Fundación EPIC _ Transient atrioventricular block after TAVI, what to do?
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Presentación de la ponencia "Tratamiento anticoagulante/antiagregante al alta en TAVI" Por la Dra. Ureña en los Diálogos EPIC_Retos Clínicos en Válvulas Transcatéter/ Clinical Challenges in TAVR today, el 10 de Mayo de 2018 en Barcelona (España)
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Fundación EPIC _ Transient atrioventricular block after TAVI, what to do?
- 1. Transient Atrioventricular Block after TAVI, What to do? Marina Urena Département de Cardiologie, Hôpital Bichat-Claude Bernard, Assistance Publique - Hôpitaux de Paris, Université Paris Diderot Paris, France Barcelona May 10th, 2018
- 2. Disclosure Statement of Financial Interest I have nothing to disclose
- 3. TAVI and PPM Auffret et al. Circulation 2017
- 4. TAVI and PPM Auffret et al. Circulation 2017
- 5. Impact of PPM on Late Clinical Outcomes Author (year) n Device Average Follow-up, yr Endpoints Results (PPM vs. No PPM) Long-term pacing D’Ancona et al. (2011) 322 ES 1 Mortality 16 vs.19%, p=0.30 NA Bullesfeld et al. (2012) 353 ESV, CV 1 Mortality Death, stroke and MI Adjusted HR: 1.06, p=0.90 Adjusted HR: 0.98, p= 0.87 NA Urena et al. (2014) 1,516 ES, CV 1.9±1.4 Mortality Death or rehospitalization for HF Adjusted HR: 0.98, p=0.87 Adjusted HR: 1.0, p=0. 98 66.9% (on ECG) Mouillet et al. (2015) 833 CV 1 Mortality Death, stroke and bleeding Heart Failure 16.9 vs. 16.3, p=0.832 32.4 vs. 31.3, p=0.774 11.0 vs. 12. 0, p=0.893 NA Nazif et al. (2015) 1,973 ES 1 Mortality Death and any rehospitalization 26 vs. 18%, p= 0.08 42 vs. 33%, p=0.007 50.5% (on ECG) Fadahunsi et al. (2016) 9,785 ES CV 1 Mortality Heart failure Death or heart failure Adjusted HR: 1.31, p = 0.003 Adjusted HR: 1.23, p = 0.162 Adjusted HR1.33, p < 0.001 NA Chamandi et al. (2017) 1,629 TAVR (ES, CV) 4 Mortality HF admission Adjusted HR: 1.15, p=0.152 Adjusted HR: 1.42, p=0.019 51% more than 40% of pacing
- 6. Impact of PPM on Late Clinical Outcomes Author (year) n Device Average Follow-up, yr Endpoints Results (PPM vs. No PPM) Long-term pacing D’Ancona et al. (2011) 322 ES 1 Mortality 16 vs.19%, p=0.30 NA Bullesfeld et al. (2012) 353 ESV, CV 1 Mortality Death, stroke and MI Adjusted HR: 1.06, p=0.90 Adjusted HR: 0.98, p= 0.87 NA Urena et al. (2014) 1,516 ES, CV 1.9±1.4 Mortality Death or rehospitalization for HF Adjusted HR: 0.98, p=0.87 Adjusted HR: 1.0, p=0. 98 66.9% (on ECG) Mouillet et al. (2015) 833 CV 1 Mortality Death, stroke and bleeding Heart Failure 16.9 vs. 16.3, p=0.832 32.4 vs. 31.3, p=0.774 11.0 vs. 12. 0, p=0.893 NA Nazif et al. (2015) 1,973 ES 1 Mortality Death and any rehospitalization 26 vs. 18%, p= 0.08 42 vs. 33%, p=0.007 50.5% (on ECG) Fadahunsi et al. (2016) 9,785 ES CV 1 Mortality Heart failure Death or heart failure Adjusted HR: 1.31, p = 0.003 Adjusted HR: 1.23, p = 0.162 Adjusted HR1.33, p < 0.001 NA Chamandi et al. (2017) 1,629 TAVR (ES, CV) 4 Mortality HF admission Adjusted HR: 1.15, p=0.152 Adjusted HR: 1.42, p=0.019 51% more than 40% of pacing
- 7. Troubles conductifs/Arythmies Fadahunsi et al. JACC interv 2016
- 8. Impact of PPI on LVEF Urena et al. Circulation, 2014 54 56 58 60 62 Baseline Discharge Follow-up Leftventricularejectionfraction(%) P=0.017, between both groups P=0.003, between discharge and follow-up accross groups P=0.001, between discharge and follow-up for no PPI groups P=0.412, between baseline and discharge accross groups P=0.061, between discharge and follow-up for 30-day PPI group 30-day PPI No PPI
- 9. Impact of PPI on LVEF Urena et al. Circulation, 2014 54 56 58 60 62 Baseline Discharge Follow-up Leftventricularejectionfraction(%) P=0.017, between both groups P=0.003, between discharge and follow-up accross groups P=0.001, between discharge and follow-up for no PPI groups P=0.412, between baseline and discharge accross groups P=0.061, between discharge and follow-up for 30-day PPI group 30-day PPI No PPI
- 10. Impact of PPI on LVEF Biner et al. Am j Cardiol, 2014 LVEF: left ventricular ejection fraction E/e’: Early transmitral filling peak velocity-Mitral annulus velocity ration SV: stroke volume RIMP: RV index of myocardial performance
- 11. PM and heart failure TTakahashi et al. Catheter Cardiovasc Interv. 2018
- 12. Impact of PPM on LVEF Urena et al.Circulation, 2014 Leftventricularejectionfraction(%) P=0.043 between groups P=0.007 between discharge and follow-up accross groups P=0.020 no PPM vs dual chamber for change between discharge and follow-up P=0.333 no PPM vs single chamber for change between discharge and follow-up 30-day single-chamber PPM No PPM 30-day dual-chamber PPM 54 56 58 60 62 Baseline Discharge Follow-up Impact of PPI on LVEF
- 13. PPM dependency after TAVR Study n Type of valve Incidence of PPM (%) Indications for PPM PPM dependency* at follow-up (%) Fracaro et al. (2011) 67 CV 39 Current guidelines 24 Goldenberg et al. (2013) 178 ES CV 18 2nd and 3erd degree AVB New-onset LBBB New-onset LBBB± PR>200 29 Van der Boon et al. (2013) 167 CV 22 At the discretion of the physician 44 Kirsten al. (2014) 105 CV 22 Current guidelines 52 Ramazzina et al. (2014) 97 ES CV 36 2nd and 3erd degree AVB New-onset LBBB± PR>200 at de discretion of the physician 29 Takahashi et al. (2018) 91 ES CV 16.4 3erd degree AVB and type II 2nd-degree AVB 53* PPM dependency: DDD mode: OR (95%CI) : 3.63 (1.12-11.7), p=0.03
- 14. PPM dependency after TAVR Study n Type of valve Incidence of PPM (%) Indications for PPM PPM dependency* at follow-up (%) Fracaro et al. (2011) 67 CV 39 Current guidelines 24 Goldenberg et al. (2013) 178 ES CV 18 2nd and 3erd degree AVB New-onset LBBB New-onset LBBB± PR>200 29 Van der Boon et al. (2013) 167 CV 22 At the discretion of the physician 44 Kirsten al. (2014) 105 CV 22 Current guidelines 52 Ramazzina et al. (2014) 97 ES CV 36 2nd and 3erd degree AVB New-onset LBBB± PR>200 at de discretion of the physician 29 Takahashi et al. (2018) 91 ES CV 16.4 3erd degree AVB and type II 2nd-degree AVB 53* PPM dependency: DDD mode: OR (95%CI) : 3.63 (1.12-11.7), p=0.03
- 15. Transient AVB?
- 16. Urena et al. Eurointervention 2015 Managing heart block after transcatheter aortic valve implantation
- 17. Timing of high-degree AVB after TAVI Toggweiler S et al. JACC interv 2016
- 18. Troubles conductifs Nazif et al. JACC int 2015
- 19. Troubles conductifs Nazif et al. JACC int 2015
- 20. Br Current European Guidelines Brignole et al. Europace 2013
- 21. Permanent pacemaker implantation is indicated for third- degree and advanced second- degree AV block at any anatomic level associated with postoperative AV block that is not expected to resolve after cardiac surgery. (Level of Evidence: C) Epstein et al. Circulation 2013
- 22. Raelson, J Cardiovasc Electrophysiol. 2017 Recovery of AV nodal conduction after PPM in TAVI patients
- 24. De Carlo Am J Cardiol, 2012 Conservative management of AVB
- 25. Arrhythmia Burden in Candidates for TAVR Urena et al. Circulation 2015
- 26. Arrhythmia Burden in Candidates for TAVR Urena et al. Circulation 2015
- 27. Toggweiler S et al. JACC interv 2016 Management of AVB-ECG postTAVI High-degree AVB according to postTAVI ECG findings
- 28. Management of AVB-LBBB postTAVI Urena et al. JACC 2012
- 29. Management of AVB-LBBB postTAVI Urena et al. JACC 2012
- 30. Urena et al. JACC, 2015 Management of AVB-LBBB postTAVI
- 31. Urena et al. JACC, 2015 Management of AVB-LBBB postTAVI
- 32. Management of AVB-LBBB postTAVI
- 33. Management of AVB-LBBB postTAVI
- 34. Management of AVB-LBBB postTAVI
- 35. Study n Type of valve Incidence of PPM (%) EPS Predicting value Badenco et al. (2017) 83 CV, ES 34 1:Before 2: Immediately after 3: 2 or 5 days after TAVI (ES, CV) HV1, HV2, HV3 or delta HV2 HV3 were not predictors of delayed AVB Eksik et al. (2013) 55 ES, Lotus 14.5 (8, 5 due to AVB) 1: Before 2: immediately after HV after predicted PPM implantation 1.16 (1.01- 1.32), p=0.033 Management AVB-EPS
- 36. Rogers et al. Am J Cardiol 2018 Management AVB-EPS
- 37. Management AVB High degree AVB Permanent Transient PPM PreTAVI ECG ECG recording PostTAVI ECG Severe CD PostTAVI ECG recording LBBB Recurrency Yes No Yes Yes No No Watchful
- 38. Leong et al. Journal of Interventional Cardiac Electrophysiology, 2018 Management AVB-Permanent temporary PM
- 39. Leong et al. Journal of Interventional Cardiac Electrophysiology, 2018 Management AVB-Permanent temporary PM
- 40. Conclusions • The occurrence of conduction disturbances remains the most frequent complication of TAVR
- 41. Conclusions • The occurrence of conduction disturbances remains the most frequent complication of TAVR • PPM implantation after TAVI might have a negative impact on clinical outcomes and hemodynamic changes over time, and therefore, all efforts should be made to avoid unnecessary PPM implantations
- 42. Conclusions • The occurrence of conduction disturbances remains the most frequent complication of TAVR • PPM implantation after TAVI might have a negative impact on clinical outcomes and hemodynamic changes over time, and therefore, all efforts should be made to avoid unnecessary PPM implantations • A period of observation might be reasonable before PPM implantation after TAVI in order to identify transient conduction disorders
- 43. Conclusions • The occurrence of conduction disturbances remains the most frequent complication of TAVR • PPM implantation after TAVI might have a negative impact on clinical outcomes and hemodynamic changes over time, and therefore, all efforts should be made to avoid unnecessary PPM implantations • A period of observation might be reasonable before PPM implantation after TAVI in order to identify transient conduction disorders • ECG monitoring before TAVR might be helpful to identify those patients with conduction disorders which are “not expected to resolve”, leading to a reduction in the length of hospital stays by allowing an earlier indication of definitive therapy
- 44. • In patients with transient AVB and severe conduction disturbances before the procedure and or new onset LBBB after TAVR with a QRS prolongation>160ms, a PPM implantation should be considered Conclusions
- 45. • In patients with transient AVB and severe conduction disturbances before the procedure and or new onset LBBB after TAVR with a QRS prolongation>160ms, a PPM implantation should be considered • The utility of EPS in this setting remains unclear and should be evaluated in futures studies Conclusions
- 46. • In patients with transient AVB and severe conduction disturbances before the procedure and or new onset LBBB after TAVR with a QRS prolongation>160ms, a PPM implantation should be considered • The utility of EPS in this setting remains unclear and should be evaluated in futures studies • Nonetheless, the best timing for PPM implantation, the best type of PPM and long-term pacing requirements remains to be determined Conclusions
- 47. Does pacemaker confers mortality benefit in the short -term postTAVR (NCT02700633) Indication of PPM after TAVR (TAVISTIM) (NCT02337140) Assessment of arrhythmias in patients undergoing TAVI using a small implantable monitor (NCT02559011) HV Electrophysiology Study in TAVI Patients (HESITATE) (NCT02659137) Ongoing studies