Value of Periprocedural Electrophysiology Testing During Transcatheter Aortic Valve Replacement for Risk Stratification of Patients With New-Onset Left Bundle-Branch Block.

Background Despite being the most frequent complication following transcatheter aortic valve replacement (TAVR), optimal management of left bundle-branch block (LBBB) remains unknown. Electrophysiology study has been proposed for risk stratification. However, the optimal timing of electrophysiology study remains unknown. We aimed to investigate the temporal dynamics of atrioventricular conduction in patients with new-onset LBBB after TAVR by performing serial electrophysiology study and to deduce a treatment strategy. Methods and Results We assessed consecutive patients undergoing TAVR via His-ventricular interval measurement prevalve and postvalve deployment and the day after TAVR. Infranodal conduction delay was defined as a His-ventricular interval >55 milliseconds. Among 107 patients undergoing TAVR, 53 patients (50%) experienced new-onset LBBB postvalve deployment and infranodal conduction delay was noted in 24 of 53 patients intraprocedurally (45%). LBBB resolved the day after TAVR in 35 patients (66%). In patients with new-onset LBBB postvalve deployment and no infrahisian conduction delay intraprocedurally, the His-ventricular interval did not prolong in any patient to >55 milliseconds the following day. Overall, 4 patients (7.5%) with new-onset LBBB after TAVR were found to have persistent infrahisian conduction delay 24 hours after TAVR. During 30-day follow-up, 1 patient (1.1%) with new LBBB and a normal His-ventricular interval after TAVR developed new high-grade atrioventricular block. Conclusions Among patients with new-onset LBBB postvalve deployment, infrahisian conduction delay can safely be excluded intraprocedurally, suggesting that early intracardiac intraprocedural conduction studies may be of value in these patients.

Non-invasive predictors for infranodal conduction delay in patients with left bundle branch block after TAVR.

AIMS: Left bundle branch block (LBBB) is the most common conduction disorder after transcatheter aortic valve replacement (TAVR) with an increased risk of atrioventricular (AV) block. The aim of the current study was to identify non-invasive predictors for infranodal conduction delay in patients with LBBB. METHODS: We analyzed consecutive patients undergoing TAVR with pre-existing or new-onset LBBB between August 2014 and August 2020. His ventricular (HV) interval measurement was performed on day 1 after TAVR. Baseline, procedural, as well as surface and intracardiac electrocardiographic parameters were included. Infranodal conduction delay was defined as HV interval > 55 ms. RESULTS: Of 825 patients screened after TAVR, 151 patients (82 ± 6 years, 39% male) with LBBB were included. Among these, infranodal conduction delay was observed in 25%. ΔPR (difference in PR interval after and before TAVR), PR and QRS duration after TAVR were significantly longer in the group with HV prolongation. In a multivariate analysis in patients with sinus rhythm (n = 123), ΔPR (OR per 10 ms increase: 1.52; 95%CI: 1.19-2.01; p = 0.002) was the only independent factor associated with infranodal conduction delay. A change in PR interval by 20 ms yielded a specificity of 83% and a sensitivity of 46%, with a negative predictive value of 84% and a positive predictive value of 45% to predict HV prolongation. CONCLUSIONS: Simple analysis of surface ECG and a calculated ΔPR < 20 ms can be used as predictor for the absence of infranodal conduction delay in post-TAVR patients with LBBB.

Incidence and predictors of atrial fibrillation progression: A systematic review and meta-analysis.

BACKGROUND: More sustained forms of atrial fibrillation (AF) are less amenable to treatment and associated with worse outcomes, but the incidence and predictors of AF progression are not well defined. OBJECTIVE: The purpose of this study was to perform a systematic review and meta-analysis assessing the incidence and predictors of AF progression. METHODS: PubMed, EMBASE, and the Cochrane Library were searched from inception to August 2017. AF progression was defined as progression from paroxysmal to persistent/permanent AF or as progression from persistent to permanent AF. Random effect models were used to calculate pooled cumulative incidence rates. Predictors related to between-study variability were assessed using meta-regression analyses. RESULTS: We identified 47 studies with 27,266 patients who were followed for 105,912 patient-years. The pooled incidence of AF progression was 8.1 per 100 patient-years of follow-up (95% confidence interval [CI] 7.1-9.1 per 100 patient-years of follow-up; I2 = 98%; P < .0001). The incidence was 7.1 per 100 patient-years of follow-up (95% CI 6.2-8.0 per 100 patient-years of follow-up; across 42 studies) for progression from paroxysmal to non-paroxysmal AF as compared with 18.6 per 100 patient-years of follow-up (95% CI 8.9-28.3 per 100 patient-years of follow-up; across 5 studies) for progression from persistent to permanent AF. Higher age (ß = 5.4; 95% CI 1.4-9.4; P = .01; R2 = 14.3%) and the prevalence of hypertension (ß = 5.2; 95% CI 1.0-9.4; P = .02; R2 = 18.0%) were associated with a higher AF progression rate. Follow-up duration (ß = -4.5; 95% CI -5.8 to -3.3; P < .0001; R2 = 68.0%) and the prevalence of paroxysmal AF (ß = -9.5; 95% CI -18.7 to -0.3; P = .04; R2 = 4.4%) were inversely associated with AF progression. Together these variables explained 73.8% of the observed between-study heterogeneity. CONCLUSION: The incidence of AF progression appears to be relatively low, and the incidence seems to decrease with longer follow-up duration. Age, hypertension, baseline AF type, and follow-up duration explained a high percentage of the observed between-study heterogeneity.