RÉSUMÉ
BACKGROUND: Variations in the aortomitral positional anatomy, including aortic root rotation appear to be related to variations in the location of the conduction system, including the bundle of His. However, little is known about their clinical significance. METHODS AND RESULTS: This study included 147 patients with normal ECGs who underwent mitral valve surgery. The aortomitral anatomy was classified using preoperative 3-dimensional transesophageal echocardiography, and postoperative conduction disorders, including atrioventricular block and bundle branch block, were analyzed. Variations classified as aortomitral appearance were designated as having a center appearance (85.7%, n=126/147) or lateral appearance (14.3%, n=21/147) on the basis of whether the aortic root was located at the center or was shifted to the left fibrous trigone side. Subsequently, those with a center appearance, aortic root rotation was classified as having a center rotation (83.3% [n=105/126]), in which the commissure of the left and noncoronary aortic leaflet was located at the center, lateral rotation (14.3% [n=18/126]), rotated to the left trigone side, or medial rotation (2.4% [n=3/126]), rotated to the right. The incidence of 3-month persistent new-onset conduction disorder was higher in the lateral appearance than the center appearance group (21.1% versus 5.0%; P=0.031) and higher in the lateral rotation than in the center or medial rotation groups (29.4% versus 1.0% versus 0.0%, respectively; P<0.001). CONCLUSIONS: Aortomitral variations can be classified using 3-dimensional transesophageal echocardiography. Lateral appearance and lateral rotation are risk factors for conduction disorders in mitral valve surgery.
Sujet(s)
Bloc atrioventriculaire , Échocardiographie tridimensionnelle , Échocardiographie transoesophagienne , Valve atrioventriculaire gauche , Humains , Mâle , Femelle , Valve atrioventriculaire gauche/imagerie diagnostique , Valve atrioventriculaire gauche/chirurgie , Valve atrioventriculaire gauche/physiopathologie , Adulte d'âge moyen , Bloc atrioventriculaire/étiologie , Bloc atrioventriculaire/physiopathologie , Bloc atrioventriculaire/diagnostic , Sujet âgé , Études rétrospectives , Électrocardiographie , Bloc de branche/physiopathologie , Bloc de branche/étiologie , Facteurs de risque , Aorte/imagerie diagnostique , Aorte/chirurgie , Aorte/physiopathologie , Procédures de chirurgie cardiaque/effets indésirables , Adulte , Résultat thérapeutique , Complications postopératoires/étiologie , Complications postopératoires/imagerie diagnostiqueRÉSUMÉ
Transcatheter aortic valve implantation may be complicated by the development of conduction disturbances, including left bundle branch block and high-grade atrioventricular blocks, especially in patients with predisposing risk factors, such as pre-existing right bundle branch block. Permanent pacemaker implantation is a procedure with potential short- and long-term complications, and it should be reserved to patients with appropriate indications. Electrophysiological testing and/or prolonged ambulatory ECG monitoring are valuable tools for stratifying the risk of pacemaker implantation. However, the management of new-onset conduction disorders is not always straightforward, and there are different approaches depending on the center's attitude. Therefore, the purpose of this review is to define clinical management based on current evidence, while awaiting data from randomized trials.
Sujet(s)
Remplacement valvulaire aortique par cathéter , Humains , Remplacement valvulaire aortique par cathéter/effets indésirables , Incidence , Facteurs de risque , Complications postopératoires/épidémiologie , Complications postopératoires/étiologie , Pacemaker/effets indésirables , Bloc de branche/étiologie , Bloc de branche/thérapie , Bloc de branche/épidémiologie , Sténose aortique/chirurgie , Bloc atrioventriculaire/thérapie , Bloc atrioventriculaire/étiologie , Bloc atrioventriculaire/épidémiologieRÉSUMÉ
New-generation transcatheter heart valves have significantly improved technical success and procedural safety of transcatheter aortic valve implantation (TAVI) procedures; however, the incidence of permanent pacemaker implantation (PPI) remains a concern. This study aimed to assess the role of anatomic annulus features in determining periprocedural conduction disturbances leading to new PPI after TAVI using the last-generation Edwards SAPIEN balloon-expandable valves. In the context of a prospective single-center registry, we integrated the clinical and procedural predictors of PPI with anatomic data derived from multislice computed tomography. A total of 210 consecutive patients treated with balloon-expandable Edwards transcatheter heart valve were included in the study from 2015 to 2023. Technical success was achieved in 197 procedures (93.8%), and 26 patients (12.4%) required new PPI at the 30-day follow-up (median time to implantation 3 days). At the univariable logistic regression analysis, preprocedural right bundle branch block (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.01 to 4.97, p = 0.047), annulus eccentricity ≥0.25 (OR 5.43, 95% CI 2.21 to 13.36, p <0.001), calcium volume at annulus of the right coronary cusp >48 mm3 (OR 2.60, 95% CI 1.13 to 5.96, p = 0.024), and prosthesis implantation depth greater than membranous septum length (OR 2.17, 95% CI 1.10 to 4.28, p = 0.026) were associated with new PPI risk. In the multivariable analysis, preprocedural right bundle branch block (OR 2.81, 95% CI 1.01 to 7.85, p = 0.049), annulus eccentricity ≥0.25 (OR 4.14, 95% CI 1.85 to 9.27, p <0.001), and annulusright coronary cusp calcium >48 mm3 (OR 2.89, 95% CI 1.07 to 7.82, p = 0.037) were confirmed as independent predictors of new PPI. In conclusion, specific anatomic features of the aortic valve annulus might have an additive role in determining the occurrence of conduction disturbances in patients who underwent TAVI with balloon-expandable valves. This suggests the possibility to use multislice computed tomography to improve the prediction of post-TAVI new PPI risk.
Sujet(s)
Sténose aortique , Valve aortique , Prothèse valvulaire cardiaque , Tomodensitométrie multidétecteurs , Pacemaker , Conception de prothèse , Remplacement valvulaire aortique par cathéter , Humains , Remplacement valvulaire aortique par cathéter/méthodes , Remplacement valvulaire aortique par cathéter/effets indésirables , Mâle , Femelle , Sténose aortique/chirurgie , Sujet âgé de 80 ans ou plus , Tomodensitométrie multidétecteurs/méthodes , Études prospectives , Valve aortique/chirurgie , Valve aortique/imagerie diagnostique , Sujet âgé , Complications postopératoires/épidémiologie , Facteurs de risque , Bloc de branche/thérapie , Bloc de branche/étiologie , EnregistrementsRÉSUMÉ
AIMS: To characterize the diagnosis, frequency, and procedural implications of septal venous channel perforation during left bundle branch area pacing (LBBAP). METHODS AND RESULTS: All consecutive patients undergoing LBBAP over an 8-month period were prospectively studied. During lead placement, obligatory septal contrast injection was performed twice, at initiation (implant entry zone) and at completion (fixation zone). An intuitive fluoroscopic schema using orthogonal views (left anterior oblique/right anterior oblique) and familiar landmarks is described. Using this, we resolved zonal distribution (I-VI) of lead position on the ventricular septum and its angulation (post-fixation angle θ). Subjects with and without septal venous channel perforation were compared. Sixty-one patients {male 57.3%, median age [interquartile range (IQR)] 69.5 [62.5-74.5] years} were enrolled. Septal venous channel perforation was observed in eight (13.1%) patients [male 28.5%, median age (IQR) 64 (50-75) years]. They had higher frequency of (i) right-sided implant (25% vs. 1.9%, P = 0.04), (ii) fixation in zone III at the mid-superior septum (75% vs. 28.3%, P = 0.04), (iii) steeper angle of fixation-median θ (IQR) [19 (10-30)° vs. 5 (4-19)°, P = 0.01], and (iv) longer median penetrated-lead length (IQR) [13 (10-14.8) vs. 10 (8.5-12.5) mm, P = 0.03]. Coronary sinus drainage of contrast was noted in five (62.5%) patients. Abnormal impedance drops during implantation (12.5% vs. 5.7%, P = NS) were not significantly different. CONCLUSION: When evaluated systematically, septal venous channel perforation may be encountered commonly after LBBAP. The fiducial reference framework described using fluoroscopic imaging identified salient associated findings. This may be addressed with lead repositioning to a more inferior location and is not associated with adverse consequence acutely or in early follow-up.
Sujet(s)
Entraînement électrosystolique , Humains , Mâle , Femelle , Études prospectives , Adulte d'âge moyen , Sujet âgé , Entraînement électrosystolique/méthodes , Septum interventriculaire/imagerie diagnostique , Lésions traumatiques du coeur/étiologie , Lésions traumatiques du coeur/imagerie diagnostique , Résultat thérapeutique , Facteurs de risque , Faisceau de His/physiopathologie , Septum du coeur/imagerie diagnostique , Produits de contraste , Radioscopie , Bloc de branche/physiopathologie , Bloc de branche/étiologieRÉSUMÉ
BACKGROUND: A delayed and recurrent complete atrioventricular block (CAVB) is a life-threatening complication of transcatheter aortic valve replacement (TAVR). Post-TAVR evaluation may be important in predicting delayed and recurrent CAVB requiring permanent pacemaker implantation (PPI). The impact of new-onset right bundle-branch block (RBBB) after TAVR on PPI remains unknown. METHODS AND RESULTS: In total, 407 patients with aortic stenosis who underwent TAVR were included in this analysis. Intraprocedural CAVB was defined as CAVB that occurred during TAVR. A 12-lead ECG was evaluated at baseline, immediately after TAVR, on postoperative days 1 and 5, and according to the need to identify new-onset bundle-branch block (BBB) and CAVB after TAVR. Forty patients (9.8%) required PPI, 17 patients (4.2%) had persistent intraprocedural CAVB, and 23 (5.7%) had delayed or recurrent CAVB after TAVR. The rates of no new-onset BBB, new-onset left BBB, and new-onset RBBB were 65.1%, 26.8%, and 4.7%, respectively. Compared with patients without new-onset BBB and those with new-onset left BBB, the rate of PPI was higher in patients with new-onset RBBB (3.4% versus 5.6% versus 44.4%, P<0.0001). On post-TAVR evaluation in patients without persistent intraprocedural CAVB, the multivariate logistic regression analysis showed that new-onset RBBB was a statistically significant predictor of PPI compared with no new-onset BBB (odds ratio [OR], 18.0 [95% CI, 5.94-54.4]) in addition to the use of a self-expanding valve (OR, 2.97 [95% CI, 1.09-8.10]). CONCLUSIONS: Patients with new-onset RBBB after TAVR are at high risk for PPI.
Sujet(s)
Sténose aortique , Bloc de branche , Entraînement électrosystolique , Électrocardiographie , Pacemaker , Remplacement valvulaire aortique par cathéter , Humains , Remplacement valvulaire aortique par cathéter/effets indésirables , Mâle , Femelle , Bloc de branche/étiologie , Bloc de branche/thérapie , Bloc de branche/physiopathologie , Bloc de branche/diagnostic , Sténose aortique/chirurgie , Sujet âgé de 80 ans ou plus , Sujet âgé , Entraînement électrosystolique/effets indésirables , Bloc atrioventriculaire/thérapie , Bloc atrioventriculaire/étiologie , Bloc atrioventriculaire/diagnostic , Bloc atrioventriculaire/physiopathologie , Facteurs de risque , Études rétrospectives , Résultat thérapeutique , Facteurs temps , Complications postopératoires/étiologie , Complications postopératoires/thérapie , Complications postopératoires/diagnostic , RécidiveRÉSUMÉ
BACKGROUND Paroxysmal third-degree atrioventricular block (AVB) can exhibit a vast array of symptoms, but commonly, paroxysmal AVB leads to presyncope, syncope, or possibly sudden cardiac death. We present a rare case of pause-dependent paroxysmal AVB that was triggered by a premature atrial contraction. CASE REPORT A 65-year-old man with frequent episodes of presyncope and syncope for 3 weeks was admitted to our hospital for further diagnosis. A resting 12-lead electrocardiogram showed an incomplete right bundle branch block, and a 24-h Holter recording showed multiple episodes of third-degree AVB. Intracardiac tracing revealed that the block site was distal, at the infra-His-Purkinje system. CONCLUSIONS This case highlights a rare case of pause-dependent paroxysmal AVB that was triggered by a premature atrial contraction. This type of AVB is an abrupt, unexpected, repetitive block of atrial impulses as they propagate to the ventricles. It is relatively rare, and due to its transient nature, it is often under recognized and can lead to sudden cardiac death.
Sujet(s)
Extrasystoles auriculaires , Bloc atrioventriculaire , Mâle , Humains , Sujet âgé , Bloc atrioventriculaire/étiologie , Bloc atrioventriculaire/complications , Extrasystoles auriculaires/diagnostic , Extrasystoles auriculaires/complications , Bloc de branche/étiologie , Bloc de branche/complications , Électrocardiographie , Syncope/étiologie , Mort subite cardiaqueRÉSUMÉ
BACKGROUND: Left bundle branch block (LBBB) represents a frequently encountered conduction system disorder. Despite its widespread occurrence, a continual dilemma persists regarding its intricate association with underlying cardiomyopathy and its pivotal role in the initiation of dilated cardiomyopathy. The pathologic alterations linked to LBBB-induced cardiomyopathy (LBBB-CM) have remained elusive. OBJECTIVE: This study sought to investigate the chronologic dynamics of LBBB to left ventricular dysfunction and the pathologic mechanism of LBBB-CM. METHODS: LBBB model was established through main left bundle branch trunk ablation in 14 canines. All LBBB dogs underwent transesophageal echocardiography and electrocardiography before ablation and at 1 month, 3 months, 6 months, and 12 months after LBBB induction. Single-photon emission computed tomography imaging was performed at 12 months. We then harvested the heart from all LBBB dogs and 14 healthy adult dogs as normal controls for anatomic observation, Purkinje fiber staining, histologic staining, and connexin43 protein expression quantitation. RESULTS: LBBB induction caused significant fibrotic changes in the endocardium and mid-myocardium. Purkinje fibers exhibited fatty degeneration, vacuolization, and fibrosis along with downregulated connexin43 protein expression. During a 12-month follow-up, left ventricular dysfunction progressively worsened, peaking at the end of the observation period. The association between myocardial dysfunction, hypoperfusion, and fibrosis was observed in the LBBB-afflicted canines. CONCLUSION: LBBB may lead to profound myocardial injury beyond its conduction impairment effects. The temporal progression of left ventricular dysfunction and the pathologic alterations observed shed light on the complex relationship between LBBB and cardiomyopathy. These findings offer insights into potential mechanisms and clinical implications of LBBB-CM.
Sujet(s)
Bloc de branche , Modèles animaux de maladie humaine , Électrocardiographie , Chiens , Animaux , Bloc de branche/physiopathologie , Bloc de branche/étiologie , Système de conduction du coeur/physiopathologie , Tomographie par émission monophotonique/méthodes , Fibres de Purkinje/physiopathologie , Myocarde/anatomopathologie , Dysfonction ventriculaire gauche/physiopathologie , Dysfonction ventriculaire gauche/étiologieRÉSUMÉ
INTRODUCTION: Right ventricular (RV) pacing sometimes causes left ventricular (LV) systolic dysfunction, also known as pacing-induced cardiomyopathy (PICM). However, the association between specifically paced QRS morphology and PICM development has not been elucidated. This study aimed to investigate the association between paced QRS mimicking a complete left bundle branch block (CLBBB) and PICM development. METHODS: We retrospectively screened 2009 patients who underwent pacemaker implantation from 2010 to 2020 in seven institutions. Patients who received pacemakers for an advanced atrioventricular block or bradycardia with atrial fibrillation, baseline LV ejection fraction (LVEF) ≥ 50%, and echocardiogram recorded at least 6 months postimplantation were included. The paced QRS recorded immediately after implantation was analyzed. A CLBBB-like paced QRS was defined as meeting the CLBBB criteria of the American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society in 2009. PICM was defined as a ≥10% LVEF decrease, resulting in an LVEF of <50%. RESULTS: Among the 270 patients analyzed, PICM was observed in 38. Baseline LVEF was lower in patients with PICM, and CLBBB-like paced QRS was frequently observed in PICM. Multivariate analysis revealed that low baseline LVEF (odds ratio [OR]: 0.93 per 1% increase, 95% confidence interval [CI]: 0.89-0.98, p = 0.006) and CLBBB-like paced QRS (OR: 2.69, 95% CI: 1.25-5.76, p = 0.011) were significantly associated with PICM development. CONCLUSION: CLBBB-like paced QRS may be a novel risk factor for PICM. RV pacing, which causes CLBBB-like QRS morphology, may need to be avoided, and patients with CLBBB-like paced QRS should be followed-up carefully.
Sujet(s)
Potentiels d'action , Bloc de branche , Entraînement électrosystolique , Cardiomyopathies , Électrocardiographie , Rythme cardiaque , Valeur prédictive des tests , Débit systolique , Fonction ventriculaire gauche , Sujet âgé , Sujet âgé de 80 ans ou plus , Femelle , Humains , Mâle , Adulte d'âge moyen , Bloc atrioventriculaire/physiopathologie , Bloc atrioventriculaire/diagnostic , Bloc atrioventriculaire/thérapie , Bloc atrioventriculaire/étiologie , Bloc de branche/physiopathologie , Bloc de branche/diagnostic , Bloc de branche/thérapie , Bloc de branche/étiologie , Entraînement électrosystolique/effets indésirables , Cardiomyopathies/physiopathologie , Cardiomyopathies/étiologie , Cardiomyopathies/thérapie , Cardiomyopathies/diagnostic , Diagnostic différentiel , Études rétrospectives , Appréciation des risques , Facteurs de risque , Facteurs temps , Résultat thérapeutique , Fonction ventriculaire droiteRÉSUMÉ
BACKGROUND: Left bundle branch block (LBBB) and atrial fibrillation (AF) are commonly coexisting conditions. The impact of LBBB on catheter ablation of AF has not been well determined. This study aims to explore the long-term outcomes of patients with AF and LBBB after catheter ablation. METHODS: Forty-two patients with LBBB of 11,752 patients who underwent catheter ablation of AF from 2011 to 2020 were enrolled as LBBB group. After propensity score matching in a 1:4 ratio, 168 AF patients without LBBB were enrolled as non-LBBB group. Late recurrence and a composite endpoint of stroke, all-cause mortality, and cardiovascular hospitalization were compared between the two groups. RESULTS: Late recurrence rate was significantly higher in the LBBB group than that in the non-LBBB group (54.8% vs. 31.5%, p = .034). Multivariate analysis showed that LBBB was an independent risk factor for late recurrence after catheter ablation of AF (hazard ratio [HR] 2.19, 95% confidence interval [CI] 1.09-4.40, p = .031). LBBB group was also associated with a significantly higher incidence of the composite endpoint (21.4% vs. 6.5%, HR 3.98, 95% CI 1.64-9.64, p = .002). CONCLUSIONS: LBBB was associated with a higher risk for late recurrence and a higher incidence of composite endpoint in the patients underwent catheter ablation.
Sujet(s)
Fibrillation auriculaire , Ablation par cathéter , Accident vasculaire cérébral , Humains , Bloc de branche/étiologie , Facteurs de risque , Accident vasculaire cérébral/étiologie , Ablation par cathéter/effets indésirables , Résultat thérapeutique , RécidiveSujet(s)
Cardiomyopathie dilatée , Humains , Cardiomyopathie dilatée/thérapie , Cardiomyopathie dilatée/complications , Cardiomyopathie dilatée/diagnostic , Entraînement électrosystolique/méthodes , Électrocardiographie , Mâle , Bloc de branche/diagnostic , Bloc de branche/thérapie , Bloc de branche/étiologie , Femelle , Septum du coeur/imagerie diagnostique , Sujet âgé , Faisceau de His/physiopathologieRÉSUMÉ
AIMS: Right bundle branch block (RBBB) morphology non-sustained ventricular arrhythmias (VAs) have been associated with the presence of non-ischaemic left ventricular scar (NLVS) in athletes. The aim of this cross-sectional study was to identify clinical and electrocardiogram (ECG) predictors of the presence of NLVS in athletes with RBBB VAs. METHODS AND RESULTS: Sixty-four athletes [median age 39 (24-53) years, 79% males] with non-sustained RBBB VAs underwent cardiac magnetic resonance (CMR) with late gadolinium enhancement in order to exclude the presence of a concealed structural heart disease. Thirty-six athletes (56%) showed NLVS at CMR and were assigned to the NLVS positive group, whereas 28 athletes (44%) to the NLVS negative group. Family history of cardiomyopathy and seven different ECG variables were statistically more prevalent in the NLVS positive group. At univariate analysis, seven ECG variables (low QRS voltages in limb leads, negative T waves in inferior leads, negative T waves in limb leads I-aVL, negative T waves in precordial leads V4-V6, presence of left posterior fascicular block, presence of pathologic Q waves, and poor R-wave progression in right precordial leads) proved to be statistically associated with the finding of NLVS; these were grouped together in a score. A score ≥2 was proved to be the optimal cut-off point, identifying NLVS athletes in 92% of cases and showing the best accuracy (86% sensitivity and 100% specificity, respectively). However, a cut-off ≥1 correctly identified all patients with NLVS (absence of false negatives). CONCLUSION: In athletes with RBBB morphology non-sustained VAs, specific ECG abnormalities at 12-lead ECG can help in detecting subjects with NLVS at CMR.
In athletes with right bundle branch block (RBBB) morphology non-sustained ventricular arrhythmias (VAs), the presence of a non-ischaemic left ventricular scar (NLVS) may be highly suspected if one or more of the following electrocardiogram (ECG) characteristics are present at the 12-lead resting ECG: low QRS voltages in limb leads, negative T waves in inferior leads, negative T waves in limb leads IaVL, negative T waves in precordial leads V4V6, presence of left posterior fascicular block, presence of pathologic Q waves, and poor R-wave progression in right precordial leads. This score should be externally validated in a larger population of athletes with VAs. In athletes with RBBB morphology non-sustained Vas, attention should be placed on the 12-lead resting ECG to suspect the presence of an NLVS. In athletes with RBBB VAs and the presence of one or more of the identified ECG characteristics, a cardiac magnetic resonance with late gadolinium enhancement is useful to rule out an NLVS.
Sujet(s)
Bloc de branche , Extrasystoles ventriculaires , Mâle , Humains , Adulte , Femelle , Bloc de branche/diagnostic , Bloc de branche/étiologie , Extrasystoles ventriculaires/diagnostic , Extrasystoles ventriculaires/étiologie , Cicatrice/anatomopathologie , Produits de contraste , Études transversales , Gadolinium , ÉlectrocardiographieRÉSUMÉ
Transcatheter aortic valve replacement (TAVR) often leads to conduction abnormalities, necessitating pacemaker implantation. This review of 38 meta-analyses identified preexisting right bundle branch block (RBBB), LAHB, and new-onset left bundle branch block as key risk factors, with a higher PPM risk in male and older patients. Procedural factors like transfemoral access and self-expandable valves also increase this risk. Prevention focuses on tailoring TAVR to individual electrophysiological and anatomical profiles. However, there's a lack of consensus in managing these conduction disturbances post-TAVR, highlighting the need for further research and standardized treatment strategies.
Sujet(s)
Sténose aortique , Pacemaker , Remplacement valvulaire aortique par cathéter , Humains , Mâle , Remplacement valvulaire aortique par cathéter/effets indésirables , Résultat thérapeutique , Sténose aortique/chirurgie , Facteurs de risque , Pacemaker/effets indésirables , Bloc de branche/diagnostic , Bloc de branche/étiologie , Bloc de branche/prévention et contrôle , Valve aortique/chirurgieRÉSUMÉ
BACKGROUND: New-generation self-expanding valves can improve the success rate of transcatheter aortic valve replacement (TAVR) for severe pure native aortic regurgitation (PNAR). However, predictors of new-onset conduction block post-TAVR using new-generation self-expanding valves in patients with PNAR remain to be established. Therefore, this study aimed to identify predictors of new-onset conduction block post-TAVR using new-generation self-expanding valves (VitaFlow Liberty™) in patients with PNAR. METHODS: In this retrospective cohort study, patients were categorized into pacemaker and non-pacemaker groups based on their need for new postoperative permanent pacemaker implantation (PPI). Based on the postoperative presence of either new-onset complete left bundle branch block (cLBBB) or high-grade atrioventricular block (AVB), patients were further classified into conduction disorder and non-conduction disorder groups. Laboratory, echocardiographic, computed tomography, preoperative and postoperative electrocardiography, and procedural and clinical data were collected immediately after TAVR and during hospitalization and compared between the groups. Multivariate logistic regression analysis was performed incorporating the significant variables from the univariate analyses. RESULTS: This study examined 68 consecutive patients with severe PNAR who underwent TAVR. In 20 patients, a permanent pacemaker was fitted postoperatively. Multivariate logistic regression analysis revealed an association between the need for postoperative PPI and preoperative complete right bundle branch block (cRBBB) or first-degree AVB, as well as a non-tubular left ventricular outflow tract (LVOT). In addition, valve implantation depth and angle of aortic root were independent predictors of new-onset cLBBB or high-grade AVB developing post-TAVR. The predictive value of valve implantation depth and angle of aortic root was further supported by receiver operating characteristic curve analysis results. CONCLUSIONS: In patients with PNAR undergoing TAVR using self-expanding valves, preoperative cRBBB or first-degree AVB and a non-tubular LVOT were indicators of a higher likelihood of PPI requirement. Moreover, deeper valve implantation depth and greater angle of aortic root may be independent risk factors for new-onset cLBBB or high-grade AVB post-TAVR. Valve implantation depth and angle of aortic root values may be used to predict the possibility of new cLBBB or high-grade AVB post-TAVR.
Sujet(s)
Insuffisance aortique , Sténose aortique , Bloc atrioventriculaire , Pacemaker , Remplacement valvulaire aortique par cathéter , Humains , Remplacement valvulaire aortique par cathéter/effets indésirables , Insuffisance aortique/imagerie diagnostique , Insuffisance aortique/étiologie , Études rétrospectives , Entraînement électrosystolique/effets indésirables , Sténose aortique/imagerie diagnostique , Sténose aortique/chirurgie , Sténose aortique/complications , Résultat thérapeutique , Bloc atrioventriculaire/diagnostic , Bloc atrioventriculaire/étiologie , Bloc atrioventriculaire/thérapie , Pacemaker/effets indésirables , Troubles du rythme cardiaque , Bloc de branche/diagnostic , Bloc de branche/étiologie , Bloc de branche/thérapie , Facteurs de risque , Valve aortique/imagerie diagnostique , Valve aortique/chirurgieRÉSUMÉ
BACKGROUND AND AIMS: Right bundle branch block (RBBB) and resulting right ventricular (RV) electromechanical discoordination are thought to play a role in the disease process of subpulmonary RV dysfunction that frequently occur post-repair tetralogy of Fallot (ToF). We sought to describe this disease entity, the role of pulmonary re-valvulation, and the potential added value of RV cardiac resynchronization therapy (RV-CRT). METHODS: Two patients with repaired ToF, complete RBBB, pulmonary regurgitation, and significantly decreased RV function underwent echocardiography, cardiac magnetic resonance, and an invasive study to evaluate the potential for RV-CRT as part of the management strategy. The data were used to personalize the CircAdapt model of the human heart and circulation. Resulting Digital Twins were analysed to quantify the relative effects of RV pressure and volume overload and to predict the effect of RV-CRT. RESULTS: Echocardiography showed components of a classic RV dyssynchrony pattern which could be reversed by RV-CRT during invasive study and resulted in acute improvement in RV systolic function. The Digital Twins confirmed a contribution of electromechanical RV dyssynchrony to RV dysfunction and suggested improvement of RV contraction efficiency after RV-CRT. The one patient who underwent successful permanent RV-CRT as part of the pulmonary re-valvulation procedure carried improvements that were in line with the predictions based on his Digital Twin. CONCLUSION: An integrative diagnostic approach to RV dysfunction, including the construction of Digital Twins may help to identify candidates for RV-CRT as part of the lifetime management of ToF and similar congenital heart lesions.
Sujet(s)
Thérapie de resynchronisation cardiaque , Tétralogie de Fallot , Dysfonction ventriculaire droite , Humains , Tétralogie de Fallot/imagerie diagnostique , Tétralogie de Fallot/chirurgie , Ventricules cardiaques , Échocardiographie , Thérapie de resynchronisation cardiaque/effets indésirables , Bloc de branche/imagerie diagnostique , Bloc de branche/étiologie , Bloc de branche/thérapie , Dysfonction ventriculaire droite/imagerie diagnostique , Dysfonction ventriculaire droite/étiologie , Dysfonction ventriculaire droite/thérapie , Simulation numériqueRÉSUMÉ
BACKGROUND: The incidence and prognosis of right bundle branch block (RBBB) following transcatheter aortic valve replacement (TAVR) are unknown. Hence, we sought to characterize the incidence of post-TAVR RBBB and determine associated risks of permanent pacemaker (PPM) implantation and mortality. METHODS: All patients 18 years and above without preexisting RBBB or PPM who underwent TAVR at US Mayo Clinic sites and Mayo Clinic Health Systems from June 2010 to May 2021 were evaluated. Post-TAVR RBBB was defined as new-onset RBBB in the postimplantation period. The risks of PPM implantation (within 90 days) and mortality following TAVR were compared for patients with and without post-TAVR RBBB using Kaplan-Meier analysis and Cox proportional hazards modeling. The risks of PPM implantation (within 90 days) and mortality following TAVR were compared for patients with and without post-TAVR RBBB using Kaplan-Meier analysis and Cox proportional hazards modeling. RESULTS: Of 1992 patients, 15 (0.75%) experienced new RBBB post-TAVR. There was a higher degree of valve oversizing among patients with new RBBB post-TAVR versus those without (17.9% versus 10.0%; P=0.034). Ten patients (66.7%) with post-TAVR RBBB experienced high-grade atrioventricular block and underwent PPM implantation (median 1 day; Q1, 0.2 and Q3, 4), compared with 268/1977 (13.6%) without RBBB. Following propensity score adjustment for covariates (age, sex, balloon-expandable valve, annulus diameter, and valve oversizing), post-TAVR RBBB was significantly associated with PPM implantation (hazard ratio, 8.36 [95% CI, 4.19-16.7]; P<0.001). No statistically significant increase in mortality was seen with post-TAVR RBBB (hazard ratio, 0.83 [95% CI, 0.33-2.11]; P=0.69), adjusting for age and sex. CONCLUSIONS: Although infrequent, post-TAVR RBBB was associated with elevated PPM implantation risk. The mechanisms for its development and its clinical prognosis require further study.
Sujet(s)
Sténose aortique , Prothèse valvulaire cardiaque , Pacemaker , Remplacement valvulaire aortique par cathéter , Humains , Remplacement valvulaire aortique par cathéter/effets indésirables , Bloc de branche/diagnostic , Bloc de branche/épidémiologie , Bloc de branche/étiologie , Sténose aortique/chirurgie , Incidence , Entraînement électrosystolique/effets indésirables , Résultat thérapeutique , Facteurs de risque , Valve aortique/chirurgieRÉSUMÉ
BACKGROUND: The aim of the study was to evaluate whether left ventricular apical-to-basal longitudinal strain differences, representing advanced basal interstitial fibrosis, are associated with conduction disorders after aortic valve replacement (AVR) in patients with severe aortic stenosis. METHODS: Patients with aortic stenosis undergoing AVR were included. The apical-to-basal strain ratio was calculated by dividing the average strain of the apical segments by the average strain of the basal segments. Values >1.9 were considered abnormal, as previously described. All patients were followed up for the occurrence of complete left or right bundle branch block or permanent pacemaker implantation within 2 years after AVR. Subgroup analysis was performed in patients undergoing transcatheter AVR. RESULTS: Two hundred seventy-four patients were included (median age of 74 years [interquartile range, 65, 80], 46.4% male). During a median follow-up of 12.2 months (interquartile range, 0.2, 24.3), 74 patients (27%) developed complete bundle branch block or were implanted with a permanent pacemaker. These patients more often had an abnormal apical-to-basal strain ratio. Cumulative event-free survival analysis showed worse outcome in patients with an abnormal apical-to-basal strain ratio (log rank χ2 = 7.258, P = .007). In multivariable Cox regression analysis, an abnormal apical-to-basal strain ratio was the only independent factor associated with the occurrence of complete bundle branch block or permanent pacemaker implantation after adjusting for other factors previously shown to be associated with conduction disorders after AVR. Subgroup analysis confirmed the independent association of an abnormal apical-to-basal strain ratio with conduction disorders after transcatheter AVR. CONCLUSION: The apical-to-basal strain ratio is independently associated with conduction disorders after AVR and could guide risk stratification in patients potentially at risk for pacemaker implantation.