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 < 3 seconds

    • 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.

 

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