1. Department of Cardiology Bern University Hospital
Managing TAVR Rhythm Disturbances: New LBBB, Bradyarrhythmias and Temporary and Permanent Pacemakers
Lutz Buellesfeld MD
FSCAI FESC
Department of Cardiology
Bern University Hospital
Switzerland

2. Lutz Buellesfeld, MD Consulting: Mitralign Medtronic CoreValve
Edwards Lifesciences, LLC
Abbott Vascular

3. Anatomical Considerations
Conduction abnormalities are not atypical following AVR due to the anatomical proximity of the aortic valve to the conduction system
Modified from Tawara.
Igawa et. al, Jap Circ 2009

4. Incidence of New Electrocardiographic Abnormalities during Hospital Stay in Patients Undergoing TAVR
Calvi V. J Interv Card Electrophysiol (2012) 34:189–195

5. Conduction Disturbances after TAVI LBBB
New-onset LBBB 30%,
Resolved in 38% and 57% at discharge and 6-12 months
Urena M. JACC 2012;60(18)

6. Conduction Disturbances after TAVI
Complete AVB
De Carlo M. Am Heart J 2012;163:492-9

7. Conduction Disturbances and Time
Roten L. J Cardiovasc Electrophysiol 2012;23:

8. Postprocedural TAVI Management Bern
Temporary pacemaker Standard back-up: 24hrs
Prolonged back-up: 48hrs in case of new LBBB plus AVB I (>250ms)
ECG telemetry Standard monitoring until day 4
Prolonged monitoring in case of new conduction disturbances
Permanent pacemaker Postprocedural AVB III or II
Postprocedural AVB I (PQ >300ms) plus bifascicular block
BAA (according to PM guideline recommendations)
In case of prior pacemaker implantation, none of this is needed

9. Time and Frequency Distribution of Pacemaker Implantation
Days post TAVI T A V I
Number of patients
98 patients (27.8%)

10. Clinical Outcome after TAVR Meta-Analysis
30 Day Event Rates
Genereux P. JACC 2012
N=3519

11. Impact of Permanent Pacemaker Implantation on Clinical Outcome Among Patients Undergoing TAVI
prior PPM: HR(95%CI)=1.28 ( )
post PPM: HR(95%CI)=1.08 ( )
p=0.77 5 10 15 20 25
All-cause mortality (%) 98 91 88 87 86 84 82 81 79
post PPM 48 46 43 41 40 39 37
prior PPM
207
194
191
188
184
180
178
175
172
171
170
169
no PPM
Number at risk 30 60 90
120
150
210
240
270
300
330
365
Days
No Pacemaker
Prior Pacemaker
Post Pacemaker
Buellesfeld L et al. JACC. 2012

12. Atrial Fibrillation and TAVI
History of AF 16-40%
New onset of AF 1-16%
Mok M. J Thromb Thrombolysis 2012

13. Anticoagulation
Anticoagulation is indicated in the majority of patients
There is little evidence on best approach and no official guideline recommendation
Triple therapy should be avoided*
New oral anticoagulation therapies (dabigatran, rivaroxaban) are probably superior to warfarin, but valve disease patients have been excluded in previous trials
Same is true for new platelet inhibitors (prasugrel, ticagrelor)
Warfarin plus one antiplatelet agent
(aspirin or clopidogrel)
*Zeymer U. Eur Heart J 2001;32(Abstract suppl):900

14. Thank you