"Although TAVR lessens many of the risks and complications of open surgical aortic valve replacement, there remain challenges with TAVR, including conduction disorders and need for PPM implantation," Dr. Ole De Backer of the University of Copenhagen told Reuters Health by email.
"Prior studies reported that a pre-existing RBBB is a strong independent predictor for PPM implantation after TAVR," he said, "and two studies even linked RBBB to a higher risk of mortality following TAVR in case patients were discharged without a PPM."
"Facing the challenge of managing these prolonged hospitalizations as well as doubts on the safety of discharging these patients without PPM, some European centers have started implementing a PPx-PPM implantation strategy," he said.
PPx-PPM is considered appropriate for RBBB patients with a QRS duration of at least 150 ms, bifascicular block and/or PR duration of at least 220 ms.
As reported in JACC: Cardiovascular Interventions, Dr. De Backer and colleagues analyzed all patients with pre-existing RBBB (QRS >120 ms) treated with streamlined transfemoral TAVR from 2016-2020 (188 of TAVR 3,051 patients).
They compared hospital patient flow and clinical endpoints for those treated in the early period (2016-2018) without PPx-PP versus the late period (2018-2020) with selective PPx-PPM.
In the early period, a PPM was implanted in 54% of all patients after TAVR (48% pre-discharge; 6% postdischarge).
In the late period, a PPM was implanted prophylactically in 44%, and in an additional 27% after TAVR (26% pre-discharge; 1% postdischarge).
Overall, 66% of all TAVR patients with a pre-existing RBBB treated in the early period ended up with a PPM versus 80% of those treated in the late period.
PPx-PPM was associated with a significantly shorter TAVR procedural time (mean, 89 min in the early period vs. 72 min in the late period) and shorter hospital stay (45% vs. 17%).
Dr. De Backer said, "Taken together, the results in this study indicate that selective PPx-PPM implantation in a TAVR population with pre-existing RBBB is safe, may stimulate early discharge and could potentially be life-saving in the early phase after discharge."
Which criteria (ECG, clinical, procedural, valve-specific criteria) should be used in the decision-making process for a PPx-PPM are not clear yet, he added.
Dr. Mathew Williams, Director of the Heart Valve Center and Chief of Adult Cardiac Surgery at NYU Langone Health in New York City, commented by email to Reuters Health, "This is an interesting approach and certainly might be warranted in some patients."
"Still, a minority of patients with RBBB require a pacemaker and there are proven methods that can help reduce the incidence," he said. "We rarely need to keep these patients in the hospital beyond the first day."
"Placing a PPM is not without risks, expense or long-term consequences and the potential benefit needs to be carefully balanced against these risks," he said. "Ideally, in the future, we can optimize the valve and procedure to reduce the risk in this higher risk patient population and find a better way to predict which patients specifically would benefit from a prophylactic PPM."
SOURCE: https://bit.ly/351D7UM JACC: Cardiovascular Interventions, online June 7, 2021.
By Marilynn Larkin
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