The impact of persistent left bundle branch block on the midterm prognosis after transcatheter «MedLab-CT» valve implantation

Aim. The aim of the study was to study the effect of first appeared persistent left bundle branch block on the prognosis of patients after «MedLab-CT» transcatheter aortic valve implantation (TAVI) in the middle long-term follow-up period.

Methods. The study included 129 patients after the TAVI procedure, who initially did not have LBBB. The average age of patients was 70.2±5.2 years, body mass index - 31.4±5.9 kg/m2, the proportion of men was 36%, arterial hypertension was diagnosed in 93%, diabetes mellitus in 32%, coronary heart disease in 59% of patients, paroxysmal form of atrial fibrillation was registered in 16%, permanent form of atrial fibrillation - in 3% of patients. According to echocardiography the end-diastolic volume was 107.7±30.9 ml, the ejection fraction was 61.4±10.4%, the maximum and average pressure gradient on the aortic valve was 91.7±25.7 mmHg and 52.7±16.4 mmHg respectively. The width of the QRS complex was 84.1±12ms. Depending on the occurrence of LBBB after the TAVI procedure, the patients were divided into 2 groups: the first group included 98 patients without LBBB (the width of the QRS complex was 98.4±16ms), the second included 31 patients with LBBB (the width of the QRS complex was 149.6±17ms). The groups were comparable in other clinical, demographic and ultrasound parameters. The follow-up period was 60 months.

Results. There were no differences in echocardiography data in both groups, and mortality rates from all causes were also comparable. During the follow-up period in the LBBB group two patients was implanted a pacemaker (6.45%; p=0.001). The LBBB after TAVI did not increase all-cause mortality in patients (OR 1.084; DI= 0.353-3.209; p=0.912).

Conclusion. The first time arisen LBBB does not increase mortality in patients after TAVI «MedLab-CT» in the middle long-term follow-up period, but it is associated with a higher risk of developing a high-grade atrioventricular block requiring pacemaker implantation.

1. 2021 ESC/ EACTS Guidelines for the management of valvular heart disease. Russian Journal of Cardiology. 2022;27(7): 5160. (In Russ.). https://doi.org/10.15829/1560-4071-2022-5160.

2. Dzhidzalova DH, Berdibekov BSh, Petrosyan KV. Transcatheter aortic valve implantation: from previously inoperable patients to low surgical risk patients. Creative Cardiology. 2021;15 (4): 440-55. (In Russ.). https://doi.org/10.24022/1997-3187-2021-15-4-440-455.

3. Joseph J, Naqvi SY, Giri J, et al. Aortic Stenosis: Pathophysiology, Diagnosis, and Therapy. Am J Med. 2017;130(3): 253-263. https://doi.org/10.1016/j.amjmed.2016.10.005.

4. Bazylev VV, Voevodin AB, Zakharova AS, et al. Immediate clinical and hemodynamic results of transcatheter implantation of the MedLab-KT aortic valve prosthesis. Circulation Pathology and Cardiac Surgery. 2018;22(3): 17-24. (In Russ.).

5. Reinöhl J, Kaier K, Reinecke H, et al. Effect of availability of transcatheter aortic-valve replacement on clinical practice. N Engl J Med. 2015;373: 2438-2447. https://doi.org/10.1056/NEJMoa1500893.

6. Vahl TP, Kodali SK, Leon MB. Transcatheter aortic valve replacement 2016: a modern-day “through the looking-glass” adventure. J Am Coll Cardiol. 2016;67: 1472- 1487. https://doi.org/10.1016/j.jacc.2015.12.059.

7. Popylkova OV, Durmanov SS, Bazylev VV, et al. Cardiac conduction disturbances following transapical «MedLab-KT» aortic valve implantation: first results. Jounal of Arrhythmology. 2019, 2019;26(2): 14-18. (In Russ.). https://doi.org/10.35336/VA-2019-2-14-18.

8. Regueiro A, Abdul-Jawad Altisent O, Del Trigo M, et al. Impact of new-onset left bundle branch block and periprocedural permanent pacemaker implantation on clinical outcomes in patients undergoing transcatheter aortic valve re placement: a systematic review and meta-analysis. Circ Cardiovasc Interv. 2016;9: e003635. https://doi.org/10.1161/CIRCINTERVENTIONS.115.003635.

9. Leon MB, Smith CR, Mack MJ, et al. PARTNER 2 Investigators. Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients. N Engl J Med. 2016 Apr 28;374(17): 1609-20. https://doi.org/10.1056/NEJMoa1514616.

10. Dowling C, Kondapally Seshasai SR, Firoozi S, Brecker SJ. Transcatheter aortic valve replacement versus surgery for symptomatic severe aortic stenosis: A reconstructed individual patient data meta-analysis. Catheter Cardiovasc Interv. 2020 Jul;96(1): 158-166. https://doi.org/10.1002/ccd.28504.

11. Ajmal Z, Rehman ZU, Ishtiaq A, et al. Comparative Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement in Moderate-Risk Patients With Aortic Stenosis: A Systematic Review of Clinical Trials. Cureus. 2024 Sep 26;16(9): e70268. https://doi.org/10.7759/cureus.70268.

12. ElGuindy A. PARTNER 2A & SAPIEN 3: TAVI for intermediate risk patients. Glob Cardiol Sci Pract. 2016 Dec 30;2016(4): e201633. https://doi.org/10.21542/gcsp.2016.33.

13. Thourani VH, Kodali S, Makkar RR, et al. Transcatheter aortic valve replacement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis. Lancet. 2016;387: 2218-2225. https://doi.org/10.1016/S0140-6736(16)30073-3.

14. Auffret V, Puri R, Urena M, et al. Conduction disturbances after transcatheter aortic valve replacement: current status and future perspectives. Circulation. 2017;136: 1049- 69. https://doi.org/10.1161/circulationaha.117.028352.

15. Young Lee M, Chilakamarri Yeshwant S, Chava S, et al. Mechanisms of heart block after transcatheter aortic valve replacement: cardiac anatomy, clinical predictors and mechanical factors that contribute to permanent pacemaker implantation. Arrhythm Electrophysiol Rev. 2015;4: 81-85. https://doi.org/10.15420/aer.2015.04.02.81.

16. Piazza N, de Jaegere P, Schultz C, et al. Anatomy of the aortic valvar complex and its implications for transcatheter implantation of the aortic valve. Circ Cardiovasc Interv. 2008;1: 74-81. https://doi.org/10.1161/CIRCINTERVENTIONS.108.780858.

17. Van der Boon RM, Nuis RJ, Van Mieghem NM, et al. New conduction abnormalities after TAVI-frequency and causes. Nat Rev Cardiol. 2012;9: 454-463. https://doi.org/10.1038/nrcardio.2012.58.

18. Moreno R, Dobarro D, López de Sá E, et al. Cause of complete atrioventricular block after percutaneous aortic valve implantation: insights from a necropsy study. Circulation. 2009;120: e29-e30. https://doi.org/10.1161/CIRCULATIONAHA.109.849281.

19. Kawashima T, Sato F. Visualizing anatomical evidences on atrioventricular conduction system for TAVI. Int J Cardiol. 2014;174: 1-6. https://doi.org/10.1016/j.ijcard.2014.04.003.

20. Hamdan A, Guetta V, Klempfner R, et al. Inverse relationship between membranous septal length and the risk of atrioventricular block in patients undergoing transcatheter aortic valve implantation. JACC Cardiovasc Interv. 2015;8: 1218-1228. https://doi.org/10.1016/j.jcin.2015.05.010.

21. De Torres-Alba F, Kaleschke G, Diller GP, et al. Changes in the pacemaker rate after transition from Edwards SAPIEN XT to SAPIEN 3 transcatheter aortic valve implantation: the critical role of valve implantation height. JACC Cardiovasc Interv. 2016;9: 805-813. https://doi.org/10.1016/j.jcin.2015.12.023.

22. Bax JJ, Delgado V, Bapat V, et al. Open issues in transcatheter aortic valve implantation, part 2: procedural issues and outcomes after transcatheter aortic valve implantation. Eur Heart J. 2014;35: 2639-2654. https://doi.org/10.1093/eurheartj/ehu257.

23. Rampat R, Khawaja MZ, Byrne J, et al. Transcatheter aortic valve replacement using the repositionable LOTUS valve: United Kingdom experience. JACC Cardiovasc Interv. 2016;9: 367-372. https://doi.org/10.1016/j.jcin.2015.12.012.

24. Zaman S, McCormick L, Gooley R, et al. Incidence and predictors of permanent pacemaker implantation following treatment with the repositionable Lotus™ transcatheter aortic valve. Catheter Cardiovasc Interv. 2017;90: 147- 154. https://doi.org/10.1002/ccd.26857.

25. Nazif TM, Williams MR, Hahn RT, et al. Clinical implications of new-onset left bundle branch block after transcatheter aortic valve replacement: analysis of the PARTNER experience. Eur Heart J. 2014;35: 1599-1607. https://doi.org/10.1093/eurheartj/eht376.

26. Sammour Y, Krishnaswamy A, Kumar A, et al. Incidence, predictors, and implications of permanent pacemecers requirement after transcatheter aortic valve replacement JACC Cardiovasc Interv. 2021;14(2): 115-34. https://doi.org/10.1016/j.jcin.2020.09.063.

27. Urena M, Webb JG, Eltchaninoff H, Muñoz-García AJ, et al. Late cardiac death in patients un dergoing transcatheter aortic valve replacement: incidence and predictors of advanced heart failure and sudden cardiac death. J Am Coll Cardiol. 2015;65: 437-448. https://doi.org/10.1016/j.jacc.2014.11.027.

28. Meguro K, Lellouche N, Yamamoto M, et al. Prognostic value of QRS duration after trans catheter aortic valve implantation for aortic stenosis using the CoreValve. Am J Cardiol. 2013;111: 1778-1783. https://doi.org/10.1016/j.amjcard.2013.02.032.

29. Chamandi C, Barbanti M, Munoz-Garcia A, et al. Long-term outcomes in patients with new onset persistent left bundle branch block following TAVR. J Am Coll Cardiol Intv 2019;12: 1175-84. https://doi.org/10.1016/j.jcin.2019.03.025.