An isolated increase in PR >240 ms without other EKG changes should not prompt PPM placement.As discussed with group 2, an EPS, continuous EKG monitoring, or empiric PPM placement can be considered. If there is no regression of these changes, the patient is considered high risk for HAVB/CHB. 1.3 percent p 150ms, the PR remains >240 ms, the QRS or PR are >20 ms than the baseline, or there are further EKG changes with ≥20 ms increase in PR or QRS, the TVP should be maintained for another 24 hours. Rapid atrial pacing after TAVR with the absence of a developed Wenckebach AVB may also be a helpful negative predictor for PPM implantation (13.1 percent vs. An EPS demonstrating an Infra-Hisian block during atrial pacing or HV interval >100 ms indicates the need for PPM placement. For patients with a persistent increase in the PR or QRS duration ☲0 ms who are at a high risk of HAVB/CHB, an invasive electrophysiology study (EPS) or continuous EKG monitoring for 48 hours to four weeks to guide PPM decision-making or empiric PPM placement.Prophylactic PPM in patients with a previous RBBB is not recommended.The TVP should be maintained for 24 hours with daily EKG/telemetry monitoring for two days, with discharge on POD #2 if no arrhythmias arise.Group 2: No EKG changes in patients with pre-existing RBBB: An EKG on post-operative day 1 (POD #1) after telemetry for 24 hours is recommended, with early hospital discharge on POD #1 if there are no arrhythmias.These patients are low risk for conduction disturbances, and the TVP can be discontinued post-operatively.Group 1: No EKG changes in patients without pre-existing RBBB: 3Īn immediate post-procedure EKG is recommended to risk stratification patients for lasting conduction disturbances (see Figure 1): 13.5 percent p 5–7 mm below the aortic annulus has been associated with an increased risk of new LBBB. 4 The presence of a pre-procedural right bundle branch block (RBBB) is associated with an increased risk of PPM implantation at 30 days (40.1 percent vs. 4 Pre-Procedural AssessmentĮliciting a history of symptoms related to a bradyarrhythmia may be helpful in determining which patients are at higher risk for conduction disturbances. 3 Another recent expert consensus decision pathway from the American College of Cardiology (ACC) Solution Set Oversight Committee affirms this pathway and discusses the pre-procedural and intraprocedural considerations in detail. Our review follows the framework of the 2019 Journal of the American College of Cardiology (JACC) Scientific Expert Panel Statement, comprised of a pre-procedural risk assessment, procedural considerations, and post-procedural evaluation. 1, 2 In this Tip of the Month, we focus on the management of these conduction disturbances post-TAVR. Despite improvements in the procedural process, there remains a significant risk of causing new onset left bundle branch block (LBBB) or high-degree atrioventricular block (HAVB)/complete heart block (CHB) requiring permanent pacemaker (PPM) implantation. Transcatheter aortic valve replacement (TAVR) has become the most prevalent treatment strategy for severe aortic stenosis. Goldsweig, MD, MS, FSVM, RPVI, FSCAI Introduction Stout, DO, MPH Harsh Golwala, MD Faisal Latif, MD, FSCAI and Andrew M.
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