Abstract
Background
Interference with the cardiac conduction system is common after transcatheter aortic valve implantation (TAVI), manifesting as atrioventricular block, or more commonly, new-onset persistent left bundle branch block (NOP-LBBB). Bundle branch block results in ventricular dyssynchrony and reduced cardiac output and may be associated with a poorer prognosis. This systematic review and meta-analysis evaluates the prognostic impact of a left or right bundle branch block after TAVI.
Methods
A systematic review was performed of the following online databases: PubMed, Medline, Scopus, and Web of Science, including English language studies from 2014 to 2024. Two separate searches for conducted for NOP-LBBB and new-onset persistent right bundle branch block (NOP-RBBB). The Newcastle-Ottawa Scale was used to evaluate risk of bias.
Results
Twenty-three studies totaling 18875 patients were included for NOP-LBBB, whilst 5 studies with a total of 3525 patients were included for NOP-RBBB. NOP-LBBB was associated with higher all-cause mortality at 1 year (risk ratio [RR] 1.41 [95% CI 1.12-1.78], I 2 = 49%, p < 0.01), cardiovascular mortality (RR 1.34 [95% CI 1.02-1.75], I 2 = 60%, p = 0.02), heart failure-related rehospitalization (RR 1.56 [95% CI 1.31-1.84], I 2 = 47%, p < 0.01), and permanent pacemaker implantation at 1 year (RR 3.05 [95% CI 2.39-3.89], I 2 = 14%, p < 0.01). NOP-RBBB was not associated with higher all-cause mortality at 1 year (RR 1.74 [95% CI 0.88-3.46], I 2 = 93%, p = 0.11), however increased the risk of pacemaker implantation at 1 year (RR 4.68 [95% CI 3.60-6.08], I 2 = 67%, p < 0.01).
Conclusions
NOP-LBBB is associated with higher mortality and heart failure rehospitalization after TAVI, whilst both NOP-LBBB and NOP-RBBB increase the risk of permanent pacemaker implantation at 1 year after TAVI.
Highlights
- •
New-onset persistent left bundle branch block (NOP-LBBB) is an important complication of transcatheter aortic valve implantation (TAVI) and is associated with a greater risk of all-cause mortality at 1 year after TAVI.
- •
NOP-LBBB after TAVI is also associated with a greater risk of cardiovascular mortality and heart failure-related rehospitalization at mid- to long-term follow-up.
- •
Both NOP-LBBB and new-onset persistent right bundle branch block are associated with a greater risk of permanent pacemaker implantation at 1 year.
Introduction
Transcatheter aortic valve implantation (TAVI) is a highly effective and minimally invasive treatment option for severe aortic stenosis and can be offered to patients of all surgical risk. , As of 2019, it has surpassed surgical aortic valve replacement as the primary treatment modality for aortic stenosis.
Interference with the conduction system is not an infrequent complication of TAVI. This occurs primarily due to the anatomical proximity of the atrioventricular node, bundle of His, and left bundle branch to the aortic annulus and left ventricular outflow tract, which may be disrupted by the insertion of a transcatheter heart valve (THV). A new permanent pacemaker (PPM) is required in 11.3% of cases, whilst the most common conduction abnormality is a new-onset persistent left bundle branch block (NOP-LBBB) which is seen in 16.3%. New-onset persistent right bundle branch block (NOP-RBBB) is a much rarer occurrence and is thus not as well studied or described in the literature.
New bundle branch block is no longer considered a benign outcome of TAVI, as the resulting ventricular dyssynchrony may manifest as reduced cardiac output resulting in increased mortality and heart failure, as well as increasing the risk of complete atrioventricular block. The aim of this systematic review and meta-analysis is to evaluate the mid- to long-term prognostic impact of a left or right bundle branch block after TAVI, with respect to mortality, heart failure-related rehospitalization and new PPM implantation.
Methods
A systematic review searching the following electronic databases was performed: PubMed, Medline, Scopus, and Web of Science from January 1, 2014, until April 1, 2024. Study screening was performed by 3 authors (K.R., M.A., and D.B.).
For the left bundle branch block (LBBB arm of the search, the keywords searched were “TAVI,” “TAVR,” “transcatheter aortic valve implantation,” or “transcatheter aortic valve replacement”; combined with “left bundle branch block” or “LBBB.” Free word and Medical Subject Headings term searches were conducted on “TAVI,” “TAVR,” “transcatheter (aorta∗),” and “left bundle branch block” or “LBBB.” The right bundle branch block (RBBB) study screening was performed with similar search terms, with replacement of LBBB with RBBB.
The review included all studies or abstracts which had accessible results and were published in English. Case reports, conference presentations, editorials, and expert opinions were excluded. Review articles were omitted due to potential publication bias and result duplication. A standardized data collection template was used for data extraction, including baseline demographics, study design, inclusion or exclusion criteria, incidence, and definition of persistent new LBBB or RBBB, length of follow-up, and valve type used.
Patients were divided into 2 groups, with and without new persistent bundle branch block. The primary outcome was all-cause mortality at 1 year, whilst secondary outcomes included all-cause mid-term (1-5 years) mortality, cardiovascular mortality, heart failure rehospitalization, and new PPM at 1 year. This review has been registered on International prospective register of systematic reviews (CRD42024533524).
Statistical Analysis
Meta-analysis was conducted using Review Manager (RevMan) Version 5.4 (Cochrane, London, United Kingdom). The Mantel-Haenszel statistical method was used with a random effects model to compute a risk ratio (RR) with a 95% CI. The I 2 test for heterogeneity was used. I 2 <30% was considered low heterogeneity, I 2 30% to 60% considered moderate, and I 2 >60% was considered high or considerable heterogeneity. All p values were 2-tailed, and p < 0.05 was considered statistically significant.
Results
New-Onset Persistent Left Bundle Branch Block
The initial search strategy yielded 1250 results, and after removal of duplicates 577 studies were removed. Through title and abstract screening, a further 634 were removed, and 39 studies remained for full study review. After application of the selection criteria, 16 further studies were excluded. The remaining 23 studies were further screened, and a bias assessment was performed using the Newcastle-Ottawa Scale (NOS) ( Figure 1 : Preferred reporting Items for systematic reviews and meta-analyses flow chart). Data extraction and critical appraisal was conducted by 3 reviewers (K.R., M.A., and D.B.), and the results were reviewed with senior investigators (P.H. and R.B.). The 23 studies included in this review consisted of a total of 18,875 patients. Of the included studies, 18 were performed retrospectively, whilst 5 were prospective. The NOS was used for bias adjudication, and all studies were determined to be of good or high quality (score 6-9).
Baseline Characteristics
Table 1 summarizes the key characteristics of the included LBBB-related studies which had similar demographics in terms of age, gender, and surgical risk score. The most common access site was transfemoral, and 15 studies used a combination of valves, whilst 6 used balloon-expandable valve exclusively, and 2 used self-expanding valve (SEV) exclusively. The incidence of new persistent LBBB varied amongst the studies (9.6%-47.5%) with an overall mean of 29.7%. The most common definition of NOP-LBBB was on electrocardiogram at hospital discharge (n = 14), followed by at 1 month (n = 4) and postprocedure/24 h (n = 4). Figure 2 reports the incidence of NOP-LBBB by year in all studies which defined NOP-LBBB as occurring at hospital discharge (n = 14) and is arranged chronologically as well as by predominant valve type used.
| Author (y) | Country | Total patients | Age (y) (LBBB/no LBBB) | Male% (LBBB/no LBBB) | New persistent LBBB definition | Incidence p-LBBB (%) | Follow-up | Valve type | Surgical risk % (LBBB/no LBBB) | Femoral access% | Study type | NOS bias score |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Akdemir (2020) | USA | 151 | 79/80 | 46/53 | Hospital discharge | 31.1 | 1 y | BEV, SEV | n/a | 100% | Retrospective, single center | 7 |
| Ashraf (2020) | USA | 243 | 81/80 | 46/58 | Postprocedure | 19.8 | 1 y | BEV | n/a | 83% | Retrospective, single center | 7 |
| Carraba (2015) | USA | 92 | 81/81 | 53/52 | Hospital discharge | 37.0 | 1 y | SEV | Log. EuroScore 20.0 (cohort) | 97% | Retrospective, single center | 7 |
| Chamandi (2019) | Canada | 1020 | 80/81 | 57/58 | Hospital discharge | 20.8 | 3 y (median) | BEV, SEV | STS 6.8/6.5 | 84% | Retrospective, multicenter | 8 |
| Eschalier (2019) | France | 80 | 82/82 | 53/63 | 24 h | 9.6 | 1 y | BEV, SEV | Euroscore II 3.5 (cohort) | 76% | Prospective, single center | 6 |
| Hamandi (2020) | USA | 424 | 82/81 | 42/53 | Postprocedure | 12.3 | 1 y | BEV, SEV | STS 7.6/7.2 | 85% | Retrospective, single center | 7 |
| Hein-Rothweiler (2017) | Germany | 225 | 81/80 | 33/44 | Hospital discharge | 23.1 | 1 y | BEV | Log. EuroScore 16.9/17.3 | 100% | Retrospective, single center | 7 |
| Houthuizen (2014) | Netherlands | 412 | 80/81 | 57/41 | 12 mo | 26.9 | 3 y (median) | BEV, SEV | Log. EuroScore 16.4 (cohort) | 63% | Retrospective, multicenter | 8 |
| Jorgensen (2019) | Denmark | 684 | 81/81 | 50/51 | Hospital discharge | 36.1 | 1 y | BEV, SEV | STS 3.1/3.3 | 93% | Prospective, single center | 9 |
| Kessler (2019) | Germany | 528 | 81/80 | 46/46 | Postprocedure | 47.5 | 2 y | BEV, SEV, MEV | STS 6.6/6.7 | n/a | Retrospective, single center | 8 |
| Kim (2022) | South Korea | 364 | 80/81 | 42/46 | Hospital discharge or 7 d | 11.3 | 1 y | BEV, SEV | STS 6.1/5.8 | n/a | Retrospective, single center | 8 |
| Lopez-Aguilera (2016) | Spain | 153 | 78/77 | 45/59 | Hospital discharge | 36.0 | 5 y | SEV | STS 9.5/12.0 | n/a | Prospective, single center | 9 |
| Nazif (2019) | USA | 1179 | 81/82 | 53/54 | Hospital discharge | 15.2 | 1 y | BEV | STS 5.5/5.5 | 83% | Prospective, multicenter | 9 |
| Nazif (2014) | USA | 1051 | 84/84 | 43/44 | Hospital discharge | 11.5 | 1 y | BEV | STS 11.3/11.1 | 57% | Prospective, multicenter | 9 |
| Paracuellos (2021) | Spain | 254 | 80/82 | n/a | Hospital discharge | 21.6 | 21 mo (median) | BEV, SEV | EuroScore II 6.1 (cohort) | n/a | Retrospective, single center (conference abstract) | 6 |
| Saito (2024) | Japan | 5716 | 85/84 | 23/33 | Hospital discharge | 29.0 | 2 y | BEV, SEV | STS 6.0/6.1 | 90% | Retrospective, multicenter | 8 |
| Sammour (2023) | USA | 612 | 80/81 | 66/52 | 1 mo | 11.4 | 3 y | BEV | STS 5.7 (cohort) | 100% | Retrospective, single center | 9 |
| Sasaki (2020) | Japan | 231 | 84/84 | 24/37 | 1 mo | 12.6 | 431 d (median) | BEV, SEV | STS 5.3/6.2 | n/a | Retrospective, single center | 8 |
| Sasaki (2023) | Japan | 245 | n/a | n/a | 1 mo | 16.7 | 3 y | BEV, SEV | n/a | n/a | Retrospective, single center | 7 |
| Schymik (2015) | Germany | 634 | 82/82 | 33/41 | Hospital discharge | 31.1 | 1 y | BEV, SEV | Log. EuroScore 21.7 | n/a | Retrospective, multicenter | 8 |
| Tomii (2022) | Switzerland | 1669 | 81/82 | 43/49 | 1 mo | 20.1 | 1 y | BEV, SEV, MEV | STS 4.8 (cohort) | 92% | Retrospective, single center | 8 |
| Tshushima (2022) | USA | 2240 | 80/81 | 41/46 | Hospital discharge | 17.5 | 1.8 (median) | BEV, SEV | STS 5.3/5.5 | n/a | Retrospective, multicenter | 9 |
| Urena (2014) | Canada | 668 | 78/81 | 49/49 | Hospital discharge | 11.8 | 13 mo (median) | BEV | STS 7.6/7.9 | 54% | Retrospective, multicenter | 9 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
