% specific for predicting the development of delayed H-AVB.
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