Incidence And Predictors Of Left Bundle Branch Block After Transcatheter Aortic Valve Implantation

Transcription

1 Incidence And Predictors Of Left Bundle Branch Block After Transcatheter Aortic Valve Implantation Ömer Aktug 1, MD; Guido Dohmen 2, MD; Kathrin Brehmer 1, MD; Verena Deserno 1 ; Ralf Herpertz 1 ; Rüdiger Autschbach 2, MD; Robert Stöhr 1, MD; Nikolaus Marx 1, MD; Rainer Hoffmann 1, MD 1 Department of Cardiology, Pneumology and Angiology, University Hospital of RWTH Aachen, Germany 2 Department of Cardiac and Thoracic Surgery, University Hospital of RWTH Aachen, Germany

2 Conflict Of Interest - Disclosure Within the past 12 months, I have had a financial interest/ arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company 1. Honoraria for lectures no 2. Honoraria for advisory board activities no 3. Participation in clinical trials no 4. Research funding no

3 Background Aortic stenosis (AS) is a consistently progressive disease that affects 2-7% of individuals older than age 65 with associated impact on morbidity and mortality Aortic valve replacement (AVR) is the most common heart valve procedure Since the initiation of transcatheter aortic valve implantation (TAVI) in 2002, there has been increasing interest in the field of catheter-based treatment of high surgical-risk and non-operable patients with symptomatic AS There is a high incidence of early alterations in atrioventricular/ interventricular conduction after TAVI and need for pacemaking

4 Dawkins S. Ann Thorac Surg 2008; 85: Thomas JL. J Thorc Cardiovasc Surg 1982; 84: El-Khally Z. Am J Cardiol 2004; 94: Conduction Defects In Surgical AVR Left Bundle Branch Block (LBBB) Thomas JL (1982) 31.6 % Ziad El-Khally (2004) 5.7 % AV-Block (AVB) Gannon PG (1965) 12.5 % Kalusche D (1986) 0.9 % Morell VO (2006) 6.5 % Global defects Koplan (2003) 5.1 % Associated with increased incidence of cardiac events*!! specifically syncope, AV dissociation and sudden death

5 Conduction Defects In TAVI Conduction disturbances (LBBB, AV-Block) and need for pacemaker implantation have also been reported after TAVI LBBB is associated with left ventricular mechanical dyssynchrony, left ventricular remodeling and impaired systolic and diastolic heart function However, there were few small systematic analyses on the frequency of conduction disturbance and in particular LBBB after TAVI

6 Aim Of Study Evaluation of frequency and possible predictors of Left Bundle Branch Block (LBBB) after TAVI using CoreValve TM as well as Edwards SAPIEN TM valve prosthesis

7 RWTH University Of Aachen Experience January 2008 December pts mean age 73 (m), 132 (f) 80 ± 7 years

8 Patients Selection I Inclusion criteria: Severe aortic valve stenosis, AVA <1 cm 2, with severe symptoms related to AS Aortic valve annulus diameter 18 mm and 27 mm Femoral or iliacal artery >7mm and absence of stenosis Patients referred for TAVI after a senior cardiologist and senior cardiac surgeon reached consensus that surgical replacement would be associated with either high or prohibitive risk or contraindications for surgery

9 Patients Selection II Contraindications: Bicuspid aortic valve Asymmetric heavy valvular calcification Aortic root dimension >45 mm Presence of LV apical thrombus Not in patients with life expectancy < 1 year (conservative treatment)

10 Arrhythmic Evaluation Pre-procedure Basal ECG 12-Lead Post-procedure 24-48h If after 48 h there is spontaneous rhythm, remotion of temporary pacing and carry out Holter ECG monitoring If after 48 h patient is still paced, implantation of permanent pacemaker (PPM) Folluw-up post-procedure ECG 12-leads pre-discharge Potential clinical, ECG, angiographic and echocardiographic predictors of permanent pacing requirement were studied

11 Patient Characteristics (n=205) N (%) Age (yrs), mean ±SD 80 ± 7 Male 73 (36) Coronary artery disease 132 (64) NYHA classification ( II) 175 (85) LV-EF (EF 45%) 143 (70) Diabetes 55 (27) Hypertension 193 (94) Hypercholesterolemia 127 (62) Renal insufficiency 85 (41) Smoker 46 (22) LA size (mm) 40.5 ± 6.7 LVEDD (mm) 47.2 ± 7.3 LVH 152 (74) Aortic valve area, preprocedural (cm 2 ) 0.7± 0.2 Agatston score 2225 ± 1341 LVOT diameter (mm), mean ±SD 19.5 ± 2.3 Aortic annulus diameter (mm), mean ±SD 22.4 ± 2.5 Prosthesis type CoreValve Edwards-SAPIEN Prosthesis inflow size CoreValve 26-mm 29-mm 96 (47) 109 (53) 52 (58) 38 (42) Edwards SAPIEN 23-mm 26-mm 27 (26) 76 (74) LVOT =left ventricular outflow tract; LV-EF= left ventricular ejection function; LA= left atrium; LVEDD= left ventricular enddiastolic diameter; LVH= left ventricular hypertrophy Aktug et al. Int J Cardiol, in press

12 Pre-implant Analysis n (%) Sinusrhythm 107 (52) Atrial fibrillation 53 (26) PPM 10 (3) AV-Block >1

13 Immediate POST-IMPLANT 23% 27% 3% SR 47% AF Complete AVB Complete AVB+AV delay

14 30-days Follow-up Methods: 12-lead ECG Pre Implantation (n=205) Post Implantation (n=185) LBBB 20 (9.7%) 52 (28.1%) CoreValve 9 (10.4%) 37 (38.5%) 30-day FU (n=179) * 28 (15.6%) 22 (12.3%) Edwards- Sapien 11 (10.1%) 15 (13.8%) 6 (3.3%) * 26 pts (=12.7%) died during FU

15 Characteristics Of Edwards vs CoreValve Patients Edwards n=109 CoreValve n=96 P Age, years 79 ± 7 82 ± Gender, male 46 (42%) 28 (29%) Ejection fraction - >60% % % % - <35% Annulus diameter, mm 22 ± 3 23 ± LBBB pre (n) 11 (10%) 9 (9%) LBBB post (n) 15 (14%) 37 (39%) Pacemaker implantation (n) 7 (6%) 37 (39%) <0.001 Prosthesis implantation depth, mm 6.6 ± ± 3.0 <0.001 All-cause death, n 10 (9%) 16 (17%) 0.432

16 Characteristics Of Patients With And Without New LBBB After TAVI New LBBB n=52 No new LBBB (prior LBBB+no LBBB) n=153 Age, years 80 ± 5 80 ± Gender, male 32 (44%) 41 (56%) P Ejection fraction, % - > < Annulus diameter, mm 22 ± 2 22 ± Agatston Score 2116 ± ± Valve type - CoreValve - Edwards 37 (38.5%) 15 (13.8%) 59 (61.5%) 94 (86.2%) Left ventricular hypertrophy 41 (79%) 87 (57%) Pacemaker implantation 16 (31%) 25 (16%) Prosthesis diameter to aortic annulus diameter ratio 1.2 ± ± Prosthesis implantation depth, mm 9.4 ± ± 3.2 <0.001 All-cause death, n 5 (10%) 22 (14%) 0.228

17 Predictors Of New LBBB After TAVI Univariate Analysis OR 95% CI P Prosthesis type being CoreValve Valve implantation depth into the left ventricular outflow tract (per mm) Ratio of prothesis diameter to aortic annulus diameter Multivariate Analysis OR 95% CI P Prosthesis type being CoreValve Valve implantation depth into the left ventricular outflow tract (per mm)

18 Conclusions TAVI is frequently associated with new LBBB. New LBBB is transient in approx. 50% of pts and may disappear after 30 days. Frequency of new LBBB is higher after implantation of the CoreValve than after implantation of the Edwards prosthesis. The only predictor of new LBBB is implantation depth of the prosthesis. An implantation depth >8 mm is related to a higher incidence of LBBB.

19 Thanks For Your Attention!