Contributor: Taylor Lynch, MD

Educational Pearls:

Conduction abnormalities are a common and clinically significant complication in patients who undergo transcatheter aortic valve replacement (TAVR)

Clinical Features

The most common abnormalities include high grade AV block and new onset LBBB

Due to the close proximity of the aortic annulus to the AV node and His-Purkinje system
More common in males, the elderly, and those with pre-existing conduction disease (RBBB or LBBB)

Sinus pauses and sinus arrest are a rare post-TAVR rhythm disturbances

Temporary failure of sinus node firing with absent P waves, followed by return of sinus rhythm

Sinus Pauses: Typically last
Sinus Arrest: Typically last > 3 seconds

Not due to direct mechanical injury from the valve, but may occur in patients as a result of pre-existing disease or other external factors:

Medications

Beta blockers, calcium channel blockers, digoxin

Pre-existing damage to the SA node

Fibrosis from a previous MI

Treatment

If the patient is asymptomatic, provide ongoing surveillance
If the patient is symptomatic, treatment should be aimed at the underlying cause:

For medication-induced abnormalities, stop the offending medication
For acute, unstable bradycardia:

Medications: Atropine, Dopamine Infusion, Epinephrine Infusion

If cardiology is not immediately available, initiate transcutaneous pacing or insert a temporary transvenous pacemaker
Definitive treatment: Pacemaker

~10–15% of patients may develop a bradyarrhythmia post TAVR, with ~8-15% later requiring a pacemaker

Due to the risk of conduction abnormalities post TAVR, many patients are discharged with ambulatory rhythm monitoring such as a ZioPatch or Holter monitor, and may present to the emergency department for evaluation of rhythm disturbances.

References:

Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. Heart Rhythm. 2019;16(9):e128-e226.
Lilly, S, Deshmukh, A, Epstein, A. et al. 2020 ACC Expert Consensus Decision Pathway on Management of Conduction Disturbances in Patients Undergoing Transcatheter Aortic Valve Replacement: A Report of the American College of Cardiology Solution Set Oversight Committee. JACC. 2020 Nov, 76 (20) 2391–2411.

https://doi.org/10.1016/j.jacc.2020.08.050

Sammour, Y, Krishnaswamy, A, Kumar, A. et al. Incidence, Predictors, and Implications of Permanent Pacemaker Requirement After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol Intv. 2021 Jan, 14 (2) 115–134.

https://doi.org/10.1016/j.jcin.2020.09.063

Tarakji KG, Patel D, Krishnaswamy A, et al. Bradyarrhythmias detected by extended rhythm recording in patients undergoing transcatheter aortic valve replacement (Brady-TAVR Study). Heart Rhythm. 2022;19(3):381-388.

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P

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