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9-17-2020

Late onset complete heart block after transcatheter aortic valve Late onset complete heart block after transcatheter aortic valve

replacement treated with permanent His-bundle pacing replacement treated with permanent His-bundle pacing

Sati Patel

Khaled Jamoor

Arfaat Khan

Waddah Maskoun

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Received: 2May 2020 Revised: 2 September 2020 Accepted: 13 September 2020

DOI: 10.1111/pace.14074

CA S E R E PORT

Late onset complete heart block after transcatheter aorticvalve replacement treatedwith permanent His-bundle pacing

Sati PatelMD1 Khaled JamoorMD2 Arfaat KhanMD1 WaddahMaskounMD1

1 Division of Cardiovascular Disease, Henry

Ford Health System, Detroit, Michigan

2 Department of InternalMedicine, Henry

Ford Health System, Detroit, Michigan

Correspondence

WaddahMaskoun, SectionofCardiacElectro-

physiology,DivisionofCardiovascularDisease,

HenryFordHospital,Detroit,MI,USA.

Email:wmaskou1@hfhs.org

This is anoriginal unpublished case report and

is notbeing considered forpublicationbyany

other journal.Noportionof the text hasbeen

copied fromothermaterial in the literature.All

authorshaveparticipated in theworkandhave

readandapproved themanuscript. All authors

donothaveany relevant conflict of interest to

disclose. Therewereno sourcesof funding for

thiswork.

Abstract

Transcatheter aortic valve replacement (TAVR) is a rapidly growing procedure. Con-

duction disease post-TAVR is frequent and routinely monitored for periprocedurally.

Permanent pacemaker placement is relatively common and usually associated with

worse outcomes post-TAVR. We report a case of very late presenting complete heart

block post-TAVR treated with His-bundle pacing. Our case underscores the need for

larger studies to further evaluate theutility of long-termcardiacmonitoring post-TAVR

and outcomes of His-bundle pacing in this population.

KEYWORDS

His-bundle pacing, late conduction disease, pacing, sudden cardiac death, TAVR

1 INTRODUCTION

Conduction disease (CD) after transcatheter aortic valve replace-

ment (TAVR) is common. Well-recognized predictors for permanent

pacemaker implantation (PMI) post-TAVR include male sex, preex-

isting right bundle branch block, first-degree atrioventricular block,

left anterior hemiblock, use of self-expanding valves, and intraoper-

ative AV block.1–4 The location of complete heart block post-TAVR

has been noted to occur both at the level of the AV node and

in the His-Purkinje system (infra AV node).5–7 The majority of CD

post-TAVR warranting PMI occurs within the first 7 days, however

late occurring CD has also been described.8–9 Deleterious effects

of long-term right ventricular apical pacing have been well estab-

lished, prompting the need for a more physiologic alternative.10

His-bundle pacing (HBP) has emerged as a suitable alternative,

however, HB mapping can be challenging.11–12 We present a case

of very late occurring CD post-TAVR in which radiographic pres-

ence of the TAVR valve facilitated dual chamber PMI with HB

pacing.

Abbreviations: CD, conduction disease; HB, His-bundle; HBP, His-bundle pacing; PMI,

pacemaker implantation; TAVR, transcatheter aortic valve replacement

2 CASE REPORT

A76-year-old womanwith hypertension, chronic kidney disease, heart

failure with preserved ejection fraction, coronary artery disease, dia-

betes mellitus, and severe aortic stenosis was referred to our institu-

tion. She was determined to be at prohibitive surgical risk due to age

and comorbidities and was referred for TAVR. Her baseline electro-

cardiogram (ECG) was unremarkable, with normal intervals and no CD

(Figure 1A). Using a right femoral approach, the patient underwent a

20 mm SAPIEN balloon valvuloplasty and successful placement of a

23 mm Edwards SAPIEN 3 valve with no significant gradient. There

were no perioperative or intraprocedural conduction changes fromher

baseline ECG (Figure 1B). This continued to be the case at 1-month

follow-up with remarkable improvement in symptoms compared to

pre-TAVR (Figure 1C). Accordingly, she did not undergo any cardiac

monitoring postprocedurally. Five months following TAVR, she pre-

sented to her cardiologist with new fatigue and dyspnea on exertion,

and ECG at that time revealed persistent complete heart block with

a junctional escape rhythm (Figure 2A and B). Notably, her ECG also

revealed P-wave inversion, suggestive of concomitant sinus node dys-

function as well. The complete heart block was attributed to late onset

post-TAVR-related CD. She was then referred for permanent PMI. In

Pacing Clin Electrophysiol. 2020;1–5. © 2020Wiley Periodicals LLC 1wileyonlinelibrary.com/journal/pace

2 PATEL ET AL.

F IGURE 1 A-C, Clockwise, baseline ECG prior to TAVR (A), ECG immediately post-TAVR (B), ECG 1month post-TAVR (C) [Color figure can beviewed at wileyonlinelibrary.com]

light of the patient’s age, frailty, and comorbidities, HBP was pur-

sued out of concern for future development of left ventricular dys-

function from right ventricular pacing. Our concern was that a future

second procedure to add a left ventricular lead or later attempt HB

pacing may carry the potential risk of having an occluded access

vein and necessitating placement of a new system on the opposite

side. A dual-chamber (His-bundle pacing) Medtronic MRI compatible

pacemaker was implanted using the Medtronic Secure Select (model

3830) (Minneapolis, MN) lead. The TAVR valve served as a radio-

graphic guide to localize the HB, which was posterior and inferior

to the valve (Figure 3A-C). The His capture threshold was 2.2 V at

1 ms. We adjusted her device programing aiming for nonselective

His-bundle pacing. At subsequent follow-up, the patient had reso-

lution of her preimplantation symptoms. She remained pacemaker

dependent and continued to have preserved left ventricular systolic

function.

3 DISCUSSION

The incidence of CD post-TAVR has not changed despite advances in

periprocedural survival and remains a significant source of morbid-

ity and mortality.4,13 Up to 90% of CD post-TAVR occurs within the

first 30 days postoperatively.2 Beyond 30 days, very late CD is a rare

and feared complication.4 One large meta-analysis attributed 11% of

deaths more than 30 days post-TAVR to sudden cardiac death from

very late CD.14

Very late occurring CD post-TAVR without preexisting or peripro-

cedurally acquired CD poses an exceptionally troubling patient

cohort as risk factors are not yet understood, and the exact

mechanism for such late occurring CD is not clear. We believe

that elderly patients with severe degenerative aortic valve steno-

sis are prone to conduction system disease and that TAVR accel-

erates the process.15–16 However, micro-migration or movement of

the aortic valve as potential cause of the CD cannot be com-

pletely excluded. Therefore, we recommend considering 30-day

event monitor post-TAVR and frequent 12-lead ECG monitoring

thereafter.

Individual studieshave foundconflicting results regardingoutcomes

in TAVR patients who have undergone PMI. However, a recent meta-

analysis found an overall harmful effect of PMI on all cause death and

heart failure hospitalizations.13 As HBP has been found to improve

quality of life, improve ejection fraction, and reduce heart failure hos-

pitalizations in the general population, it represents an attractive alter-

native for TAVR patients.12 Sharma et al studied 30 patients with pros-

thetic valves undergoingHBP: 12 patients had prosthetic aortic valves,

PATEL ET AL. 3

F IGURE 2 Late development of complete heart block with junctional escape rhythm. A, (Top) ECG from outside cardiologist office; note thepresence of inverted P-waves is suggestive of sinus node dysfunction. B, (Bottom) ECG at electrophysiology clinic visit [Color figure can be viewedat wileyonlinelibrary.com]

four of which were via TAVR.17 The study found prosthetic aortic

valves (including TAVR) useful as fluoroscopic landmarks with the HB

located inferiorly relative to the valve.Hence, presenceof a TAVRvalve

may improve feasibility of HBP as it serves as a radiographic guide.

Future studies should be dedicated to evaluating outcomes of HBP

post-TAVR.

4 CONCLUSION

Very late development of complete heart block post-TAVR with-

out preexisting CD poses a significant concern as a cause of

late major adverse events related to TAVR. HBP might be a

feasible option in a portion of this patient population, and the

valve, itself a fluoroscopic marker, can serve as an asset for His

localization.

AUTHOR CONTRIBUTIONS

Study concept and design: Khaled Jamoor and Waddah Mask-

oun. Drafting of the manuscript: Sati Patel. Critical revision of the

manuscript for important intellectual content: Waddah Maskoun.

Approval of the article: Arfaat Khan.

ORCID

Sati PatelMD https://orcid.org/0000-0002-7039-029X

WaddahMaskounMD https://orcid.org/0000-0001-9128-6128

4 PATEL ET AL.

F IGURE 3 A-C, Clockwise: TAVR valve with respect to pacing leads during placement (A) and the following day (B). ECG post-His-bundlepacing (C) [Color figure can be viewed at wileyonlinelibrary.com]

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How to cite this article: Patel S, Jamoor K, Khan A,Maskoun

W. Late onset complete heart block after transcatheter aortic

valve replacement treated with permanent His-bundle pacing.

Pacing Clin Electrophysiol. 2020;1–5.

https://doi.org/10.1111/pace.14074