Ambulatory Rhythm Monitoring to Detect Late High-Grade Atrioventricular Block Following Transcatheter Aortic Valve Replacement

J Am Coll Cardiol. 2019 May 28;73(20):2538-2547. doi: 10.1016/j.jacc.2019.02.068.


Background: High-grade atrioventricular block (H-AVB) is a well-described in-hospital complication of transcatheter aortic valve replacement (TAVR). Delayed high-grade atrioventricular block (DH-AVB) has not been systematically studied among outpatients post-TAVR, using latest-generation TAVR technology and in the early post-TAVR discharge era.

Objectives: The purpose of this study was to assess utility of ambulatory event monitoring (AEM) in identifying post-TAVR DH-AVB and associated risk factors.

Methods: Patients without pre-existing pacing device undergoing TAVR at the University of Colorado Hospital from October 2016 to March 2018, and who did not require permanent pacemaker implantation pre-discharge, were discharged with 30-day AEM to assess for DH-AVB (≥2 days post-TAVR). Clinical and follow-up data were collected and compared among those without incident H-AVB.

Results: Among 150 consecutive TAVR patients without a prior pacing device, 18 (12%) developed H-AVB necessitating permanent pacemaker <2 days post-TAVR, 1 died pre-discharge, and 13 declined AEM; 118 had 30-day AEM data. DH-AVB occurred in 12 (10% of AEM patients, 8% of total cohort) a median of 6 days (range 3 to 24 days) post-TAVR. DH-AVB versus non-AVB patients were more likely to have hypertension and right bundle branch block (RBBB). Sensitivity and specificity of RBBB in predicting DH-AVB was 27% and 94%, respectively.

Conclusions: DH-AVB is an underappreciated complication of TAVR among patients without pre-procedure pacing devices, occurring at rates similar to in-hospital, acute post-TAVR H-AVB. RBBB is a risk factor for DH-AVB but has poor sensitivity, and other predictors remain unclear. In this single-center analysis, AEM was helpful in expeditious identification and treatment of 10% of post-TAVR outpatients. Prospective study is needed to clarify incidence, risk factors, and patient selection for outpatient monitoring.

Keywords: ambulatory event monitoring; complete heart block; pacemaker; transcatheter aortic valve replacement.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aortic Valve / surgery
  • Aortic Valve Stenosis / surgery*
  • Atrioventricular Block / diagnosis*
  • Atrioventricular Block / epidemiology
  • Atrioventricular Block / physiopathology
  • Colorado / epidemiology
  • Electrocardiography, Ambulatory / methods*
  • Female
  • Follow-Up Studies
  • Humans
  • Incidence
  • Male
  • Postoperative Complications*
  • Prospective Studies
  • Reproducibility of Results
  • Risk Factors
  • Survival Rate / trends
  • Time Factors
  • Transcatheter Aortic Valve Replacement / adverse effects*