EUROPACE: New Predictor Points to Post-TAVI Pacemaker Need
MADRID -- Patients who have a right bundle branch block before undergoing transcatheter aortic valve implantation (TAVI) are more likely to require a permanent pacemaker after the procedure, a single-center study showed.
Nearly one-third of patients who underwent TAVI (32.1%) required implantation of a permanent pacemaker because of a complete atrioventricular block, according to Sergio Conti, MD, of the University of Catania in Italy.
The only significant predictor of pacemaker need was a preoperative right bundle branch block (HR 16.5, 95% CI 3.3 to 82.3), Conti reported here at EUROPACE, the meeting of the European Heart Rhythm Association.
That makes sense, Conti said, when one considers the high rate of left bundle branch block (50.3%) at discharge. If patients already have a right bundle branch block, then a procedure-induced left bundle branch block will result in a complete atrioventricular block requiring a pacemaker.
Although TAVI is an effective option for high-risk patients with severe aortic stenosis, conduction disorders are common complications. Reported rates of the need for permanent pacemaker implantation range from 5.7% to 39%, depending on which of the two available valves -- the Medtronic CoreValve or the Edwards Sapien prosthesis -- is used.
CoreValve carries the higher risk, which was confirmed in another study that included 208 patients presented by Andrea Radinovic, MD, of San Raffaele Hospital in Milan. Following TAVI, the rate of pacemaker implantation was 25% with CoreValve and 8.3% with the Edwards Sapien valve ( P =0.001).
Several small studies have identified various predictors of the need for a permanent pacemaker after TAVI, but Conti and his colleagues wanted to explore the issue with a larger series of patients.
They analyzed data from 162 consecutive patients who underwent TAVI with the CoreValve prosthesis at their center.
In all patients, a 12-lead electrocardiogram and 24-hour Holter monitoring were performed before and after TAVI to assess the presence of conduction disorders. Patients remained in the intensive care unit for two days of monitoring following the procedure.
Patients who needed a pacemaker after the procedure generally had similar baseline characteristics to those who did not need one, although they were significantly more likely to have right bundle branch block before TAVI (28.8% versus 2.7%, P <0.0001).
Right bundle branch block joins several other predictors of permanent pacemaker implantation post-TAVI identified in prior studies, including septal hypertrophy, a baseline thickness of the noncoronary cusp greater than 8 mm, a preoperative left bundle branch block with left axis deviation, left-sided QRS axis, narrow left ventricular outflow tract, severity of mitral annular calcification, and prosthesis depth in the left ventricular outflow tract.
Left Bundle Block - News
Note that postoperative left bundle branch block was the most common conduction abnormality following TAVI. MADRID -- Patients who have a right bundle branch block before undergoing transcatheter aortic valve implantation (TAVI) are more likely to
He notes that patients with left bundle branch block QRS morphology derived the most benefit from CRT-D, however, additional methods are needed to further ensure benefit of this therapy. Dr. Zareba is Professor of Medicine, Director of Cardiology
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In this case we have left bundle branch morphology in lead V1 (QS complex) but right bundle branch morphology in lead I (Rs complex). When an ECG shows left bundle branch block in the precordial leads and right bundle branch block in the limb leads,
The electrode was placed in the right ventricle, which depolarized first, followed by the left ventricle. This placement generates a wide QRS complex similar to that seen in left bundle branch block. A sequential pacemaker stimulates the atrium first
Left Bundle Branch Block doesn't demand the Cath Lab
Left Bundle Branch Block (LBBB) doesn’t = STEMI!A few months ago, we had Dr. Stephen Smith on the podcast to discuss a variety of EKG issues . Dr. Smith has an EKG blog that is required reading for every ED and ICU doc. This is Part II and I think it discusses an incredibly important issue: right now major medical societies including the AHA and ACEP are asking us to fibrinolyse or PCI patients with new or presumed new LBBB. However, your interventionalists will tell you that this strategy is a ridiculous waste given how few acute occlusions will actually be found. Why this discrepancy?
Dr. Smith actually created a post specifically for this podcast; here is the full text:
A 45 year old male with no history of cardiac disease presented with new onset pulmonary edema. He was intubated prehospital. BP before and after intubation was 110 systolic, with HR of 120.
has proportionally excessively discordant ST depression, with 1.25 mm STD and only 4.0 mm R-wave, for a ratio of 0.31. This is also a sign if ischemia (reciprocal inferior ST depression). Also, look at V3 : complexes vary slightly: 2nd complex has approx 2.5-3.0 mm STE following a 14 mm S-wave; complex 4 has 2-2.5 mm STE following a 10.5 mm S-wave. So these approach an ST/S ratio of 0.20, but it is not definite.
In a study of 19 patients with LAD occlusion, vs. 129 controls with ischemic symptoms and LBBB, at least one complex in V1-V4 with at least 2mm of STE and an ST/S ratio > 0.20 was highly specific for LAD occlusion (1). Here is the reference for the abstract on proportionally excessively discordant ST depression (2).
Cases with excessive discordance of at least 5mm [Sgarbossa criteria 3] that did not have discordance, did not have LAD occlusion. The mean highest ST/S ratio for those without occlusion was 0.10 (95% CI: 0.09-0.11); the mean highest ST/S ratio for those with occlusion was 0.44 (95% CI: 0.19-1.05)
Because of this study, I believe the following rule is as good for diagnosis of STEMI in the setting of LBBB as standard interpretation of STEMI in the absence of BBB (and that it is more sensitive and specific than the Sgarbossa rule):
3) proportionally excessively discordant ST elevation in V1-V4, as defined by an ST/S ratio of equal to or more than 0.20 and at least 2 mm of STE.
Left Bundle Block - Bookshelf
The disorders of cardiac rhythm
141 The Wenckebach Phenomenon in Left Bundle Branch Block (From Friedberg, HD, ... 2) reflects the pattern of incomplete left bundle branch block. ...12 lead ECG, the art of interpretation
Left Bundle Branch Block Remember these words of wisdom: Whenever you look ... The pathology involved in LBBB is caused by a block of the left bundle or of ...Chou's electrocardiography in clinical practice, adult and pediatric
In humans, left bundle branch block (LBBB) caused the following changes in epicardial activation4-5: (1) right ventricular activation began earlier than ...Clinical cardiac electrophysiology, techniques and interpretations
Site of conduction delay in left bundle branch block. Two His bundle electrograms (HBE) and a right bundle electrogram (RBE) are shown. The HrV, and RVVV, ...Encyclopedia of heart diseases
LEFT BUNDLE BRANCH BLOCK Left bundle branch block (LBBB) is common after age 60 and is due to a block of the conduction in the bundle that receives impulses ...Detect Information Directory
Left bundle branch block - Wikipedia, the free encyclopedia
The criteria to diagnose a left bundle branch block on the electrocardiogram: ... This is known as appropriate T wave discordance with bundle branch block. ...
Pediatric Left Bundle Branch Block
Left bundle branch block (LBBB) occurs when transmission of the cardiac electrical impulse is delayed or fails to be conducted along the rapidly conducting ...
Bundle branch block - Wikipedia, the free encyclopedia
The left bundle branch subdivides into two fascicles: the left anterior fascicle and the ... A bundle branch block can be diagnosed when the duration of the QRS complex on ...
Left bundle branch block - wikidoc
Left bundle branch block. You don't need to be Editor-In-Chief to add or edit content to WikiDoc. ... Articles on Left bundle branch block in N Eng J Med, Lancet, BMJ ...
Bundle Branch Block - Texas Heart Institute Heart Information ...
Bundle Branch Block ... The bundle of His divides into a right bundle branch and a left bundle branch, which lead to your heart's lower chambers (the ventricles) ...