已有右束支传导阻滞患者经导管主动脉瓣置入术后晚期传导障碍的风险分层与管理
Risk Stratification and Management of Advanced Conduction Disturbances Following TAVI in Patients With Pre-Existing RBBB.
作者信息
Isogai Toshiaki, Dykun Iryna, Agrawal Ankit, Shekhar Shashank, Saad Anas M, Verma Beni Rai, Abdelfattah Omar M, Kalra Ankur, Krishnaswamy Amar, Reed Grant W, Kapadia Samir R, Puri Rishi
机构信息
Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.
出版信息
Struct Heart. 2022 Mar 17;6(1):100006. doi: 10.1016/j.shj.2022.100006. eCollection 2022 Apr.
BACKGROUND
Pre-existing right bundle branch block (RBBB) is a strong predictor of increased need for a permanent pacemaker (PPM) following transcatheter aortic valve implantation (TAVI). Yet, further risk stratification and management remain challenging in patients with pre-existing RBBB owing to limited data. Therefore, we sought to investigate the incidence, predictors, and management of advanced conduction disturbances after TAVI in patients with pre-existing RBBB.
METHODS
We retrospectively reviewed 261 consecutive patients with pre-existing RBBB (median age 81 years; 28.0% female; 95.0% received a balloon-expandable valve) without a pre-existing PPM who underwent TAVI at our institution in 2015-2019. Outcomes were high-degree atrioventricular block/complete heart block (HAVB/CHB) and PPM requirement.
RESULTS
Overall, the 30-day HAVB/CHB rate was 28.0%, of which 76.7% occurred during the TAVI procedure. The delayed HAVB/CHB rate was 8.3%. Implantation depth below aortic annulus (per 1-mm increase) was significantly associated with increased risk of procedural HAVB/CHB (adjusted odds ratio = 1.25, 95% confidence interval = 1.07-1.46), delayed HAVB/CHB (1.34 [1.01-1.79]), and 30-day PPM (1.32 [1.11-1.55]). Predilation was associated with delayed HAVB/CHB (4.02 [1.22-13.23]). The combination of no predilation and implantation depth of ≤2.0 mm had lower rates of procedural HAVB/CHB (11.2% vs. 26.7%-30.4%, = 0.011), delayed HAVB/CHB (2.1% vs. 7.6%-28.1%, < 0.001), and 30-day PPM (10.3% vs. 20.0%-43.5%, < 0.001) than the other strategies of valve deployment. Complete HAVB/CHB recovery after PPM implantation was uncommon at 7.1%.
CONCLUSIONS
In patients with pre-existing RBBB, the majority of HAVB/CHB events occurred during the TAVI procedure. Avoidance of predilation coupled with high valve deployment may result in relatively low rates of procedural and delayed HAVB/CHB, along with 30-day PPM rates.
背景
既往存在右束支传导阻滞（RBBB）是经导管主动脉瓣植入术（TAVI）后永久性起搏器（PPM）需求增加的有力预测指标。然而，由于数据有限，对于既往存在RBBB的患者，进一步的风险分层和管理仍然具有挑战性。因此，我们试图研究既往存在RBBB的患者TAVI后高级传导障碍的发生率、预测因素及管理方法。
方法
我们回顾性分析了2015 - 2019年在我们机构接受TAVI的261例连续既往存在RBBB的患者（中位年龄81岁；28.0%为女性；95.0%接受球囊扩张瓣膜），这些患者术前未植入PPM。观察指标为高度房室传导阻滞/完全性心脏传导阻滞（HAVB/CHB）和PPM需求。
结果
总体而言，30天HAVB/CHB发生率为28.0%，其中76.7%发生在TAVI手术过程中。延迟性HAVB/CHB发生率为8.3%。主动脉瓣环以下植入深度每增加1毫米，手术中发生HAVB/CHB（调整优势比 = 1.25，95%置信区间 = 1.07 - 1.46）、延迟性HAVB/CHB（1.34 [1.01 - 1.79]）和30天PPM（1.32 [1.11 - 1.55]）的风险显著增加。预扩张与延迟性HAVB/CHB相关（4.02 [1.22 - 13.23]）。未进行预扩张且植入深度≤2.0毫米的联合策略与其他瓣膜置入策略相比，手术中HAVB/CHB发生率（11.2%对26.7% - 30.4%，P = 0.011）、延迟性HAVB/CHB发生率（2.1%对7.6% - 28.1%，P < 0.001）和30天PPM发生率（10.3%对20.0% - 43.5%，P < 0.001）更低。PPM植入后完全性HAVB/CHB恢复情况不常见，为7.1%。
结论
在既往存在RBBB的患者中，大多数HAVB/CHB事件发生在TAVI手术过程中。避免预扩张并进行高位置瓣膜置入可能导致手术中及延迟性HAVB/CHB发生率以及30天PPM发生率相对较低。
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