Clinical management of conduction abnormalities following transcatheter aortic valve replacement: prospective evaluation of a standardized management pathway

PURPOSE: Limited evidence guides management of conduction abnormalities following TAVR. Standardized clinical pathways may reduce variability in care while minimizing bradyarrhythmic morbidity, length of stay (LOS), and pacemaker (PPM) implantation rates. METHODS: A multidisciplinary consensus pathway to standardize post-TAVR management was developed. We evaluated (1) pathway adherence; (2) LOS; (3) PPM implantation rates; (4) 1-month survival, and (5) late heart block. Exploratory analyses evaluated factors associated with PPM implantation. RESULTS: A total of 181 consecutive patients without prior PPM who underwent TAVR between February 2020 and February 2021 (mean age 77.9 ± 9.1, 38% women) were included. Average LOS was 3.0 days (± 2.7), and no deaths related to syncope/bradyarrhythmia were reported by 1 month. Overall, 93% of the 181 patients were managed by pathway; deviations were due to failure of discharge with a heart monitor when it was clinically indicated for either pre-existing RBBB or new PR prolongation/new LBBB. PPM implantation occurred in 19 patients by discharge, and 21 by 1-month (13%). In our exploratory analysis, pre-existing RBBB, transient peri-procedural heart block, and LOTUS valves were associated with pacemaker implantation: OR (CI) of 8.16 (3.06–21.78), 6.83 (1.94–24.03), and 8.32 (1.11–62.49), respectively. CONCLUSIONS: This report illustrates that a standardized protocol for the management of conduction abnormalities after TAVR can be implemented with high compliance, safe management of conduction disturbance, and relatively short LOS with discharge supported by ambulatory monitoring.