1. Self-Expanding TAVR: Conduction Abnormalities Jeffrey J. Popma, MD
Director, Interventional Cardiology
Clinical Services
Beth Israel Deaconess Medical Center
Associate Professor of Medicine
Harvard Medical School
Boston, MA

2. Conflict of Interest Statement
Within the past 12 months, I have had a financial interest/arrangement or affiliation with the organization(s) listed below.
Physician Name Company/Relationship
Jeffrey J. Popma, MD Research Grants: Cordis, Boston Scientific,
Medtronic, Abbott-Guidant, eV3, LabCoat
Medical Advisory Board: Cordis, Boston Scientific, Abbot Vascular
Disclaimer: “Caution – Percutaneous Aortic Valves are investigational devices, limited by United States to Investigation use only.”

3. Managing Post TAVR Rhythm Disturbances
Why Do They Occur?
How Often Do Problems Develop?
How Can we Predict Them?
Who Should Receive PPMs?

4. The Triangle of Koch (Right Atrium)
The atrioventricular node is contiguous to the membranous septum
The origin of the LBBB and is found at the apex of the triangle of Koch
Atrioventricular node
Courtesy of Professor Damian Sanchez-Quintana

5. Conduction Abnormalities
Piazza et al JACC CV Interv 2008;1;

6. Permanent Pacemaker Need
Khawaja Circulation. 2011;123:

7. Managing Post TAVR Rhythm Disturbances
Why Do They Occur?
How Often Do Problems Develop?
How Can we Predict Them?
Who Should Receive PPMs?
Left Bundle Branch Block
AV Conduction Disturbances
Complete Heart Block
Permanent Pacemaker Use

8. CoreValve Implantation Case
Day 1 post-procedure
New onset LBBB
Day 3
Post-procedure LBBB
Serruys et al. Tips & Tricks to Avoid Failure (Informa Healthcare 2010)

9. New LBBB After CoreValve
30 day follow-up 65 46 38 39 40
% patients 30
Piazza N TVT2010 Seattle

10. EuroPCR: National Registries Outcomes
Registry
Pts
Device
Stroke
PPM
COR 72
Corevalve
7.1
25.4
Contemporary Registries
Italian Registry2
772
CoreValve
1.7
18.5
Belgian Registry3
141 4
23.0
French Transfemoral4 66
3.6
26.9
UK CoreValve Registry5
417 NR
26.0
Total
1,396
Source Registry (Cohort 1) 6
463
Edwards
4.0 8
Appropriate PPM may be < 20%
EuroPCR2010: 1 Gerckens et al; 2Petronio et al; 3 Bosmans et al; 4 Eltchaninoff et al; 5 Ludman et al; 6 Thomas et al

11. Other Contemporary Series
Italian Registry: New PPM in 17.4% at 30 Days
Tamburino Circulation. 2011;123:
Hospital Universitario N=181
EuroPCR 2011
P=0.007
34.5
Hazard Ratio
P Value
Depth of Implant
1.15
0.001
RBBB
3.08
0.007
Standard 59 14
STD
Accutrak

12. Managing Post TAVR Rhythm Disturbances
Why Do They Occur?
How Often Do Problems Develop?
How Can we Predict Them?
Who Should Receive PPMs?

13. Permanent Pacemaker Need
270 patients from 10 clinical center in UK
8% of patients with prior PPM
LBBB 13% at baseline  61% after procedure
33.3% new permanent pacemaker requirement
Baseline conduction abnormalities
- Baseline RBBB  65.2% PPM
- Base LBBB  43.75% PPM
- Normal QRS complex  27.6% PPM
Median time to PPM implant, 4 days
Multivariable predictors: AV block, balloon predilation, use of 29 mm valve, IV septum diameter, prolonged QRS
Khawaja Circulation. 2011;123:

14. Predictors of Permanent Pacemaker Placement
Jilaihawi et al. Am Heart J 2009
LBBB +left axis deviation
Thickness of non-coronary leaflet
Septal wall thickness
Bleiziffer et al. JACC Interv 2010
Intra-operative AV block
Borderline small annulus size
Baan et al. Am Heart J 2010
Small LVOT
Left axis deviation
Mitral annular calcification
Latsios et al. CCI 2010
Aortic valve calcification (MSCT)
Female gender
Left ventricular dysfunction

15. Conduction Abnormalities After CoreValve
Depth of Implantation Relates to PPM Requirements
Piazza JACC Interventions 2008; 1: 310

16. Predictors of New LBBB and PPM
Pulmonary hypertension
Septal wall thickness
Right bundle branch block
Depth of implant from non-coronary leaflet
Depth of implant from left coronary leaflet
Multivariable Analysis
Piazza et al. EuroIntervention 2010 (in press)

17. What Are We Doing to Reduce This?
Sizing of pre-dilation balloon based on minimal diameter of the CTA to lessen trauma to membranous septum
Shorter pre-dilatation balloon length
Rapid ventricular pacing
CoreValve sizing based on CTA annular diameter
Accutrek deployment system
High implantation deph (< 6 mm)
Follow ACC/AHA for PPM
Judicious use EPS to determine HV intervals

18. Managing Post TAVR Rhythm Disturbances
Why Do They Occur?
How Often Do Problems Develop?
How Can we Predict Them?
Who Should Receive PPMs?

19. Managing Post TAVR Rhythm Disturbances

25. HV Interval and Complete Heart Block
Three major prospective studies have shown prolonged HV intervals (> 70ms) predict patients at higher risk of AV block.
Even in highest risk patients (HV > 80msec and symptomatic) rate of CHB approaches 6%/yr -- > low PPV
Patients with HV interval great than 100msec (rare) are at extreme high risk by all accounts.

26. Baseline Chronic Fascicular Block
Epstein et al JACC Vol. 51, No. 21, 2008; e1–62

27. Baseline Chronic Fascicular Block
Epstein et al JACC Vol. 51, No. 21, 2008; e1–62

28. Atrial Fibrillation Post TAVR
138 patients without prior atrial fibrillation
New onset atrial fibrillation in 31.9% with 72 hours
Predictive factors of AF were left atrial size (odds ratio [OR]: 1.21 for each increase in 1 mm/m2) and transapical approach (OR: 4.08, 95% CI: 1.35 to 12.31, p = 0.019).
Cumulative stroke and stroke/systemic embolism rates at FU in the NOAF group were 13.6% and 15.9% in the NOAF group vs. 3.2% in the no-NOAF group (p = 0.039, adjusted p = for stroke; p = 0.020, adjusted p = for stroke/systemic embolism).
Amat-Santo J Am Coll Cardiol 2012;59:178–88

29. Preventative Measurement: PPM
Pre-procedural PPM when indicated
Undersized, shorter BAV balloon
? Avoid oversizing device
High (< 6 mm implantation)
Temporary pacemaker x 48 hours
AHA/ACC Indications for PPM
EP study may assist