Risk of delayed atrioventricular block in patients without procedural conduction disturbances during transcatheter aortic valve replacement.

Background: Among patients undergoing transcatheter aortic valve replacement (TAVR), the risk of delayed atrioventricular block (AVB) in those without procedural conduction disturbances (CDs) remains largely unknown. This may affect hospital stay, particularly same- or next-day discharge after the procedure.

Objective: The purpose of this study was to evaluate the timing, type, and factors associated with delayed (up to 30 days) AVB in patients without procedural CDs.

Methods: This was a subanalysis of the PRospective Application of a Pre-Specified Scientific Expert Panel AlgOrithm for the Management of COnduction Disturbances Following Transcatheter Aortic Valve REplacement (PROMOTE) trial, a prospective multicenter study including consecutive patients without a prior pacemaker undergoing TAVR and with a prespecified strategy for managing CDs. Patients with no prior right bundle branch block and no procedural CDs were included in this subanalysis. Data on 30-day occurrence and timing of AVB and permanent pacemaker implantation (PPI) were collected in a dedicated database, and analyzed overall and according to the preprocedural electrocardiographic (ECG) abnormalities (either first-degree AVB or abnormal QRS morphology).

Results: A total of 675 patients were included, 334 of which (49.5%) exhibited baseline ECG abnormalities. At 30 days, 23 patients (3.4%) had delayed AVB (0.6% vs 6.3% in patients with normal and abnormal ECGs preprocedurally, respectively; P < .001). Most (74%) delayed AVB occurred on day 1 or 2 after the procedure. In the multivariable analysis, the factors associated with an increased risk of delayed AVB were preexisting abnormal ECG (odds ratio 5.28; 95% confidence interval 1.53-18.27; P = .009) and left ventricular ejection fraction < 50% (odds ratio 4.17; 95% confidence interval 1.75-9.93; P = .001). Among patients in sinus rhythm with a preprocedural abnormal ECG, those with QRS duration > 120 ms and first-degree AVB exhibited the highest risk (PPI rate: 17.8%) followed by those with isolated QRS duration > 120 ms (PPI rate: 8.7%).

Conclusion: Among TAVR recipients with no procedural CDs, those with a preexisting abnormal ECG represent a high-risk group for delayed AVB requiring PPI. This would support a tailored strategy, with a minimalist approach (same- or next-day discharge) in low-risk patients and a more prolonged hospitalization or continuous ECG ambulatory monitoring in those at higher risk.

Trial Registration: Clinicaltrials.gov identifier: NCT04139616.