Comparing predictors of permanent pacemaker insertion after TAVR in new-generation versus early generation heart valves

Abstract Introduction Transcatheter Aortic Valve Replacement (TAVR) has emerged as the standard of care for patient with severe aortic stenosis. Conduction abnormalities leading to permanent pacemaker (PPM) implantation is one of the most common complication after TAVR. Newer generation valves (NGV) such as Sapien S3, XT and Evolut are widely being used in real time practice. The aim of this analysis is to compare the predictors associated with increased risk of PPM implantation after TAVR in newer generation valves (NGV) as compared to older generation valves (OGV). Methods A comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify relevant trials. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints. Results 18 observational studies with 16,004 patients were identified. The incidence of PPM implantation after TAVR in our analysis was 8.9%. For the NGV, right bundle branch block (RBBB) and atrioventricular (AV) block were independent predictors of PPM insertion after TAVR. Baseline heart rate, presence of atrial fibrillation, and baseline intraventricular conduction delay were not significant predictors. However, for the OGV, risk of PPM implantation after TAVR was higher in presence of RBBB, depth of implant, valve size/annulus size, presence of atrial fibrillation and post-procedure AV block. Conclusions Our analysis identified 2 factors that were significantly associated with increased risk of PPM insertion after TAVR in NGV compared to 6 factors with OGV. With the increasing physician expertise with TAVI and use of NGV, the incidence of post TAVR PPM insertion has reduced but baseline RBBB and AV conduction block still continue to be significant predictors of increased PPM insertion after TAVR. FUNDunding Acknowledgement Type of funding sources: None.

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Abstract 14876: Predictors of Permanent Pacemaker Insertion After TAVR: A Systematic Review and Meta-Analysis

Circulation ◽

10.1161/circ.142.suppl_3.14876 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Rahul Gupta ◽

Aaqib h Malik ◽

Wilbert S Aronow

Keyword(s):

Severe Aortic Stenosis ◽

Meta Analysis ◽

Conduction Block ◽

Balloon Dilation ◽

Permanent Pacemaker ◽

Conduction Delay ◽

Bundle Branch Block ◽

Increased Risk ◽

High Calcium ◽

Coronary Cusp

Introduction: Transcatheter Aortic Valve Replacement (TAVR) has evolved as the standard of care for patient with severe aortic stenosis. Conduction abnormalities leading to permanent pacemaker (PPM) implantation is one of the most common complication after TAVR. The aim of this analysis is to evaluate the predictors associated with increased risk of PPM implantation after TAVR. Methods: A comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify relevant trials. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints. Results: 37 observational studies with 71455 patients were identified. The incidence of PPM implantation after TAVR in our analysis was 22%. The risk of PPM implantation after TAVR was more in men, it increased with increasing age, and in patients with diabetes mellitus, presence of right bundle branch block , baseline atrioventricular conduction block, and left anterior fascicular block. Significant predictors of PPM insertion post TAVR included the presence of high calcium volume in the area below left and non-coronary cusp, use of self-expandable valve over balloon-expandable valve, depth of implant, valve size/annulus size, pre-dilatation balloon valvuloplasty and post-implant balloon dilation. However, the risk did not increase with atrial fibrillation, left bundle branch block, baseline interventricular conduction delay, change in QRS duration after the procedure and with the presence of high calcium in the area below right coronary cusp. Conclusions: Our meta-analysis identified 14 factors that were significantly associated with increased risk of PPM insertion after TAVR. Early identification of high-risk populations and targeting modifiable risk factors can help to reduce the rate of PPM insertion after TAVR.

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P1875Nonspecific intraventricular conduction delay is associated with future occurrence of atrial fibrillation in patients with structurally normal heart and sinus rhythm

European Heart Journal ◽

10.1093/eurheartj/ehz748.0624 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

J S Uhm ◽

M N Jin ◽

I S Kim ◽

H J Bae ◽

H T Yu ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Conduction Delay ◽

Normal Heart ◽

Interval Model ◽

Intraventricular Conduction ◽

Sinus Rate ◽

Increased Risk ◽

Pr Interval ◽

Intraventricular Conduction Delay

Abstract Background This study aimed to elucidate long-term prognosis of nonspecific intraventricular conduction delay (NIVCD) in patients with structurally normal heart. Methods We included 107,838 patients (age, 52.1±15.5 years; men, 46.8%) who underwent electrocardiography in outpatient clinics or medical checkup (model 1). NIVCD was defined as QRS duration ≥110 ms and incompatibility with bundle branch block. The patients with structurally normal heart and sinus rhythm were assigned to the NIVCD group and normal QRS group according to propensity score with matching variables of age, sex, hypertension, and diabetes (model 2), and additional PR interval (model 3). Baseline characteristics, electrocardiographic parameters, and clinical outcomes were compared in model 1, 2, and 3, respectively. Results In model 1, the frequencies of male and preexisting atrial fibrillation (AF) were significantly higher in the NIVCD group than in the normal QRS group. In model 2, sinus rate and PR interval were significantly slower and longer in the NIVCD group than in the normal QRS group. In model 3, cumulative incidence of AF was significantly higher in the NIVCD group than in the normal QRS group during follow-up of 8.8±2.9 years (Figure). NIVCD significantly increased risk of AF (hazard ratio, 2.571; 95% confidence interval, 1.074–6.156; p=0.034). NIVCD did not significantly increase risk of sick sinus syndrome, complete atrioventricular block, and heart failure. Atrial fibrillation-free survival Conclusions NIVCD is associated with slow sinus rate and prolonged PR interval. NIVCD is an independent risk factor of AF in patients with structurally normal heart.

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Oral anticoagulants in atrial fibrillation with valvular heart disease and bioprosthetic heart valves

Heart ◽

10.1136/heartjnl-2019-314767 ◽

2019 ◽

Vol 105 (18) ◽

pp. 1432-1436 ◽

Cited By ~ 7

Author(s):

Aaqib H Malik ◽

Srikanth Yandrapalli ◽

Wilbert S Aronow ◽

Julio A Panza ◽

Howard A Cooper

Keyword(s):

Atrial Fibrillation ◽

Heart Disease ◽

Major Bleeding ◽

Valvular Heart Disease ◽

Heart Valves ◽

Meta Analysis ◽

Oral Anticoagulants ◽

Cardiac Events ◽

Increased Risk ◽

Randomised Controlled

ObjectiveCurrent guidelines endorse the use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF). However, little is known about their safety and efficacy in valvular heart disease (VHD). Similarly, there is a paucity of data regarding NOACs use in patients with a bioprosthetic heart valve (BPHV). We, therefore, performed a network meta-analysis in the subgroups of VHD and meta-analysis in patients with a BPHV.MethodsPubMed, Cochrane and Embase were searched for randomised controlled trials. Summary effects were estimated by the random-effects model. The outcomes of interest were a stroke or systemic embolisation (SSE), myocardial infarction (MI), all-cause mortality, major adverse cardiac events, major bleeding and intracranial haemorrhage (ICH).ResultsIn patients with VHD, rivaroxaban was associated with more ICH and major bleeding than other NOACs, while edoxaban 30 mg was associated with least major bleeding. Data combining all NOACs showed a significant reduction in SSE, MI and ICH (0.70, [0.57 to 0.85; p<0.001]; 0.70 [0.50 to 0.99; p<0.002]; and 0.46 [0.24 to 0.86; p<0.01], respectively). Analysis of 280 patients with AF and a BPHV showed similar outcomes with NOACs and warfarin.ConclusionsNOACs performed better than warfarin for a reduction in SSE, MI and ICH in patients with VHD. Individually NOACs performed similarly to each other except for an increased risk of ICH and major bleeding with rivaroxaban and a reduced risk of major bleeding with edoxaban 30 mg. In patients with a BPHV, results with NOACs seem similar to those with warfarin and this needs to be further explored in larger studies.

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Late onset of new conduction disturbances requiring permanent pacemaker implantation following TAVI

Heart ◽

10.1136/heartjnl-2019-315967 ◽

2020 ◽

Vol 106 (16) ◽

pp. 1244-1251 ◽

Cited By ~ 2

Author(s):

Nynke H M Kooistra ◽

Martijn S van Mourik ◽

Ramón Rodríguez-Olivares ◽

Alexander H Maass ◽

Vincent J Nijenhuis ◽

...

Keyword(s):

Risk Factors ◽

Late Onset ◽

Pacemaker Implantation ◽

Early Discharge ◽

Permanent Pacemaker ◽

Conduction Delay ◽

Intraventricular Conduction ◽

Conduction Disturbances ◽

Permanent Pacemaker Implantation ◽

Timing Of Onset

BackgroundThe timing of onset and associated predictors of late new conduction disturbances (CDs) leading to permanent pacemaker implantation (PPI) following transcatheter aortic valve implantation (TAVI) are still unknown, however, essential for an early and safe discharge. This study aimed to investigate the timing of onset and associated predictors of late onset CDs in patients requiring PPI (LCP) following TAVI.Methods and resultsWe performed retrospective analysis of prospectively collected data from five large volume centres in Europe. Post-TAVI electrocardiograms and telemetry data were evaluated in patients with a PPI post-TAVI to identify the onset of new advanced CDs. Early onset CDs were defined as within 48 hours after procedure, and late onset CDs as after 48 hours. A total of 2804 patients were included for analysis. The PPI rate was 12%, of which 18% was due to late onset CDs (>48 hours). Independent predictors for LCP were pre-existing non-specific intraventricular conduction delay, pre-existing right bundle branch block, self-expandable valves and predilation. At least one of these risk factors was present in 98% of patients with LCP. Patients with a balloon-expandable valve without predilation did not develop CDs requiring PPI after 48 hours.ConclusionsSafe early discharge might be feasible in patients without CDs in the first 48 hours after TAVI if no risk factors for LCP are present.

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Abstract 17255: Premature Atrial Stimulation Reveals Increased Conduction Slowing and Block in Cardiac Surgery Patients That Develop Postoperative Atrial Fibrillation

Circulation ◽

10.1161/circ.142.suppl_3.17255 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Muhammad S Khan ◽

Vikas Sharma ◽

Ravi Ranjan ◽

Jason P Glotzbach ◽

Craig Selzman ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Pulmonary Veins ◽

Conduction Block ◽

Postoperative Atrial Fibrillation ◽

Conduction Delay ◽

Epicardial Mapping ◽

Conduction Abnormalities ◽

History Of ◽

Atrial Stimulation

Introduction: Postoperative atrial fibrillation (POAF) is a common cardiac surgery complication that is highly associated with increased morbidity and mortality. The relation of presurgical left atrial (LA) conduction abnormalities and POAF during intraoperative premature atrial stimulation (S1S2) pacing is investigated and reported. Hypothesis: Intraoperative premature atrial stimulation reveals increased areas of slowed or blocked conduction in patients that develop POAF. Methods: High-density intraoperative epicardial mapping was conducted in 20 cardiac surgery patients with no history of preoperative atrial fibrillation (AF) both in sinus rhythm (SR) and during S1S2 pacing. A flexible array comprised of 240 electrodes was placed on the posterior LA wall in between the pulmonary veins. For each patient, the area of conduction block (CB), conduction delay (CD) and combined conduction delay and block (CDCB) for conduction velocity <0.1 m/s, 0.1 - 0.2 m/s and <0.2 m/s, respectively were quantified. Results: In 20 patients, 6 (30%) developed POAF. As shown in the Figure, conduction maps revealed the presence of significantly higher areas of CD (13.2±6.6% vs. 6.1±4.2%, p=0.03) and CDCB (17.5±8.7% vs. 7.4±6.4%, p=0.03), and a trend toward larger CB (4.2±3.8% vs. 1.3±2.9%, p=0.09) in patients that developed POAF for premature atrial beat S2 compared to patients that remained in SR after cardiac surgery. S1 paced beats and SR did not show significant differences in abnormal conduction percentages between patients with and without POAF. Conclusions: Premature atrial stimulation accentuates conduction abnormalities in cardiac surgery patients that develop POAF, revealing a pre-surgical substrate that may indicate greater risk for post-surgical atrial arrhythmias.

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Paroxysmal and persistent atrial fibrillation; does the clinical classification match the substrate?

European Heart Journal ◽

10.1093/ehjci/ehaa946.0483 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

W.F.B Van Der Does ◽

A Heida ◽

L.J.M.E Van Der Does ◽

A.J.J.C Bogers ◽

N.M.S De Groot

Keyword(s):

Atrial Fibrillation ◽

Conduction Block ◽

Persistent Atrial Fibrillation ◽

Conduction Delay ◽

Clinical Classification ◽

Activation Time ◽

Conduction Disorders ◽

Arrhythmogenic Substrate ◽

Appropriate Therapy ◽

The Right

Abstract Background/Introduction The classification of atrial fibrillation (AF) currently is based on clinical characteristics, however classifying underlying electropathology would assist in selecting appropriate therapy. In this study, we measured atrial conduction parameters in sinus rhythm (SR) using an intra-operative high resolution epicardial mapping approach in paroxysmal (PAF) and persistent AF (persAF) patients. Purpose To study whether the clinical classification is related to the amount and severity of conduction disorders in SR. Methods We included 47 PAF and 24 persAF patients for intra-operative measurements of SR at the right atrium (RA), Bachmann's Bundle (BB), the left atrium (LA) and the pulmonary vein area (PV). Various conduction parameters were calculated, including number of continuous conduction delay and block (cCDCB) lines, total activation time (TAT), and orientation of conduction block (CB) lines at BB. Results After adjustment for confounders, only TAT of BB was significantly longer in persAF patients, 75 [53–92] ms vs 55 [40–76] ms. This can be attributed to more CB line parts orientated perpendicular to the conduction direction and a higher number of cCDCB lines. Other conduction characteristics at BB and other atrial areas showed no difference between PAF and persAF patients. Conclusion(s) Patients with persAF have a longer activation time at BB compared to patients with PAF. Other conduction parameters show significant overlap between these groups at BB and in other atrial areas, suggesting that, in SR, the clinical classification does not match the arrhythmogenic substrate. Funding Acknowledgement Type of funding source: None

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Effects of Polymorphisms in Myc-Related Genes on Bleeding Complications in Patients with Stable Warfarin Responses

Cardiovascular Therapeutics ◽

10.1155/2019/1813747 ◽

2019 ◽

Vol 2019 ◽

pp. 1-8

Author(s):

Jeong Yee ◽

Woorim Kim ◽

Byung Chul Chang ◽

Jee Eun Chung ◽

Kyung Eun Lee ◽

...

Keyword(s):

Atrial Fibrillation ◽

Degrees Of Freedom ◽

Heart Valves ◽

Warfarin Therapy ◽

Attributable Risk ◽

Bleeding Complications ◽

Nucleotide Polymorphisms ◽

Analysis Model ◽

Clinical Value ◽

Increased Risk

Objectives. This study aimed to identify the possible effects of Myc and 8q24 polymorphisms on bleeding complications in patients who maintained international normalized ratio (INR) of 2.0-3.0 with warfarin therapy after cardiac valve replacement. Methods. Twenty-five single nucleotide polymorphisms were analyzed, including VKORC1, CYP2C9, Myc, and 8q24. Univariate and multivariate analyses were conducted to evaluate the associations between genetic polymorphisms and bleeding complications. Attributable risk and the number needed to genotype (NNG) were also calculated to evaluate the potential clinical value of genotyping. Results. We included 142 patients, among whom 21 experienced bleeding complications. Multivariate models showed that patients carrying the CC genotype of rs6983561 and the A allele of rs13281615 at 8q24 had 27.6- and 10.0-fold higher bleeding complications, compared with patients with the A allele and the GG genotype, respectively. For rs6983561, the attributable risk and NNG were 96.4% and 36.8, respectively, whereas, for rs13281615, the attributable risk and NNG were 90.0% and 8.3, respectively. Atrial fibrillation was associated with a 5.5-fold increased risk of bleeding complications. The AUROC value was 0.761 (95% CI 0.659-0.863, p<0.001), and the Hosmer–Lemeshow test showed that the fitness of the multivariate analysis model was satisfactory (χ2=0.846; 3 degrees of freedom; p=0.838). Conclusions. Bleeding complications during warfarin therapy were associated with 8q24 polymorphisms and atrial fibrillation in patients with mechanical heart valves.

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Ischemic stroke in a patient with interatrial block: Is it only a coincidence or a clear relationship?

Monaldi Archives for Chest Disease ◽

10.4081/monaldi.2021.1692 ◽

2021 ◽

Vol 91 (2) ◽

Author(s):

Athanassios Antonopoulos ◽

Laila Fiorani

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Case Report ◽

Early Identification ◽

Conduction Block ◽

Embolic Stroke ◽

P Wave ◽

Wave Analysis ◽

Increased Risk ◽

Interatrial Block

Atrial fibrillation (AF) can be detected in nearly 25% of all patients with stroke by sequentially combining different electrocardiographic methods. Prediction of early cardio-embolic stroke remain a permanent challenge in everyday practice. The early identification of an increased risk for atrial fibrillation episodes (which are frequently asymptomatic) is essential for the prevention of cardioembolic events. One of the noninvasive modalities of atrial fibrillation prediction is represented by the electrocardiographic P-wave analysis. This includes study and diagnosis of interatrial conduction block. Our short case report presents a case with ischemic cortico-sottocortical stroke involving capsulo and caudo regions in a woman patient with interatrial block as realized by electrocardiographic P analysis.

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Association of inverted T wave during atrial fibrillation rhythm with subsequent cardiac events

Heart ◽

10.1136/heartjnl-2021-319199 ◽

2021 ◽

pp. heartjnl-2021-319199

Author(s):

Tetsuma Kawaji ◽

Hisashi Ogawa ◽

Yasuhiro Hamatani ◽

Masashi Kato ◽

Takafumi Yokomatsu ◽

...

Keyword(s):

Atrial Fibrillation ◽

Multivariable Analysis ◽

Conduction Delay ◽

Cardiac Events ◽

Intraventricular Conduction ◽

T Wave ◽

St Segment ◽

Intraventricular Conduction Delay ◽

The Impact ◽

Ecg Abnormalities

ObjectiveThe clinical significance of ECG abnormalities during atrial fibrillation (AF) rhythm is poorly understood. The aim of the current study was to explore the impact of inverted T wave on cardiac prognosis in patients with AF.MethodsThe current study enrolled 2709 patients with AF whose baseline ECG was available from a Japanese community-based prospective survey, the Fushimi AF Registry, and the impact of inverted T wave in baseline ECG at AF rhythm on the composite of cardiac death, myocardial infarction and hospitalisation due to heart failure was examined.ResultsIntraventricular conduction delay, ST segment depression and inverted T wave were observed in 15.8%, 24.7% and 41.4% of baseline ECG with a mean heart rate of 94.7 beats per minute. The median follow-up duration was 5.0 years. The incidence rate of the composite cardiac endpoint was significantly higher in patients with inverted T wave than those without (5.8% vs 3.3% per patient-year, log-rank p<0.01). The higher risk associated with inverted T wave was consistent even for individual components of the composite cardiac endpoint. By multivariable analysis, inverted T wave was an independent predictor of the composite cardiac endpoint (HR 1.53, 95% CI 1.26 to 1.85, p<0.01). Inverted T wave was detected in 15.7% at anterior leads, 19.8% at inferior leads and 26.6% at lateral leads. The location of inverted T wave was not associated with risk of composite cardiac endpoint.ConclusionsInverted T wave was commonly observed in patients with AF and its presence during AF rhythm was associated with subsequent cardiac events.

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Risk of sick sinus syndrome in patients diagnosed with atrial fibrillation: a population-based cohort

10.22541/au.161555510.06165605/v1 ◽

2021 ◽

Author(s):

Pil-Sung Yang ◽

Daehoon Kim ◽

Eunsun Jang ◽

Hee Tae Yu ◽

Tae-Hoon Kim ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Elderly Population ◽

Sick Sinus Syndrome ◽

Sinus Node ◽

Pacemaker Implantation ◽

Population Based ◽

Av Block ◽

Increased Risk ◽

Observation Period

Background: Sinoatrial node dysfunction and atrial fibrillation (AF) frequently coexist and interact with each other, often to initiate and perpetuate each other. Objective: To determine the effect of AF on the incidence and risk of sick sinus syndrome (SSS). Methods: The association of incident AF with the development of incident SSS was assessed from 2004 to 2013 in 302,229 SSS- and pacemaker-free participants aged ≥60 years in the Korea National Health Insurance Service-Senior cohort. Results: During an observation period of 1,854,800 person-years, incident AF was observed in a total of 12,797 participants (0.69%/year). The incidence of SSS was 0.2 and 3.4 per 1000 person-years in the incident AF and the propensity score matched no-AF groups, respectively. After adjustment, the risk of SSS caused by incident AF was significantly increased, with a hazard ratio (HR) of 13.4 (95% confidence interval [CI]: 8.4–21.4). This finding was consistently observed after censoring for heart failure (HR, 16.0; 95% CI: 9.2–28.0) or heart failure/myocardial infarction (HR, 16.6; 95% CI: 9.3-29.7). Incident AF also was associated with an increased risk of pacemaker implantation related with both SSS (HR, 21.8; 95% CI: 8.7–18.4) and atrioventricular (AV) block (HR, 9.5; 95% CI: 4.9–18.4). These results were consistent regardless of sex and comorbidities. Conclusion: Incident AF was associated with more than ten times increased risk of SSS in an elderly population regardless of comorbidities. Risk of pacemaker implantations related with both sinus node dysfunction and AV block were increased in elderly population with incident AF.

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