Author + information
- Received November 5, 2018
- Revision received February 17, 2019
- Accepted February 26, 2019
- Published online May 20, 2019.
- Karen Ream, PACa,
- Amneet Sandhu, MDa,
- Javier Valle, MD, MSCSa,
- Rachel Weber, BSb,
- Alexander Kaizer, PhDb,
- Dominik M. Wiktor, MDa@DWiktorMD,
- Ryan T. Borne, MDa,
- Alexis Z. Tumolo, MDa,
- Megan Kunkel, BSa,b,
- Matthew M. Zipse, MDa,
- Joseph Schuller, MDa,
- Christine Tompkins, MDa,
- Michael Rosenberg, MDa,
- Duy T. Nguyen, MDa,
- Joseph C. Cleveland Jr., MDa,
- David Fullerton, MDa,
- John D. Carroll, MDa,
- John Messenger, MDa,
- William H. Sauer, MDa,
- Ryan G. Aleong, MDa and
- Wendy S. Tzou, MDa,∗ (, )@Zo_EP2@HeartMedEd@reliablerhythm@True_EP
- aUniversity of Colorado School of Medicine, Division of Cardiology, Aurora, Colorado
- bUniversity of Colorado School of Public Health, Center for Innovative Design and Analysis, Aurora, Colorado
- ↵∗Address for correspondence:
Dr. Wendy S. Tzou, Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado School of Medicine, 12401 East 17th Avenue, MS B136, Aurora, Colorado 80045.
Background High-grade atrioventricular block (H-AVB) is a well-described in-hospital complication of transcatheter aortic valve replacement (TAVR). Delayed high-grade atrioventricular block (DH-AVB) has not been systematically studied among outpatients post-TAVR, using latest-generation TAVR technology and in the early post-TAVR discharge era.
Objectives The purpose of this study was to assess utility of ambulatory event monitoring (AEM) in identifying post-TAVR DH-AVB and associated risk factors.
Methods Patients without pre-existing pacing device undergoing TAVR at the University of Colorado Hospital from October 2016 to March 2018, and who did not require permanent pacemaker implantation pre-discharge, were discharged with 30-day AEM to assess for DH-AVB (≥2 days post-TAVR). Clinical and follow-up data were collected and compared among those without incident H-AVB.
Results Among 150 consecutive TAVR patients without a prior pacing device, 18 (12%) developed H-AVB necessitating permanent pacemaker <2 days post-TAVR, 1 died pre-discharge, and 13 declined AEM; 118 had 30-day AEM data. DH-AVB occurred in 12 (10% of AEM patients, 8% of total cohort) a median of 6 days (range 3 to 24 days) post-TAVR. DH-AVB versus non-AVB patients were more likely to have hypertension and right bundle branch block (RBBB). Sensitivity and specificity of RBBB in predicting DH-AVB was 27% and 94%, respectively.
Conclusions DH-AVB is an underappreciated complication of TAVR among patients without pre-procedure pacing devices, occurring at rates similar to in-hospital, acute post-TAVR H-AVB. RBBB is a risk factor for DH-AVB but has poor sensitivity, and other predictors remain unclear. In this single-center analysis, AEM was helpful in expeditious identification and treatment of 10% of post-TAVR outpatients. Prospective study is needed to clarify incidence, risk factors, and patient selection for outpatient monitoring.
Transcatheter aortic valve replacement (TAVR) has dramatically increased in use, with the number of procedures performed in the United States nearly doubling each year since 2012 (1). A common complication of TAVR, as well as for open-surgical AVR, is development of conduction abnormalities after valve implantation, the most significant of which is high-grade atrioventricular block (H-AVB), often necessitating permanent pacemaker (PPM) implantation (1–8). Conduction abnormalities are associated with increased morbidity and mortality for ≤1 year beyond the initial procedure (1,3,5,6,9). Advances in technology and operator experience have led to overall improvements in post-TAVR mortality rates as well as in overall length of hospitalization. However, the rate of PPM placement within the first 30 days continues to increase, and unexplained 30-day mortality post-TAVR remains significant (1). Syncope and sudden cardiac death occurring in such patients have been suggested to be related to H-AVB occurring after hospital discharge (1,10,11). Although the incidence of conduction disease and PPM requirement occurring during the same hospitalization period as index TAVR have been well studied (3–5,9,12,13), the incidence and predictors of delayed high-grade atrioventricular block (DH-AVB) have not been well studied.
The present study was initiated by observations of DH-AVB as our program was progressively reducing length of stay post-TAVR, in line with national standards. We recently reported findings from a cohort of 158 patients without pre-existing pacing indication undergoing TAVR at our center from July 2015 to November 2016, the majority of whom had usual clinical follow-up (11). Of the prior group, 14.5% developed H-AVB necessitating PPM implantation before discharge. After discharge, 4 developed DH-AVB despite uncomplicated TAVR and absence of significant changes in pre- and post-TAVR electrocardiograms (ECGs) or abnormal QRS durations. A total of 3 patients were readmitted and received prompt treatment with dual-chamber PPM, but 1 died as a result of syncope and intracranial hemorrhage. These patients were identified based on symptoms and subsequent clinical evaluation. Based on this experience, as well as the lack of data to provide guidance about identification and timely management of DH-AVB following TAVR, ambulatory event monitoring (AEM), using a 30-day real-time mobile cardiac telemetry device, was then used to better identify the incidence and potential risk factors of delayed high-grade atrioventricular (AV) block among patients who had undergone TAVR. Of the 158 patients included in the previous cohort, most did not undergo AEM, as the protocol of routine post-TAVR AEM was not uniformly instituted until October 2016 (n = 14). Therefore, interpretations regarding DH-AVB incidence and risk factors were limited. The findings reported here incorporate data from those 14 subjects and provide an update to our previously published report, with a larger, more contemporary patient cohort in which AEM was systematically used and from which more concrete insights could be gleaned regarding DH-AVB following TAVR.
Patients undergoing a TAVR procedure at the University of Colorado Hospital between October 2016 and March 2018 and who did not have a pre-existing PPM or implantable cardioverter-defibrillator (ICD) were included in the study (Figure 1). The present patient cohort included 14 patients who were in our previously published analysis, and spanned from July 2015 to November 2016, during which routine AEM was only implemented in October 2016 (11). Data collection and analysis were approved by the institutional review board of the University of Colorado School of Medicine.
Clinical and procedural data
Baseline clinical information, including use of AV nodal blocking medications, and procedural characteristics included in the STS/ACC TVT Registry (Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry) were evaluated and summarized in Table 1. Twelve-lead ECGs were collected from each patient within 2 weeks before TAVR and before hospital discharge. Each ECG was interpreted by a cardiologist, and interpretations were confirmed by a cardiac electrophysiologist (W.S.T.). Established criteria were used for diagnosing AV and interventricular conduction delays and block (14).
The predominant TAVR valve types used at our institution during this time period were from the Evolut series (Evolut-R and Evolut Pro, Medtronic, Dublin, Ireland) and Sapien 3 (Edwards Lifesciences, Irvine, California). Type, size, and technique of TAVR implantation, including arterial approach, were at the discretion of the operating physicians and the multidisciplinary TAVR team, which included noninvasive cardiologists, interventional cardiologists, and cardiothoracic surgeons.
AEM and management procedures
Patients who did not have a pre-existing or an immediate post-TAVR permanent pacing device were discharged with a 30-day real-time mobile cardiac telemetry monitor (Biotel ACT EX, BioTelemetry, Malvern, Pennsylvania), which included an initial 48-h Holter that then converted into real-time mobile cardiac telemetry. All transmitted tracings were reviewed as available, first by the telemetry monitor staff (24-h coverage), and then by our clinical staff once the strips were posted to a secure online website. Additionally, medium-urgency alerts were triggered for patients with pauses lasting between 3 to 5 s or with incident atrial fibrillation or flutter, for which a fax notification was sent to the ordering provider within an hour from detection. Review of and response to medium-urgency alerts, as clinically appropriate and if sent during business hours (Monday to Friday, 8:00 am to 5:00 pm Mountain Standard Time), was within 2 business days, and usually was within the same business day if the initial fax was sent before noon. On weekends or at night, the response was within the next business day. The on-call physician for the cardiac electrophysiology section was paged directly upon detection of any high-urgency alerts, which comprised the following: pause >5 s, heart rate <30 or >200 beats/min, wide complex tachycardia, or H-AVB (second-degree Mobitz II or third-degree AVB). All patients with high-urgency alerts were immediately contacted to assess symptoms and to guide further clinical management, including rehospitalization for PPM implantation.
H-AVB was defined as the presence of any second-degree Mobitz II or third-degree AVB. DH-AVB was defined as H-AVB occurring on or after post-procedure day 2, as the median length of post-TAVR hospitalization at institutions participating in the STS/ACC TVT registry is 1.9 days. H-AVB events occurring before post-procedure day 2 prompted immediate consultation from the cardiac electrophysiology inpatient service, following which pacing device implantation was arranged (PPM, ICD, or cardiac-resynchronization PPM or ICD, depending on the clinical indication) before hospital discharge (15).
Patients were followed routinely in the outpatient setting at 1 week, 1 month, and 1 year following initial hospital discharge, or more frequently as clinically indicated. Data collected at visits included clinical status, 12-lead ECG, and transthoracic echocardiography.
Summary characteristics are reported using mean ± SD for continuous variables and frequency (%) for categorical variables. Univariate analyses were completed using 2-sample Student’s t-tests for continuous variables and Fisher exact test for categorical variables to identify potentially significant relationships between ECG and other clinical characteristics before TAVR or at discharge. To develop the multivariate logistic regression model, simple logistic regression analyses were performed for outcomes of H-AVB or DH-AVB based on results from univariate comparisons and for clinically meaningful predictors. Multivariable analyses were performed using logistic regression for the outcomes of any H-AVB and DH-AVB post-TAVR and were adjusted for sex, age, TAVR valve type, and any other significant ECG or clinical variables identified from the simple logistic regression analyses. All analyses were conducted in R version 3.4.3 (R Foundation, Vienna, Austria), with an alpha value of <0.05 considered significant for all statistical inferences.
Of 170 consecutive patients who underwent TAVR during the study period, 20 had a pre-existing pacing device (13 PPM, 7 ICD). Among the 150 patients without baseline PPM or ICD, 18 (12%) developed H-AVB before discharge, 1 died during the index hospitalization, and 13 declined AEM, resulting in a cohort of 118 patients with AEM data (Figure 1). Twelve patients (10% of those with AEM and 8% of the analyzed cohort of 150) developed H-AVB ≥2 days post-TAVR (DH-AVB), with all events occurring before routine 30-day clinical follow-up (Central Illustration). Five had symptoms associated with DH-AVB (dizziness in 3, syncope in 2), and all had events while awake. None of the 13 who declined AEM developed DH-AVB during usual follow-up. Baseline characteristics of each of the patient subsets are displayed in Table 1. Overall, the mean age was 77 ± 10 years, left ventricular ejection fraction (LVEF) was 62 ± 13%, and 52% were male. Mean AEM time was 27 ± 7 days, and mean follow-up time was 11 ± 5 months.
Among those treated with AV-nodal-blocking agents pre-TAVR, beta-blockers were most common, with metoprolol (40 of 64 treated with any beta-blocker; 63%) predominating. Diltiazem was the most commonly prescribed calcium-channel blocker (n = 9 of 10; 90%), and digoxin was a baseline medication in 10 (7% of the studied cohort of 136). For the most common AV nodal agents prescribed in each class, respective pre- and post-TAVR doses of metoprolol were 35.9 ± 19.0 mg and 29.4 ± 23.6 mg (p = 0.01), diltiazem 160.0 ± 67.1 mg and 120.0 ± 108.2 mg (p = 0.002), and digoxin 145.8 ± 51.0 μg and 104.2 ± 94.1 μg (p = 0.08). There were no significant differences in pre- or post-doses of AVN blockers between categories of patients (i.e., those with any H-AVB or DH-AVB vs. those without any AVB).
Compared with patients who did not develop H-AVB, those with H-AVB were more likely to have hypertension (p = 0.005) (Table 1) and to have undergone TAVR using an Evolut series valve (40% vs. 18.9%; p = 0.03) (Table 1). The subset of H-AVB patients with DH-AVB also were more likely to have hypertension (p = 0.04) and to be treated with digoxin (p = 0.01) compared with the non–H-AVB patients (Table 1). There were otherwise no significant differences in clinical characteristics between AV block and non-AV block groups.
12-lead ECG characteristics
Conduction abnormalities evident on ECG (Table 2) were more often present among patients with H-AVB and DH-AVB compared with those without H-AVB, both at baseline (67.7% and 75.0%, respectively, vs. 33.0%) and before discharge (97.7% and 91.7%, respectively, vs. 50.9%; all p ≤ 0.01). These differences were driven primarily by a greater prevalence of right bundle branch block (RBBB) among patients with H-AVB and DH-AVB (30.0% and 33.3% vs. 1.9% in patients without H-AVB; all p ≤ 0.001). Respective PR intervals pre- and post-TAVR did not change significantly (174 ± 34 ms and 178 ± 33 ms; p = 0.06, for the whole cohort; 189 ± 43 ms and 200 ± 44 ms; p = 0.12, for those developing DH-AVB; and 197 ± 37 ms and 196 ± 36 ms; p = 0.95, for those with any new H-AVB). Although a high proportion of patients developed left bundle branch block (LBBB) following TAVR (from 11% pre-TAVR to 28.7% post-TAVR; p < 0.001), development of LBBB was not associated with H-AVB or DH-AVB.
Characteristics associated with development of H-AVB
Important characteristics were identified on multivariable analyses that were associated with either any H-AVB, including events occurring <2 days post-TAVR, or those associated with DH-AVB identified on AEM in the outpatient setting (Table 3). Patients with RBBB, either at baseline or following TAVR, had 26-fold increased odds of developing H-AVB compared with those without RBBB (p < 0.001). Other risk factors that remained associated with any incident H-AVB on adjusted analyses were hypertension (odds ratio [OR]: 39.56; 95% confidence interval [CI]: 2.15 to 728.52; p = 0.01), and implantation of the Evolut valve (OR: 3.60; 95% CI: 1.24 to 10.47; p = 0.02).
Characteristics associated with development of DH-AVB
After adjustment for other significant covariates and excluding patients who developed H-AVB <2 days post-TAVR, only RBBB remained significantly associated with development of DH-AVB (Table 3) (OR: 20.46; 95% CI: 2.67 to 158.31; p = 0.004). The Evolut valve was not associated with a higher frequency of DH-AVB. Although 8 of the 12 cases (67%) of DH-AVB were in patients with Sapien 3 valves, this was not statistically significant given that 75% of all TAVR were treated with Sapien 3. Additional details of the patients who developed DH-AVB on AEM are listed in Table 4. The median time post-TAVR for development of DH-AVB was 6 days (range 3 to 24 days) (Table 4, Central Illustration panel A). All patients identified with DH-AVB were then urgently rehospitalized for PPM implantation. No serious adverse events, including death, occurred among the patients discharged with AEM.
Predictive value of RBBB in H-AVB post-TAVR
The sensitivity and specificity of RBBB in predicting any H-AVB among the cohort was 30% and 98%, respectively. Its sensitivity and specificity in predicting DH-AVB was 27% and 94%, respectively.
In the present single-center analysis of patients without baseline pacing need and undergoing TAVR with either the Evolut or Sapien 3 valve, high-grade AV block necessitating PPM implantation occurred in 20%, 12% of which occurred within 2 days post-TAVR, before hospital discharge (Central Illustration). Delayed high-grade AV block, developing ≥2 days post-TAVR and necessitating PPM implantation, was diagnosed in 10% of patients who were discharged with an ambulatory event monitor. The median time to developing DH-AVB post-procedure was 6 days (range 3 to 24 days). Baseline hypertension, digoxin use, and RBBB were observed in higher proportions among those that went on to develop DH-AVB, but only RBBB remained statistically significantly associated in adjusted analysis. Importantly, many of these events would not have been captured on inpatient telemetry post-TAVR, as the median post-TAVR length-of-stay has been reduced to 1.8 days for institutions participating in the STS/ACC TVT Registry (16). Use of AEM in these patients may have prevented severe adverse clinical events, especially those related to bradycardia-mediated syncope or sudden cardiac death (11). These results indicate that DH-AVB is an important complication of TAVR, especially in the era of early post-procedure discharge, and routine AEM following TAVR offers the ability to better refine management by rapid detection and treatment of AVB, and potentially reduce the morbidity and mortality associated with H-AVB occurring in the outpatient setting.
Importantly, although RBBB was predictor of both acute and delayed H-AVB with excellent specificity, its sensitivity was very poor. Therefore, although some temptation may exist to recommend prophylactic PPM implantation in all patients with RBBB undergoing TAVR, there remains insufficient data to support this practice. Additional efforts to identify other risk factors that may contribute to increased risk of H-AVB following TAVR should be explored, especially as indications and eligible patient populations expand for TAVR.
To our knowledge, this is the only study to date to systematically assess for post-TAVR DH-AVB events after implantation of the latest TAVR technology when patients rapidly transition to the outpatient setting. Furthermore, this study evaluates associated risk factors and demonstrates the value of routine post-discharge AEM allowing rapid detection of AVB meeting pacing indications. The work builds upon preliminary data recently reported from our center, which has been included in and further developed in the present analysis (11).
High-grade AV block following TAVR
The rate of acute H-AVB, which led to pacing device implantation <2 days post-TAVR and pre-discharge, was 13.2%, and the overall proportion of patients developing any H-AVB was 22.1%. These rates are similar to the rates of post-TAVR PPM implantation (5.9% to 33.7%) previously reported from registry studies or meta-analyses (4,5,7,8,13). Also similar to prior studies, we observed higher rates of H-AVB with the use of self-expanding valves (5,7,8,13,17,18), and among those with RBBB (2–4,13,17–23). In fact, in our study, patients with RBBB were 26× more likely to develop H-AVB than those without RBBB. Development of an LBBB, while common, did not result in a statistically significant association with the development of H-AVB. Our results differ from a meta-analysis pooling data from 5 studies (n = 3,363), in which new LBBB was significantly associated with H-AVB and PPM implantation after >1 year of follow-up post-TAVR (6). Our data might differ given smaller sample size, as well as shorter duration of follow-up.
The potential to directly injure the proximal left-sided conduction system with TAVR or even with surgical AVR (2–4,13,17–23) is well recognized, and puts those with RBBB at baseline at particularly high risk for developing H-AVB following TAVR; this has been consistently demonstrated in multiple studies, one of the largest of which (n = 1,973) demonstrated a >7× increased risk of PPM requirement, even in the absence of use of self-expanding valves (4). In our study, the greatest period of risk for RBBB patients was in the acute post-procedural period, with most H-AVB events occurring within 24 h after TAVR.
Invasive assessment of conduction using electrophysiological study has demonstrated variable utility in risk stratification (18,24,25), but it may be of utility in the group of patients in whom non-RBBB conduction disease has been observed (18). For example, Rivard et al. (18) found that an HV interval increase of ≥13 ms after TAVR compared to before TAVR, as well as an absolute HV measurement of ≥65 ms in patients with new LBBB following TAVR significantly predicted incident H-AVB and PPM implantation (18). We did not routinely perform additional electrophysiological study evaluation among the current cohort of patients, but such an evaluation could be valuable to refine risk stratification for DH-AVB and better determine who may benefit most from post-TAVR AEM.
Other factors significantly associated with PPM implantation post-TAVR, in addition to those already discussed, have varied depending on patient population and implantation details, including age (5), porcelain aorta (8), any prior conduction system disease (5,17,21,23), intraprocedural AV block (21,24,26), and LV end-diastolic diameter (4), as well as features specific to the site and associated mode of implantation, including increased ratio of prosthesis size to annulus diameter (2,4), presence of a bicuspid aortic valve (21), and increased interventricular septal dimension (21). We did not assess specifics regarding implantation techniques or echocardiographic measurements in the present study; however, hypertension, which we found to be a significant predictor of post-TAVR H-AVB, may be closely related to some of the previously identified predictors related to implantation details, including increased interventricular septal dimension, LV end-diastolic diameter, and outflow tract size.
Prior studies assessing DH-AVB following TAVR
Two prior studies have specifically assessed features associated with development of DH-AVB, but with important differences in methodology (17,23). Toggweiler et al. (23) defined DH-AVB as occurring anytime between the immediate post-TAVR ECG and ≤30 days (23). DH-AVB, based on this definition, occurred in 6.7% of 1,064 patients, and periprocedural H-AVB occurred in 8.6%. Similar to our study, the proportion of patients with RBBB post-TAVR was higher among the DH-AVB patients. However, RBBB and LBBB patients were combined in their analyses, and in multivariable analysis, male sex and presence of either LBBB or RBBB post-TAVR were significantly associated with incident DH-AVB. Also, when defining DH-AVB as we did, only 3.7% of patients developed DH-AVB (≥2 days post-TAVR), and the median time to development of DH-AVB was 3 days (range 2 to 8 days). Notably, all of the patients with DH-AVB remained hospitalized until PPM implantation, and outpatient ambulatory event monitoring was not conducted throughout the stated timing of DH-AVB (≤30 days), which raises the possibility of missing events. In contrast, our analysis used a novel, systematic method of routine post-TAVR AEM, likely increasing the sensitivity of our data for occult episodes of DH-AVB. Additionally, our analysis used a more restrictive definition of DH-AVB, which is likely more clinically meaningful in identifying those patients that may be at risk for H-AVB when no longer directly observed by a care team and inpatient telemetry. These differences highlight the importance of a larger, multicenter trial to validate these findings.
A more recent, single-center analysis by Mangieri et al. (17) found that DH-AVB (defined as occurring >2 days post-TAVR), occurred in 8.8% of 611 patients without pre-existing PPM and could be predicted on adjusted analysis by presence of either RBBB at baseline (OR: 3.56; 95% CI: 1.07 to 11.77; p = 0.037) or PR prolongation by 10-ms increments (OR: 1.31; 95% CI: 1.18 to 1.45; p < 0.001) (17). As was true in our study and Toggweiler et al. (23), most PPM implantations occurred in the first week after TAVR. However, patients were ostensibly only admitted for ≤72 h following TAVR, and details regarding hospitalization length of the DH-AVB patients was not reported in the paper. Importantly, AEM was not used, and the 22.2% of patients with DH-AVB who were diagnosed >1 week after TAVR were discovered by the use of follow-up ECGs and outpatient clinic visits. It is possible that use of AEM up to 30 days might also have detected a greater number of DH-AVB events.
This was a single-center, retrospective analysis with relatively small sample size; the number of DH-AVB cases was therefore also very small (12 cases), although it still accounted for an important proportion of the cohort. We did not prospectively collect details of specific procedural techniques, including valve index (valve size: outflow tract size ratio), depth of prosthesis placement, post-dilation, quantification of membranous septum calcifications, or other echocardiographic parameters that might provide additional insights on risk factor assessment. Although these factors are important considerations when assessing post-TAVR heart block risk, our cohort was not appreciably different in baseline or other characteristics from other TAVR patients within the STS/ACC TVT Registry, nor was our procedural technique in contemporary prosthetic valve sizing and deployment. We therefore do not believe that there were other features that would have conferred higher risk for DH-AVB compared with other post-TAVR patients; this is, in fact, the first study to systematically and continuously monitor for DH-AVB in this fashion and for this duration. We did not routinely perform invasive electrophysiological assessment of AV conduction. Additionally, although we reviewed all transmitted AEM telemetry strips, especially those with alerts, some DH-AVB events might have been missed, and the true incidence might be underestimated. However, this is the largest study to report the utility of post-TAVR ambulatory monitoring, and our protocol afforded greater ability to detect DH-AVB in comparison to absence of AEM. Finally, some of our cohort could have had H-AVB episodes that were not clinically detected, as none underwent routine AEM pre-TAVR. A larger prospective study, ideally with collaboration of multiple centers, incorporating relevant details listed in the previous text, is warranted to further investigate DH-AVB risks and the potential need for extended monitoring for DH-AVB.
DH-AVB, occurring ≥2 days following TAVR and necessitating PPM implantation, was detected in 9% of patients in our single-center study. Detection and appropriate care were facilitated by use of ambulatory 30-day monitoring post-discharge. Presence of RBBB was found to be a significant risk factor for DH-AVB post-TAVR. These findings suggest that DH-AVB is an underappreciated complication of TAVR, and that routine AEM post-TAVR may be helpful in promptly identifying such patients, as well as in better clarifying risk factors for its development.
COMPETENCY IN PATIENT CARE AND PROCEDURAL SKILLS: Although H-AVB is a recognized in-hospital complication of TAVR, 30-day ambulatory monitoring detects AVB developing >2 days post-TAVR in nearly 10% of patients after discharge.
TRANSLATIONAL OUTLOOK: Prospective surveillance of larger cohorts is necessary to identify risk factors for development of DH-AVB among patients undergoing TAVR who do not exhibit an immediate indication for pacemaker implantation and to determine the optimum frequency and duration of ambulatory rhythm monitoring.
This research was funded in part by an educational grant from BioTelemetry, Inc. (LifeWatch). The sponsors played no role in study design, analysis, or manuscript development. Dr. Nguyen has received educational grants from Abbott, Boston Scientific, and Medtronic. Dr. Carroll has served as an investigator for the Medtronic Low Risk Trial and the Edwards PARTNER 2 Trial. Dr. Tzou has received speaker honoraria from Medtronic, Boston Scientific, Biosense Webster, Abbott, and Biotronik; and has served as a consultant for Biotronik, Boston Scientific, Biosense Webster, and Abbott.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Abbreviations and Acronyms
- ambulatory event monitoring
- atrioventricular block
- delayed high-grade atrioventricular block
- high-grade atrioventricular block
- implantable cardioverter-defibrillator
- permanent pacemaker
- right bundle branch block
- transcatheter aortic valve replacement
- Received November 5, 2018.
- Revision received February 17, 2019.
- Accepted February 26, 2019.
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