经导管主动脉瓣置换术患者传导障碍的预测。
Prediction of conduction disturbances in patients undergoing transcatheter aortic valve replacement.
机构信息
Klinik Für Innere Medizin III, Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Saarland University, Kirrberger Str, 66421, Homburg/Saar, Germany.
Klinik Für Diagnostische Und Interventionelle Radiologie, Universitätsklinikum Des Saarlandes, Saarland University, Homburg/Saar, Germany.
出版信息
Clin Res Cardiol. 2023 May;112(5):677-690. doi: 10.1007/s00392-023-02160-0. Epub 2023 Jan 21.
AIM
Transcatheter aortic valve replacement (TAVR) can cause intraventricular conduction disturbances (ICA), particularly left bundle branch block (BBB) and high-degree atrioventricular block (HAVB). The aim of this study was to investigate clinical, anatomical, procedural, and electrophysiological parameters predicting ICA after TAVR.
METHODS
Patients with severe aortic stenosis (n = 203) without pacing devices undergoing TAVR with a self-expanding (n = 103) or balloon-expanding (n = 100) valve were enrolled. Clinical and anatomical parameters, such as length of the membranous septum (MS) and implantation depth, were assessed. His-ventricular interval (HVi) before and after implantation was determined. 12-lead-electrocardiograms (ECG) before, during and after 3 and 30 days after TAVR were analyzed for detection of any ICA.
RESULTS
Among 203 consecutive patients (aortic valve area 0.78 ± 0.18 cm, age 80 ± 6 years, 54% male, left ventricular ejection fraction 52 ± 10%), TAVR led to a significant prolongation of infranodal conduction in all patients from 49 ± 10 ms to 59 ± 16 ms (p = 0.01). The HVi prolongation was independent of valve types, occurrence of HAVB or ICA. Fifteen patients (7%) developed HAVB requiring permanent pacemaker (PPM) implantation and 63 patients (31%) developed ICA within 30 days. Pre-existing BBB (OR 11.64; 95% CI 2.87-47.20; p = 0.001), new-onset left BBB (OR 15.72; 95% CI 3.05-81.03; p = 0.001), and diabetes mellitus (OR 3.88; 95% CI 1.30-15.99; p = 0.02) independently predicted HAVB requiring PPM. Neither pre-existing right BBB, a prolonged postHVi, increases in PR duration, any of the TAVR implantation procedural and anatomic nor echocardiographic characteristics were predictive for later HAVB.
CONCLUSIONS
New-onset left BBB and diabetes mellitus independently predicted HAVB requiring PPM after TAVR and helped to identify patients at risk. Electrophysiologic study (EPS) of atrioventricular conduction was neither specific nor predictive of HAVB and can be skipped.
TRIAL REGISTRATION NUMBER
NCT04128384 ( https://www.
CLINICALTRIALS
gov ).
目的
经导管主动脉瓣置换术（TAVR）可导致室内传导障碍（ICA），特别是左束支传导阻滞（BBB）和高度房室传导阻滞（HAVB）。本研究旨在探讨预测 TAVR 后 ICA 的临床、解剖、手术和电生理参数。
方法
入组 203 例无起搏器装置的严重主动脉瓣狭窄患者（n=203），行自膨式（n=103）或球囊扩张式（n=100）瓣膜 TAVR。评估临床和解剖参数，如膜间隔（MS）长度和植入深度。植入前后测量 His 心室间隔（HVi）。分析 TAVR 前、中、后 3 天和 30 天的 12 导联心电图（ECG），以检测任何 ICA。
结果
在 203 例连续患者中（主动脉瓣面积 0.78±0.18 cm，年龄 80±6 岁，54%为男性，左心室射血分数 52±10%），TAVR 导致所有患者的窦房结下传导明显延长，从 49±10 ms 延长至 59±16 ms（p=0.01）。HVi 延长与瓣膜类型、HAVB 或 ICA 的发生无关。15 例（7%）患者出现 HAVB，需要植入永久性起搏器（PPM），63 例（31%）患者在 30 天内出现 ICA。术前存在完全性左束支传导阻滞（OR 11.64；95%CI 2.87-47.20；p=0.001）、新发左束支传导阻滞（OR 15.72；95%CI 3.05-81.03；p=0.001）和糖尿病（OR 3.88；95%CI 1.30-15.99；p=0.02）独立预测需要 PPM 的 HAVB。术前存在右束支传导阻滞、HVi 延长、PR 间期延长、任何 TAVR 植入术的解剖和程序特征均不能预测迟发性 HAVB。
结论
新发左束支传导阻滞和糖尿病独立预测 TAVR 后需要 PPM 的 HAVB，并有助于识别高危患者。房室传导的电生理研究（EPS）既不特异也不能预测 HAVB，可以跳过。
试验注册号
NCT04128384（https://www.clinicaltrials.gov/）。
Zotero 插件