van der Boon Robert M A, Houthuizen Patrick, Urena Marina, Poels Thomas T, van Mieghem Nicolas M, Brueren Guus R G, Altintas Sibel, Nuis Rutger Jan, Serruys Patrick W, van Garsse Leen A F M, van Domburg Ron T, Cabau Joseph Rodés, de Jaegere Peter P T, Prinzen Frits W
Erasmus Medical Center, Rotterdam, The Netherlands.
Catheter Cardiovasc Interv. 2015 Apr;85(5):E144-52. doi: 10.1002/ccd.25765. Epub 2014 Dec 27.
The aim of the study was to investigate trends over time in the occurrence of left bundle branch block (LBBB) and permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) with the Medtronic CoreValve System (MCS) and Edwards SAPIEN Valve (ESV).
TAVI-induced conduction abnormalities (TAVI-CAs) such as LBBB and the need for PPI are frequent postoperative complication. New techniques, procedural refinements, and increased awareness are focused on the reduction of these abnormalities.
Electrocardiograms of 549 patients without preprocedural LBBB and/or pacemaker were assessed to determine the frequency and nature of TAVI-CAs. To study the effect of experience, patients were subdivided per center into tertiles based on the number of procedures. Univariate and multivariate logistic regression was used to study predictors of TAVI-induced LBBB (TAVI-LBBB) and PPI.
TAVI-LBBB occurred in 185 patients (33.7%) and significantly decreased over time, from 42.6% to 27.3% (P=0.006). This effect was only significant after implantation of the MCS (59.6% vs. 46.5% vs. 31.1%, P=0.001, ESV: 22.6% vs. 13.1% vs. 24.8%, P=0.11). Between tertiles there was no difference in the frequency of PPI after TAVI (n=73, 13.1% vs. 14.8% vs. 12%, P=0.74). Multivariate analysis revealed that, independent from valve type, depth of implantation was the only significant predictor of TAVI-LBBB (OR [95% C.I.]: 1.16 [1.10-1.24], P<0.001). In case of PPI pre-existing RBBB (OR [95% C.I.]: 7.22 [3.28-15.88], P<0.001) was the only significant predictor.
Over time the frequency of LBBB after TAVI decreased significantly, especially in patients undergoing TAVI with the MCS. Experience and the subsequent reduction in depth of implantation seem responsible for this reduction. Contrary to TAVI-LBBB, the incidence of PPI remained unchanged over time and was not affected by experience. Although experience has led to a decrease in new CAs after TAVI, elucidation of pathophysiologic mechanisms underlying these CAs and subsequent changes in patient stratification, valve design and the procedure are needed to further reduce this complication.
本研究旨在调查使用美敦力CoreValve系统（MCS）和爱德华兹SAPIEN瓣膜（ESV）进行经导管主动脉瓣植入术（TAVI）后，左束支传导阻滞（LBBB）的发生情况及永久起搏器植入（PPI）随时间的变化趋势。
TAVI引起的传导异常（TAVI-CAs），如LBBB以及PPI需求，是常见的术后并发症。新技术、操作改进及意识提高都聚焦于减少这些异常情况。
对549例术前无LBBB和/或起搏器的患者的心电图进行评估，以确定TAVI-CAs的频率和性质。为研究经验的影响，根据各中心手术例数将患者分为三分位数组。采用单因素和多因素逻辑回归分析来研究TAVI引起的LBBB（TAVI-LBBB）和PPI的预测因素。
185例患者（33.7%）发生了TAVI-LBBB，且随时间显著下降，从42.6%降至27.3%（P = 0.006）。这种效应仅在植入MCS后显著（59.6%对46.5%对31.1%，P = 0.001，ESV：22.6%对13.1%对24.8%，P = 0.11）。TAVI后PPI的频率在三分位数组之间无差异（n = 73，13.1%对14.8%对12%，P = 0.74）。多因素分析显示，独立于瓣膜类型，植入深度是TAVI-LBBB的唯一显著预测因素（比值比[95%置信区间]：1.16[1.10 - 1.24]，P < 0.001）。对于PPI，术前存在右束支传导阻滞（比值比[95%置信区间]：7.22[3.28 - 15.88]，P < 0.001）是唯一显著预测因素。
随着时间推移，TAVI后LBBB的频率显著下降，尤其是在接受MCS TAVI的患者中。经验以及随后植入深度的降低似乎是导致这种下降的原因。与TAVI-LBBB相反，PPI的发生率随时间保持不变，且不受经验影响。尽管经验已导致TAVI后新的传导异常减少，但仍需要阐明这些传导异常的病理生理机制以及随后患者分层、瓣膜设计和手术的变化，以进一步减少这种并发症。
