Implantation of Leadless Pacemaker for the Development of New Left Bundle Branch Block and Symptomatic Pause Following Transcatheter Aortic Valve Replacement.

Cardiac conduction disturbances such as left bundle branch block (LBBB) and atrioventricular blocks (AVB) occur frequently following transcatheter aortic valve replacement (TAVR) and may be associated with adverse clinical events. There is a lack of consensus regarding permanent pacemaker implantation in the case of occurrence of TAVR-related bundle branch blocks or combination of AVB and bundle blocks. Furthermore, there are no guidelines regarding the use of the leadless pacemaker in this setting. We present a patient who underwent successful implantation of a leadless pacemaker for a new LBBB post-TAVR. Copyright:

INTRODUCTION

Cardiac conduction disturbances such as left bundle branch block (LBBB) and atrioventricular blocks (AVBs) occur frequently following transcatheter aortic valve replacement (TAVR) and may be associated with adverse clinical events. There are no evidence-based guidelines regarding the implantation of a leadless pacemaker following the development of a new LBBB post-TAVR.

CASE PRESENTATION

A 71-year-old female with permanent atrial fibrillation and severe symptomatic aortic valve stenosis underwent a TAVR procedure with a 26-mm Sapiens S3 valve. Postprocedure, her electrocardiographic (ECG) demonstrated a new LBBB with QRS duration of 172 ms. Four days postoperatively; she developed presyncope and had an 8 s pause on telemetry. Due to patient body habitus and Body Mass Index (BMI) of 54 kg/m2, as well as permanent atrial fibrillation precluding the need for an atrial lead, a leadless pacemaker (Medtronic Micra) was implanted transcutaneously. The patient felt well and was discharged in stable condition.

DISCUSSION

TAVR has become an alternative to surgical aortic valve replacement for inoperable or surgical high-risk patients with severe aortic stenosis.[1]

LBBB rates of 12%–22% have been reported after implantation of the Edwards SAPIEN 3 valve.[2] AVB and the need for permanent pacemaker implantation (PPI) are complications commonly reported after surgical or percutaneous aortic valve replacement. The PPI rate after surgical aortic valve replacement is 5.8%, while that after TAVR ranges from 8% to 33.7% based on meta-analyses.[34]

There is a lack of consensus regarding PPI in TAVR-related bundle branch blocks or combination AVB and bundle blocks, as was the case in our patient. Furthermore, there are no guidelines regarding the use of the leadless pacemaker in this setting.

The indication for PPI and its time of performance are frequently individualized according to the center and/or the operating physician's preference. The current European Society of Cardiology guidelines[5] on cardiac pacing and cardiac resynchronization therapy recommend PPI be performed before completing the observation period of 7 days in AVB after TAVR only if the escape rhythm is considered unstable. In view of our patient's symptomatic pause and ECG suggestive of complete heart block, she underwent implantation of the leadless pacemaker on the postoperative day.[4]

The patient factors that prompted us to consider a leadless pacemaker were: (a) Large patient body habitus with a BMI of 54 kg/m2 that made a conventional pacemaker unsuitable and (b) a history of permanent atrial fibrillation that precluded the need for an atrial lead. The Medtronic Micra was the leadless pacemaker implanted through transfemoral access. Postdevice insertion, the patient was hemodynamically stable [Figure 1].

Figure 1

Lateral view chest X-ray showing transcatheter aortic valve replacement valve shadow and leadless Micra pacemaker

CONCLUSION

The leadless pacemaker may be a good option for patients not requiring atrial leads and having conduction abnormalities post-TAVR placement.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.