43
Anna Kostopoulou Cardiologist - Electrophysiologist Onassis Cardiac Surgery Center Pacemaker indication: yes no and the grey zone
Anna Kostopoulou
Cardiologist - Electrophysiologist
Onassis Cardiac Surgery Center
Pacemaker indication yes no and the grey zone
none
Conflicts
Yes
grey
no
Indications for Pacing
bull Pre-existing calcification of LV outflow
bull mechanical injury amp compression of AV bundle and LBBB which are located more anteriorly distally and cranially to the aortic valve complex
NON PENETRATING HIS
Mechanisms of conduction damage after TAVR
Block at the level or below the His bundle
LBBB
Piazza N et alAnatomy of the aortic valvar complex and its implications for
transcatheter implantation of the aortic valve Circ Cardiovasc Interv 2008174ndash81
Kawashima T Sato F Visualizing anatomical evidences on atrioventricular conduction system for TAVI Int J Cardiol 20141741-6
Most common conduction abnormalities after TAVR
Absolute indications
bull CHB and high degree block and 21
bull major indications 142 0-34 median 97
bull 80 of PM implantations
Erkapic D1 et al Cardiovasc Electrophysiol 2012 Apr23(4)391-7Siontis GC et al J Am Coll Cardiol 201464129ndash40
Baan J Jr et al Factors associated with cardiac conduction
disorders and Am Heart J 2010159497ndash503
Risk factors for complete block
Sex male
Preexisting conduction defects1st AV block RBBB and LAH and
intraprocedural AV block
Prosthesis relatedDepth Sizing
Type of valve Footprint that mimics anatomy Core valve 208 (93-30)- approx 13Edwards ndashSapien 54 (0-1018)
bull Still unclear TAVR but it seems comparable to SAVR (Recovery 65-100)
bull registries 92 remained paced
bull Observation period 5-7 daysbull AV block first 24 hours persisting gt48hours
resolution unlikely 1-2 weeks ndashconsider earlier implantation
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after
transcatheter aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-
9Erkapic D1 De Rosa S Kelava A Lehmann R Fichtlscherer S Hohnloser SHRisk for permanent pacemaker after transcatheter aortic valve implantation a comprehensive analysis of theliterature J Cardiovasc Electrophysiol 2012 Apr23(4)391-7
Timing
Brignole M Auricchio A Baron-Esquivias G et al 2013 ESC
guidelines on cardiac pacing and cardiac resynchronization
therapy the task force on cardiac pacing and
resynchronization therapy of the European Society of
Cardiology (ESC) Europace 2013151070-118
True life
Male 79 y
Case 1
Day 2
bull not included as a basic indication
bull In the pacing guidelines it is an indication only if there are symptoms or positive EP ndashprolonged HV
2nd degree type 1
Wenckebach - split His- intrahisian damage
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
none
Conflicts
Yes
grey
no
Indications for Pacing
bull Pre-existing calcification of LV outflow
bull mechanical injury amp compression of AV bundle and LBBB which are located more anteriorly distally and cranially to the aortic valve complex
NON PENETRATING HIS
Mechanisms of conduction damage after TAVR
Block at the level or below the His bundle
LBBB
Piazza N et alAnatomy of the aortic valvar complex and its implications for
transcatheter implantation of the aortic valve Circ Cardiovasc Interv 2008174ndash81
Kawashima T Sato F Visualizing anatomical evidences on atrioventricular conduction system for TAVI Int J Cardiol 20141741-6
Most common conduction abnormalities after TAVR
Absolute indications
bull CHB and high degree block and 21
bull major indications 142 0-34 median 97
bull 80 of PM implantations
Erkapic D1 et al Cardiovasc Electrophysiol 2012 Apr23(4)391-7Siontis GC et al J Am Coll Cardiol 201464129ndash40
Baan J Jr et al Factors associated with cardiac conduction
disorders and Am Heart J 2010159497ndash503
Risk factors for complete block
Sex male
Preexisting conduction defects1st AV block RBBB and LAH and
intraprocedural AV block
Prosthesis relatedDepth Sizing
Type of valve Footprint that mimics anatomy Core valve 208 (93-30)- approx 13Edwards ndashSapien 54 (0-1018)
bull Still unclear TAVR but it seems comparable to SAVR (Recovery 65-100)
bull registries 92 remained paced
bull Observation period 5-7 daysbull AV block first 24 hours persisting gt48hours
resolution unlikely 1-2 weeks ndashconsider earlier implantation
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after
transcatheter aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-
9Erkapic D1 De Rosa S Kelava A Lehmann R Fichtlscherer S Hohnloser SHRisk for permanent pacemaker after transcatheter aortic valve implantation a comprehensive analysis of theliterature J Cardiovasc Electrophysiol 2012 Apr23(4)391-7
Timing
Brignole M Auricchio A Baron-Esquivias G et al 2013 ESC
guidelines on cardiac pacing and cardiac resynchronization
therapy the task force on cardiac pacing and
resynchronization therapy of the European Society of
Cardiology (ESC) Europace 2013151070-118
True life
Male 79 y
Case 1
Day 2
bull not included as a basic indication
bull In the pacing guidelines it is an indication only if there are symptoms or positive EP ndashprolonged HV
2nd degree type 1
Wenckebach - split His- intrahisian damage
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Yes
grey
no
Indications for Pacing
bull Pre-existing calcification of LV outflow
bull mechanical injury amp compression of AV bundle and LBBB which are located more anteriorly distally and cranially to the aortic valve complex
NON PENETRATING HIS
Mechanisms of conduction damage after TAVR
Block at the level or below the His bundle
LBBB
Piazza N et alAnatomy of the aortic valvar complex and its implications for
transcatheter implantation of the aortic valve Circ Cardiovasc Interv 2008174ndash81
Kawashima T Sato F Visualizing anatomical evidences on atrioventricular conduction system for TAVI Int J Cardiol 20141741-6
Most common conduction abnormalities after TAVR
Absolute indications
bull CHB and high degree block and 21
bull major indications 142 0-34 median 97
bull 80 of PM implantations
Erkapic D1 et al Cardiovasc Electrophysiol 2012 Apr23(4)391-7Siontis GC et al J Am Coll Cardiol 201464129ndash40
Baan J Jr et al Factors associated with cardiac conduction
disorders and Am Heart J 2010159497ndash503
Risk factors for complete block
Sex male
Preexisting conduction defects1st AV block RBBB and LAH and
intraprocedural AV block
Prosthesis relatedDepth Sizing
Type of valve Footprint that mimics anatomy Core valve 208 (93-30)- approx 13Edwards ndashSapien 54 (0-1018)
bull Still unclear TAVR but it seems comparable to SAVR (Recovery 65-100)
bull registries 92 remained paced
bull Observation period 5-7 daysbull AV block first 24 hours persisting gt48hours
resolution unlikely 1-2 weeks ndashconsider earlier implantation
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after
transcatheter aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-
9Erkapic D1 De Rosa S Kelava A Lehmann R Fichtlscherer S Hohnloser SHRisk for permanent pacemaker after transcatheter aortic valve implantation a comprehensive analysis of theliterature J Cardiovasc Electrophysiol 2012 Apr23(4)391-7
Timing
Brignole M Auricchio A Baron-Esquivias G et al 2013 ESC
guidelines on cardiac pacing and cardiac resynchronization
therapy the task force on cardiac pacing and
resynchronization therapy of the European Society of
Cardiology (ESC) Europace 2013151070-118
True life
Male 79 y
Case 1
Day 2
bull not included as a basic indication
bull In the pacing guidelines it is an indication only if there are symptoms or positive EP ndashprolonged HV
2nd degree type 1
Wenckebach - split His- intrahisian damage
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
bull Pre-existing calcification of LV outflow
bull mechanical injury amp compression of AV bundle and LBBB which are located more anteriorly distally and cranially to the aortic valve complex
NON PENETRATING HIS
Mechanisms of conduction damage after TAVR
Block at the level or below the His bundle
LBBB
Piazza N et alAnatomy of the aortic valvar complex and its implications for
transcatheter implantation of the aortic valve Circ Cardiovasc Interv 2008174ndash81
Kawashima T Sato F Visualizing anatomical evidences on atrioventricular conduction system for TAVI Int J Cardiol 20141741-6
Most common conduction abnormalities after TAVR
Absolute indications
bull CHB and high degree block and 21
bull major indications 142 0-34 median 97
bull 80 of PM implantations
Erkapic D1 et al Cardiovasc Electrophysiol 2012 Apr23(4)391-7Siontis GC et al J Am Coll Cardiol 201464129ndash40
Baan J Jr et al Factors associated with cardiac conduction
disorders and Am Heart J 2010159497ndash503
Risk factors for complete block
Sex male
Preexisting conduction defects1st AV block RBBB and LAH and
intraprocedural AV block
Prosthesis relatedDepth Sizing
Type of valve Footprint that mimics anatomy Core valve 208 (93-30)- approx 13Edwards ndashSapien 54 (0-1018)
bull Still unclear TAVR but it seems comparable to SAVR (Recovery 65-100)
bull registries 92 remained paced
bull Observation period 5-7 daysbull AV block first 24 hours persisting gt48hours
resolution unlikely 1-2 weeks ndashconsider earlier implantation
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after
transcatheter aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-
9Erkapic D1 De Rosa S Kelava A Lehmann R Fichtlscherer S Hohnloser SHRisk for permanent pacemaker after transcatheter aortic valve implantation a comprehensive analysis of theliterature J Cardiovasc Electrophysiol 2012 Apr23(4)391-7
Timing
Brignole M Auricchio A Baron-Esquivias G et al 2013 ESC
guidelines on cardiac pacing and cardiac resynchronization
therapy the task force on cardiac pacing and
resynchronization therapy of the European Society of
Cardiology (ESC) Europace 2013151070-118
True life
Male 79 y
Case 1
Day 2
bull not included as a basic indication
bull In the pacing guidelines it is an indication only if there are symptoms or positive EP ndashprolonged HV
2nd degree type 1
Wenckebach - split His- intrahisian damage
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Block at the level or below the His bundle
LBBB
Piazza N et alAnatomy of the aortic valvar complex and its implications for
transcatheter implantation of the aortic valve Circ Cardiovasc Interv 2008174ndash81
Kawashima T Sato F Visualizing anatomical evidences on atrioventricular conduction system for TAVI Int J Cardiol 20141741-6
Most common conduction abnormalities after TAVR
Absolute indications
bull CHB and high degree block and 21
bull major indications 142 0-34 median 97
bull 80 of PM implantations
Erkapic D1 et al Cardiovasc Electrophysiol 2012 Apr23(4)391-7Siontis GC et al J Am Coll Cardiol 201464129ndash40
Baan J Jr et al Factors associated with cardiac conduction
disorders and Am Heart J 2010159497ndash503
Risk factors for complete block
Sex male
Preexisting conduction defects1st AV block RBBB and LAH and
intraprocedural AV block
Prosthesis relatedDepth Sizing
Type of valve Footprint that mimics anatomy Core valve 208 (93-30)- approx 13Edwards ndashSapien 54 (0-1018)
bull Still unclear TAVR but it seems comparable to SAVR (Recovery 65-100)
bull registries 92 remained paced
bull Observation period 5-7 daysbull AV block first 24 hours persisting gt48hours
resolution unlikely 1-2 weeks ndashconsider earlier implantation
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after
transcatheter aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-
9Erkapic D1 De Rosa S Kelava A Lehmann R Fichtlscherer S Hohnloser SHRisk for permanent pacemaker after transcatheter aortic valve implantation a comprehensive analysis of theliterature J Cardiovasc Electrophysiol 2012 Apr23(4)391-7
Timing
Brignole M Auricchio A Baron-Esquivias G et al 2013 ESC
guidelines on cardiac pacing and cardiac resynchronization
therapy the task force on cardiac pacing and
resynchronization therapy of the European Society of
Cardiology (ESC) Europace 2013151070-118
True life
Male 79 y
Case 1
Day 2
bull not included as a basic indication
bull In the pacing guidelines it is an indication only if there are symptoms or positive EP ndashprolonged HV
2nd degree type 1
Wenckebach - split His- intrahisian damage
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Absolute indications
bull CHB and high degree block and 21
bull major indications 142 0-34 median 97
bull 80 of PM implantations
Erkapic D1 et al Cardiovasc Electrophysiol 2012 Apr23(4)391-7Siontis GC et al J Am Coll Cardiol 201464129ndash40
Baan J Jr et al Factors associated with cardiac conduction
disorders and Am Heart J 2010159497ndash503
Risk factors for complete block
Sex male
Preexisting conduction defects1st AV block RBBB and LAH and
intraprocedural AV block
Prosthesis relatedDepth Sizing
Type of valve Footprint that mimics anatomy Core valve 208 (93-30)- approx 13Edwards ndashSapien 54 (0-1018)
bull Still unclear TAVR but it seems comparable to SAVR (Recovery 65-100)
bull registries 92 remained paced
bull Observation period 5-7 daysbull AV block first 24 hours persisting gt48hours
resolution unlikely 1-2 weeks ndashconsider earlier implantation
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after
transcatheter aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-
9Erkapic D1 De Rosa S Kelava A Lehmann R Fichtlscherer S Hohnloser SHRisk for permanent pacemaker after transcatheter aortic valve implantation a comprehensive analysis of theliterature J Cardiovasc Electrophysiol 2012 Apr23(4)391-7
Timing
Brignole M Auricchio A Baron-Esquivias G et al 2013 ESC
guidelines on cardiac pacing and cardiac resynchronization
therapy the task force on cardiac pacing and
resynchronization therapy of the European Society of
Cardiology (ESC) Europace 2013151070-118
True life
Male 79 y
Case 1
Day 2
bull not included as a basic indication
bull In the pacing guidelines it is an indication only if there are symptoms or positive EP ndashprolonged HV
2nd degree type 1
Wenckebach - split His- intrahisian damage
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Erkapic D1 et al Cardiovasc Electrophysiol 2012 Apr23(4)391-7Siontis GC et al J Am Coll Cardiol 201464129ndash40
Baan J Jr et al Factors associated with cardiac conduction
disorders and Am Heart J 2010159497ndash503
Risk factors for complete block
Sex male
Preexisting conduction defects1st AV block RBBB and LAH and
intraprocedural AV block
Prosthesis relatedDepth Sizing
Type of valve Footprint that mimics anatomy Core valve 208 (93-30)- approx 13Edwards ndashSapien 54 (0-1018)
bull Still unclear TAVR but it seems comparable to SAVR (Recovery 65-100)
bull registries 92 remained paced
bull Observation period 5-7 daysbull AV block first 24 hours persisting gt48hours
resolution unlikely 1-2 weeks ndashconsider earlier implantation
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after
transcatheter aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-
9Erkapic D1 De Rosa S Kelava A Lehmann R Fichtlscherer S Hohnloser SHRisk for permanent pacemaker after transcatheter aortic valve implantation a comprehensive analysis of theliterature J Cardiovasc Electrophysiol 2012 Apr23(4)391-7
Timing
Brignole M Auricchio A Baron-Esquivias G et al 2013 ESC
guidelines on cardiac pacing and cardiac resynchronization
therapy the task force on cardiac pacing and
resynchronization therapy of the European Society of
Cardiology (ESC) Europace 2013151070-118
True life
Male 79 y
Case 1
Day 2
bull not included as a basic indication
bull In the pacing guidelines it is an indication only if there are symptoms or positive EP ndashprolonged HV
2nd degree type 1
Wenckebach - split His- intrahisian damage
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
bull Still unclear TAVR but it seems comparable to SAVR (Recovery 65-100)
bull registries 92 remained paced
bull Observation period 5-7 daysbull AV block first 24 hours persisting gt48hours
resolution unlikely 1-2 weeks ndashconsider earlier implantation
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after
transcatheter aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-
9Erkapic D1 De Rosa S Kelava A Lehmann R Fichtlscherer S Hohnloser SHRisk for permanent pacemaker after transcatheter aortic valve implantation a comprehensive analysis of theliterature J Cardiovasc Electrophysiol 2012 Apr23(4)391-7
Timing
Brignole M Auricchio A Baron-Esquivias G et al 2013 ESC
guidelines on cardiac pacing and cardiac resynchronization
therapy the task force on cardiac pacing and
resynchronization therapy of the European Society of
Cardiology (ESC) Europace 2013151070-118
True life
Male 79 y
Case 1
Day 2
bull not included as a basic indication
bull In the pacing guidelines it is an indication only if there are symptoms or positive EP ndashprolonged HV
2nd degree type 1
Wenckebach - split His- intrahisian damage
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Brignole M Auricchio A Baron-Esquivias G et al 2013 ESC
guidelines on cardiac pacing and cardiac resynchronization
therapy the task force on cardiac pacing and
resynchronization therapy of the European Society of
Cardiology (ESC) Europace 2013151070-118
True life
Male 79 y
Case 1
Day 2
bull not included as a basic indication
bull In the pacing guidelines it is an indication only if there are symptoms or positive EP ndashprolonged HV
2nd degree type 1
Wenckebach - split His- intrahisian damage
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
True life
Male 79 y
Case 1
Day 2
bull not included as a basic indication
bull In the pacing guidelines it is an indication only if there are symptoms or positive EP ndashprolonged HV
2nd degree type 1
Wenckebach - split His- intrahisian damage
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Male 79 y
Case 1
Day 2
bull not included as a basic indication
bull In the pacing guidelines it is an indication only if there are symptoms or positive EP ndashprolonged HV
2nd degree type 1
Wenckebach - split His- intrahisian damage
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Day 2
bull not included as a basic indication
bull In the pacing guidelines it is an indication only if there are symptoms or positive EP ndashprolonged HV
2nd degree type 1
Wenckebach - split His- intrahisian damage
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
bull not included as a basic indication
bull In the pacing guidelines it is an indication only if there are symptoms or positive EP ndashprolonged HV
2nd degree type 1
Wenckebach - split His- intrahisian damage
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Wenckebach - split His- intrahisian damage
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
EP
HV=70
HV baseline 58 after TAVI 70
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Case 2
Male 82 y chronic Afib
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Temporary block during the procedure recovery before exit-new LBBB -QRS 162msec- Afib
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
bull New persistent LBBB- Develops in 29-65
bull New RBBB less frequent- if RBBB preexisting additional damage usually causes CHB
bull New LBBB resolves in 30ndash50
bull new LBBB in 40 of SAPIEN valve pts resolves in 1 month
bull LBBB worsens outcomes and heart failure hospitalization
bull Association to mortality conflicting data
Neither new LBBB or RBBB are absolute indications for PM
Nazif TM et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter
aortic valve replacement the PARTNER study JACC Cardiovasc Interv 2015860-9 Aktug O et al Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 201216026ndash30 Houthuizen P Van Garsse LA Poels TT et al Left bundle branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012126720ndash 8
New BBB
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
REMOVAL OF TEMPORARY WIRE
DAY 3
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
4 HOURS LATER -DAY 3
PM implanted on emergency basis
CLUE SLOW CONDUCTION AFIB COMPARED TO BASELINE
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
80 y woman Baseline SR LBBB
Case 3
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Exit from lab with LBBB QRS 200 msec+ PR prolongation 200
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
bull inconsistency in literature
bull preexisting abnormalities and worsening of preexisting conduction defects
bull Changes LBBB + ΔPR gt20 ms increase risk of CHB
Implant PM
Akin et alBMC Cardiovasc Disord 2012 Oct 41287Predictive factors for pacemaker requirement after transcatheter aortic valve implantation
BBB- Increased risk for CHB
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
EP
HV 90 +split
His
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
82 y male
Case 4
LV EF 35-40
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
CHB during procedure
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Before EXIT from lab
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Day 1 same afternoon
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
CRT indications
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
bull up to 30 of these patients report recovery of the conduction in the first 30 days post procedure the decision on placement of a device can be made at that time
Suggested solutions
bull Prolong FU monitoring period with a secure type temporary lead screwed in for 30 days at VVI 50
bull Early Implant of a CRT- P device
LV dysfunction and LBBB
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
CRT-P day 5
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Donrsquot forget other indicationsSinus node disease- SND
88y womanSyncope prior to TAVI
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
bull There are grey zones
bull Pacemakers are implanted earlier than proposed
bull Landmark studies PPMimplanted during the index hospitalization (971) in the majority of the patients with median time to PPM being 3 days post-TAVR
Urena M Webb JG Tamburino C et al Permanent pacemaker implantation after
transcatheter aortic valve implantation impact on late clinical outcomes and left ventricular
function Circulation 20141291233-43 Nazif TM Dizon JM Hahn RT et al Predictors and clinical outcomes of permanent pacemaker implantation after transcatheter aortic valve replacement the PARTNER (Placement of AoRticTraNscathetER Valves) trial and registry JACC Cardiovasc Interv 2015860-9
True life
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
bull Risk of death ndashdislocation of temporary wires
bull Complications - thrombosis infection
bull Pt immobilized prolonged ICU old pts
Why is it different
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Are there any tools that could help
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
grey cases
bull EP
bull ILR
bull Timing -Prolong monitoring
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
EP in diagnosis of grey zones
Baseline EP may predict PM implantation and identify pts that need a PM after TAVI in a grey zone
bull Kostopoulou A Karyofillis P Livanis E Thomopoulou S Stefopoulos C Doudoumis K Theodorakis G Voudris V Permanent pacing after transcatheter aortic valve implantation of a CoreValve prosthesis as determined by electrocardiographic and electrophysiological predictors a single-centre experience Europace 2016 Jan18(1)131-7
bull Tovia-Brodie O Ben-Haim Y Joffe E Finkelstein A Glick A Rosso R Belhassen B Michowitz Y The value of electrophysiologic study in decision-making regarding the needfor pacemaker implantation after TAVI J Interv CardElectrophysiol 2017 Mar48(2)121-130
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
bull Recovery before the end of the procedure
bull No Pre-existing conduction abnormalities
bull No abnormalities after
bull EP +- ILR
bull Present ACCHRS guidelines encourage that these decisions be left to the discretion of the phycisian
bull European grey ndash nothing significant
ILR
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
bull Prognosis assessment of persistent left bundle branch block after TAVI by an electrophysiological and remote monitoring risk-adapted algorithm rationale and design of the multicentre LBBBndashTAVI Study
bull EP guided implantations - programming at a mode that can evaluate recovery of rhythm- expected in 2018
bull Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftBundle Branch Block After Transcatheter Aortic Valve Implantation The MARE Study
bull ILR guided
Future studies
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
What do the experts recommend
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Class I indication
bull If a patient at any point during or after TAVR develops Mobitz Type 2 AV block or complete AV block
bull EP should be consulted for pacemaker implantation prior to discharge
PM implantation
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Expert
AnalysisRisk Stratification for
Pacemaker Placement
After TAVR 2016
Rohan Kalathiya MD
Atman P Shah MD
Gaurav A Upadhyay
MD FACC
Thank you for your attention
Thank you for your attention
