PM indications before and after TAVI

Transcription

1 PM indications before and after TAVI PD Dr. med. Stefan Toggweiler LA Herzzentrum Leiter interventionelle Klappentherapie Luzerner Kantonsspital 6000 Luzern

2 Agenda Basics Predictors for PPM implantation Is the ECG post TAVI a better predictor? Does complete heart block or PM dependency resolve? Prognostic relevance of PPM PM indications

3 PM after TAVI and SAVR: PARTNER A Smith et al., NEJM 2011

4 PARTNER and PARTNER registry Randomized cohort: 5.6% Non-randomized registry: 9.6% Overall: 8.8%

5 PM after SAVR and TAVI (matched) Bagur et al., JACC Intv 2012

6 PPM rates in Switzerland Wenaweser et al., EuroIntervention 2014

7 Anatomy: Conduction system and valve

8 LBBB occurs before RBBB Pooled data from USZ and LUKS

9 Anatomy: conduction system and cusps

10 Implantation height: measure between RC and NC cusp NCC RCC LCC

11 Amount of septal compression Nazif et al., JACC Intv 2015

12 PPM and Sapien 3 Pooled data from USZ and LUKS 9.4% 17.9%

13 PPM and Sapien 3

14 Predictors for a new PPM Predictor OR RBBB Oversizing 4.1 CoreValve use Bradycardia / AVB LAHB Prior radiation of chest 2.3 Age > 80 years 1.4 Prosthesis/LVOT diameter per Implantation depth per mm Male sex 1.2 LV-EDD, per cm.76 LVOT diameter per mm.37 Porcelain aorta / Calcification Nazif et al., JACC Intv 2015 Lewdoch et al, CCI 2013 Bagur et al., JACC Intv 2012 Bleiziffer et al., JACC Intv 2010 Baan et al., Am Heart J 2010 Sinhal et al., JACC Intv 2008 Van der Boon et al., CCI 2015 Siontis et al, JACC 2014 Boerlage et al, PACE 2014 Tchetche et al., EuroInterv 2012

15 The prognostic value of the ECG post TAVI: Need for a PPM No difference between CV and SAPIEN XT/3 Pooled data from USZ and LUKS

16 Timing of complete heart block Pooled data from USZ and LUKS

17 The problem of late heart blocks Day Valve ECG at ECG post TAVI baseline 1 CoreValve Normal ECG LBBB 1 SAPIEN XT Normal ECG LBBB 1 CoreValve LBBB LBBB 1 SAPIEN 3 LBBB LBBB + AVB 1 2 CoreValve RBBB RBBB 2 CoreValve Normal ECG LBBB 2 CoreValve LBBB LBBB 2 SAPIEN 3 RBBB RBBB 2 CoreValve Normal ECG LBBB + AVB 1 3 CoreValve AVB 1 LBBB + AVB 1 3 SAPIEN 3 Normal AVB 1 3 SAPIEN 3 RBBB RBBB + AVB 1 4 CoreValve Normal LBBB + AVB 1 5 SAPIEN 3 LBBB LBBB + AVB 1 Pooled data from USZ and LUKS

18 The problem of very late heart blocks Valve Day 1 Day 2 Day 3 Day 4 Day 5 CoreValve AVB II SAPIEN AVB II SAPIEN AVB II CoreValve AVB II SAPIEN AVB III Pooled data from USZ and LUKS

19 ECG post TAVI: summary Predictor for heart block and need for PPM, valid for Medtronic CV and Sapien XT/3 Normal postprocedural ECG: No heart blocks, no need for PPM Very late heart blocks occur in those with first degree AVB (or bradicardia, if afib), PQ gradually increases Manuscript in preparation

20 Recommended duration of telemetry monitoring Manuscript in preparation

21 Very late heart block with bradycardia (CE-mark study self expanding valve) Baseline: Afib, bradycardia, HR 53/min, asymptomatic Post TAVI: New LBBB, Afib, bradycardia, HR 40-60/min, asymptomatic 7 days after TAVI Syncope at home CHB PM implantation

22 Do conduction disorders resolve? Houthuizen et al., EuroIntervention 2014

23 Do conduction disorders resolve? Houthuizen et al., EuroIntervention 2014

24 Pacemaker dependency during followup Median follow-up of 11.5 months Van der Boon et al., Int J Cardiol 2014

25 Evolution of VP and AP Most patients paced > 10% of time

26 Prognostic relevance of new PPM Buellesfeld et al., JACC 2012

27 Prognostic relevance: PARTNER data Nazif et al., JACC Intv 2015

28 Effect on LV-EF Data from LUKS

29 Indication for PPM after TAVI o Complete AV block o o o o o o o o Usually PM indication Consider watchful waiting if balloon expandable valve was implanted First degree AV block and narrow QRS Watchful waiting, daily ECG. PM if PQ continues to increase First degree AV block and wide QRS (LSB) Watchful waiting if PQ < 250 ms. PM indication more liberal Afib with bradycardia or sinus bradycardia Only watchful waiting if HR > 50/min and asymptomatic, monitor for 5 days

30 Indication for PPM before TAVI: personal recommendations Recommended: any symptomatic bradycardia or higher degree AVB Consider: RBBB or LBBB and AVB 1 or bradycardia (afib, SB) < 60/min May consider: RBBB and planned intervention with a selfexpanding valve or big valve in small LVOT

31 Think about CRT! Any patient requiring a permanent PM and LV-EF < 45%

32 Apparently + =