Abstract
Background
Interference with the cardiac conduction system is common after transcatheter aortic valve implantation (TAVI), manifesting as atrioventricular block, or more commonly, new-onset persistent left bundle branch block (NOP-LBBB). Bundle branch block results in ventricular dyssynchrony and reduced cardiac output and may be associated with a poorer prognosis. This systematic review and meta-analysis evaluates the prognostic impact of a left or right bundle branch block after TAVI.
Methods
A systematic review was performed of the following online databases: PubMed, Medline, Scopus, and Web of Science, including English language studies from 2014 to 2024. Two separate searches for conducted for NOP-LBBB and new-onset persistent right bundle branch block (NOP-RBBB). The Newcastle-Ottawa Scale was used to evaluate risk of bias.
Results
Twenty-three studies totaling 18875 patients were included for NOP-LBBB, whilst 5 studies with a total of 3525 patients were included for NOP-RBBB. NOP-LBBB was associated with higher all-cause mortality at 1 year (risk ratio [RR] 1.41 [95% CI 1.12-1.78], I2 = 49%, p < 0.01), cardiovascular mortality (RR 1.34 [95% CI 1.02-1.75], I2 = 60%, p = 0.02), heart failure-related rehospitalization (RR 1.56 [95% CI 1.31-1.84], I2 = 47%, p < 0.01), and permanent pacemaker implantation at 1 year (RR 3.05 [95% CI 2.39-3.89], I2 = 14%, p < 0.01). NOP-RBBB was not associated with higher all-cause mortality at 1 year (RR 1.74 [95% CI 0.88-3.46], I2 = 93%, p = 0.11), however increased the risk of pacemaker implantation at 1 year (RR 4.68 [95% CI 3.60-6.08], I2 = 67%, p < 0.01).
Conclusions
NOP-LBBB is associated with higher mortality and heart failure rehospitalization after TAVI, whilst both NOP-LBBB and NOP-RBBB increase the risk of permanent pacemaker implantation at 1 year after TAVI.
Keywords: Aortic stenosis, LBBB, Left bundle branch block, Pacemaker, RBBB, Right bundle branch block, TAVI, Transcatheter Aortic Valve Implantation
Highlights
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New-onset persistent left bundle branch block (NOP-LBBB) is an important complication of transcatheter aortic valve implantation (TAVI) and is associated with a greater risk of all-cause mortality at 1 year after TAVI.
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NOP-LBBB after TAVI is also associated with a greater risk of cardiovascular mortality and heart failure-related rehospitalization at mid- to long-term follow-up.
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Both NOP-LBBB and new-onset persistent right bundle branch block are associated with a greater risk of permanent pacemaker implantation at 1 year.
Introduction
Transcatheter aortic valve implantation (TAVI) is a highly effective and minimally invasive treatment option for severe aortic stenosis and can be offered to patients of all surgical risk.1,2 As of 2019, it has surpassed surgical aortic valve replacement as the primary treatment modality for aortic stenosis.3
Interference with the conduction system is not an infrequent complication of TAVI. This occurs primarily due to the anatomical proximity of the atrioventricular node, bundle of His, and left bundle branch to the aortic annulus and left ventricular outflow tract, which may be disrupted by the insertion of a transcatheter heart valve (THV). A new permanent pacemaker (PPM) is required in 11.3%4 of cases, whilst the most common conduction abnormality is a new-onset persistent left bundle branch block (NOP-LBBB) which is seen in 16.3%.5 New-onset persistent right bundle branch block (NOP-RBBB) is a much rarer occurrence and is thus not as well studied or described in the literature.
New bundle branch block is no longer considered a benign outcome of TAVI, as the resulting ventricular dyssynchrony may manifest as reduced cardiac output resulting in increased mortality and heart failure, as well as increasing the risk of complete atrioventricular block.6, 7, 8, 9 The aim of this systematic review and meta-analysis is to evaluate the mid- to long-term prognostic impact of a left or right bundle branch block after TAVI, with respect to mortality, heart failure-related rehospitalization and new PPM implantation.
Methods
A systematic review searching the following electronic databases was performed: PubMed, Medline, Scopus, and Web of Science from January 1, 2014, until April 1, 2024. Study screening was performed by 3 authors (K.R., M.A., and D.B.).
For the left bundle branch block (LBBB arm of the search, the keywords searched were “TAVI,” “TAVR,” “transcatheter aortic valve implantation,” or “transcatheter aortic valve replacement”; combined with “left bundle branch block” or “LBBB.” Free word and Medical Subject Headings term searches were conducted on “TAVI,” “TAVR,” “transcatheter (aorta∗),” and “left bundle branch block” or “LBBB.” The right bundle branch block (RBBB) study screening was performed with similar search terms, with replacement of LBBB with RBBB.
The review included all studies or abstracts which had accessible results and were published in English. Case reports, conference presentations, editorials, and expert opinions were excluded. Review articles were omitted due to potential publication bias and result duplication. A standardized data collection template was used for data extraction, including baseline demographics, study design, inclusion or exclusion criteria, incidence, and definition of persistent new LBBB or RBBB, length of follow-up, and valve type used.
Patients were divided into 2 groups, with and without new persistent bundle branch block. The primary outcome was all-cause mortality at 1 year, whilst secondary outcomes included all-cause mid-term (1-5 years) mortality, cardiovascular mortality, heart failure rehospitalization, and new PPM at 1 year. This review has been registered on International prospective register of systematic reviews (CRD42024533524).
Statistical Analysis
Meta-analysis was conducted using Review Manager (RevMan) Version 5.4 (Cochrane, London, United Kingdom). The Mantel-Haenszel statistical method was used with a random effects model to compute a risk ratio (RR) with a 95% CI. The I2 test for heterogeneity was used. I2 <30% was considered low heterogeneity, I2 30% to 60% considered moderate, and I2 >60% was considered high or considerable heterogeneity. All p values were 2-tailed, and p < 0.05 was considered statistically significant.
Results
New-Onset Persistent Left Bundle Branch Block
The initial search strategy yielded 1250 results, and after removal of duplicates 577 studies were removed. Through title and abstract screening, a further 634 were removed, and 39 studies remained for full study review. After application of the selection criteria, 16 further studies were excluded. The remaining 23 studies were further screened, and a bias assessment was performed using the Newcastle-Ottawa Scale (NOS) (Figure 1: Preferred reporting Items for systematic reviews and meta-analyses flow chart). Data extraction and critical appraisal was conducted by 3 reviewers (K.R., M.A., and D.B.), and the results were reviewed with senior investigators (P.H. and R.B.). The 23 studies included in this review consisted of a total of 18,875 patients. Of the included studies, 18 were performed retrospectively, whilst 5 were prospective. The NOS was used for bias adjudication, and all studies were determined to be of good or high quality (score 6-9).
Figure 1.
Preferred reporting Items for systematic reviews and meta-analyses diagram outlining the process of database search and study screening for both LBBB (left) and RBBB (right) arms of the review.
Abbreviations: LBBB, left bundle branch block; RBBB, right bundle branch block.
Baseline Characteristics
Table 1 summarizes the key characteristics of the included LBBB-related studies which had similar demographics in terms of age, gender, and surgical risk score. The most common access site was transfemoral, and 15 studies used a combination of valves, whilst 6 used balloon-expandable valve exclusively, and 2 used self-expanding valve (SEV) exclusively. The incidence of new persistent LBBB varied amongst the studies (9.6%-47.5%) with an overall mean of 29.7%. The most common definition of NOP-LBBB was on electrocardiogram at hospital discharge (n = 14), followed by at 1 month (n = 4) and postprocedure/24 h (n = 4). Figure 2 reports the incidence of NOP-LBBB by year in all studies which defined NOP-LBBB as occurring at hospital discharge (n = 14) and is arranged chronologically as well as by predominant valve type used.
Table 1.
Studies which assessed the prognostic outcome of NOP-LBBB after TAVI
| Author (y) | Country | Total patients | Age (y) (LBBB/no LBBB) | Male% (LBBB/no LBBB) | New persistent LBBB definition | Incidence p-LBBB (%) | Follow-up | Valve type | Surgical risk % (LBBB/no LBBB) | Femoral access% | Study type | NOS bias score |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Akdemir (2020) | USA | 151 | 79/80 | 46/53 | Hospital discharge | 31.1 | 1 y | BEV, SEV | n/a | 100% | Retrospective, single center | 7 |
| Ashraf (2020) | USA | 243 | 81/80 | 46/58 | Postprocedure | 19.8 | 1 y | BEV | n/a | 83% | Retrospective, single center | 7 |
| Carraba (2015) | USA | 92 | 81/81 | 53/52 | Hospital discharge | 37.0 | 1 y | SEV | Log. EuroScore 20.0 (cohort) | 97% | Retrospective, single center | 7 |
| Chamandi (2019) | Canada | 1020 | 80/81 | 57/58 | Hospital discharge | 20.8 | 3 y (median) | BEV, SEV | STS 6.8/6.5 | 84% | Retrospective, multicenter | 8 |
| Eschalier (2019) | France | 80 | 82/82 | 53/63 | 24 h | 9.6 | 1 y | BEV, SEV | Euroscore II 3.5 (cohort) | 76% | Prospective, single center | 6 |
| Hamandi (2020) | USA | 424 | 82/81 | 42/53 | Postprocedure | 12.3 | 1 y | BEV, SEV | STS 7.6/7.2 | 85% | Retrospective, single center | 7 |
| Hein-Rothweiler (2017) | Germany | 225 | 81/80 | 33/44 | Hospital discharge | 23.1 | 1 y | BEV | Log. EuroScore 16.9/17.3 | 100% | Retrospective, single center | 7 |
| Houthuizen (2014) | Netherlands | 412 | 80/81 | 57/41 | 12 mo | 26.9 | 3 y (median) | BEV, SEV | Log. EuroScore 16.4 (cohort) | 63% | Retrospective, multicenter | 8 |
| Jorgensen (2019) | Denmark | 684 | 81/81 | 50/51 | Hospital discharge | 36.1 | 1 y | BEV, SEV | STS 3.1/3.3 | 93% | Prospective, single center | 9 |
| Kessler (2019) | Germany | 528 | 81/80 | 46/46 | Postprocedure | 47.5 | 2 y | BEV, SEV, MEV | STS 6.6/6.7 | n/a | Retrospective, single center | 8 |
| Kim (2022) | South Korea | 364 | 80/81 | 42/46 | Hospital discharge or 7 d | 11.3 | 1 y | BEV, SEV | STS 6.1/5.8 | n/a | Retrospective, single center | 8 |
| Lopez-Aguilera (2016) | Spain | 153 | 78/77 | 45/59 | Hospital discharge | 36.0 | 5 y | SEV | STS 9.5/12.0 | n/a | Prospective, single center | 9 |
| Nazif (2019) | USA | 1179 | 81/82 | 53/54 | Hospital discharge | 15.2 | 1 y | BEV | STS 5.5/5.5 | 83% | Prospective, multicenter | 9 |
| Nazif (2014) | USA | 1051 | 84/84 | 43/44 | Hospital discharge | 11.5 | 1 y | BEV | STS 11.3/11.1 | 57% | Prospective, multicenter | 9 |
| Paracuellos (2021) | Spain | 254 | 80/82 | n/a | Hospital discharge | 21.6 | 21 mo (median) | BEV, SEV | EuroScore II 6.1 (cohort) | n/a | Retrospective, single center (conference abstract) | 6 |
| Saito (2024) | Japan | 5716 | 85/84 | 23/33 | Hospital discharge | 29.0 | 2 y | BEV, SEV | STS 6.0/6.1 | 90% | Retrospective, multicenter | 8 |
| Sammour (2023) | USA | 612 | 80/81 | 66/52 | 1 mo | 11.4 | 3 y | BEV | STS 5.7 (cohort) | 100% | Retrospective, single center | 9 |
| Sasaki (2020) | Japan | 231 | 84/84 | 24/37 | 1 mo | 12.6 | 431 d (median) | BEV, SEV | STS 5.3/6.2 | n/a | Retrospective, single center | 8 |
| Sasaki (2023) | Japan | 245 | n/a | n/a | 1 mo | 16.7 | 3 y | BEV, SEV | n/a | n/a | Retrospective, single center | 7 |
| Schymik (2015) | Germany | 634 | 82/82 | 33/41 | Hospital discharge | 31.1 | 1 y | BEV, SEV | Log. EuroScore 21.7 | n/a | Retrospective, multicenter | 8 |
| Tomii (2022) | Switzerland | 1669 | 81/82 | 43/49 | 1 mo | 20.1 | 1 y | BEV, SEV, MEV | STS 4.8 (cohort) | 92% | Retrospective, single center | 8 |
| Tshushima (2022) | USA | 2240 | 80/81 | 41/46 | Hospital discharge | 17.5 | 1.8 (median) | BEV, SEV | STS 5.3/5.5 | n/a | Retrospective, multicenter | 9 |
| Urena (2014) | Canada | 668 | 78/81 | 49/49 | Hospital discharge | 11.8 | 13 mo (median) | BEV | STS 7.6/7.9 | 54% | Retrospective, multicenter | 9 |
Abbreviations: BEV, balloon-expandable valve; LBBB, left bundle branch block; NOP-LBBB, new-onset persistent left bundle branch block; NOS, Newcastle-Ottawa Scale; SEV, self-expanding valve; STS, Society of Thoracic Surgeons; TAVI, transcatheter aortic valve implantation.
Figure 2.
Figure illustrating the incidence of NOP-LBBB (%) by study year. Only studies which defined NOP-LBBB as “on hospital discharge” were included to minimize heterogeneity. The blue columns represent studies with both self-expanding and balloon-expandable valve use, the green columns are studies which only used BEV, whilst the maroon column used only SEV.
Abbreviations: BEV, balloon-expandable valve; NOP-LBBB, new-onset persistent left bundle branch block; SEV, self-expanding valve; TAVI, transcatheter aortic valve implantation.
The primary outcome of this meta-analysis was all-cause mortality at 1 year, which was reported in 13 out of 23 studies, and was found to be greater in patients with a NOP-LBBB; overall RR: 1.41 (95% CI 1.12-1.78) with moderate heterogeneity: I2 = 49%, p = 0 < 0.01 (Figure 3).
Figure 3.
Meta-analysis of primary outcome, new-onset persistent LBBB and all-cause mortality at 1 year. Blue squares represent the estimated risk ratio of the individual studies, whilst the diamond square represents the estimated overall risk ratio with an incorporated CI after meta-analysis.
Abbreviation: LBBB, left bundle branch block.
The secondary outcomes of this meta-analysis were mid-term all-cause mortality, cardiovascular mortality, heart failure-related hospitalization and new PPM at 1 year. The results are summarized in Figure 4.
Figure 4.
Meta-analysis of secondary outcomes of new-onset persistent LBBB.
Abbreviation: LBBB, left bundle branch block.
When analyzing, mid-term all-cause mortality data were combined for all studies which reported mortality outcomes between 1 and 5 years (n = 13). There was no increase in risk of all-cause mortality with a NOP-LBBB, with an overall RR of 1.09 (95% CI 0.99-1.21) with moderate heterogeneity: I2 = 49%, p = 0.02. Cardiovascular mortality was reported by 7 studies. The results favored an increase in CV mortality at 1 year in the NOP-LBBB group; overall RR 1.34 (95% CI 1.02-1.75) with moderate to high heterogeneity: I2 = 60%, p = 0.02. Heart failure rehospitalization was reported by 14 studies, with a higher risk in patients with a NOP-LBBB; overall RR 1.56 (95% CI 1.31-1.84) with moderate heterogeneity: I2 = 47%, p < 0.01. New PPM at 1 year was reported in 10 studies and was greater in patients with NOP-LBBB; RR 3.05 (95% CI 2.39-3.89) with low heterogeneity: I2 = 14%, p < 0.01.
New-Onset Persistent Right Bundle Branch Block
The initial search strategy yielded 229 results, and after removal of duplicates 119 studies were removed. Through title and abstract screening, a further 97 were removed and 13 underwent full review. After full text review and application of the selection criteria, 8 further studies were excluded. The remaining 5 underwent bias assessment using the NOS (Figure 1: Preferred reporting Items for systematic reviews and meta-analyses flow chart) and were included.
The 5 studies included consisted of a total of 3525 patients. Of the included studies, all were retrospective and of good or high quality (score 6-9) using the NOS. They key characteristics are displayed in Table 2. The incidence of NOP-RBBB varied amongst the studies varied (0.8%-9.6%), and all studies defined NOP-RBBB as per the electrocardiogram prior to discharge.
Table 2.
Studies which assessed the prognostic outcome of NOP-RBBB after TAVI
| Author (y) | Country | Total patients | Age (y) (RBBB/no RBBB) | Male% (RBBB/no RBBB) | New persistent RBBB definition | Incidence p-RBBB (%) | Follow-up | Valve type | Surgical risk % (RBBB/no RBBB) | Femoral access% | Study type | NOS bias score |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Kilkuchi et al (2024) | Japan | 407 | 86/84 | 17/32 | Postoperative d 1 & 5 | 4.6 | 30-d | BEV, SEV | N/R | N/R | Retrospective, single center | 8 |
| Tan et al (2024) | USA | 1992 | 83/81 | 60/56 | Postprocedure | 0.75 | 1 y | BEV, SEV | N/R | N/R | Retrospective, multicenter | 9 |
| Agha et al (2019) | USA | 489 | N/R | N/R | Postprocedure | 2.9 | 1 y | N/R | N/R | 62 | Retrospective, single center | 7 |
| Jorgensen et al (2018) | Denmark | 467 | N/R | N/R | Postprocedure | 9.6 | 30-d | BEV, SEV, MECH | N/R | 93 | Prospective, single center | 7 |
| Rajah et al (2021) | Saudi Arabia | 170 | N/R | N/R | Postprocedure | 1.18 | 30-d | BEV, SEV | N/R | N/R | Retrospective, single center | 6 |
Abbreviations: BEV, balloon-expandable valve; NOS, Newcastle-Ottawa Scale; RBBB, right bundle branch block; SEV, self-expanding valve; TAVI, transcatheter aortic valve implantation.
The primary outcome of all-cause mortality was only reported in 2 studies (Figure 5), and there was no association of NOP-RBBB with all-cause mortality at 1 year, overall RR 1.74 (95% CI 0.88-3.46) and high heterogeneity: I2 = 93%, p = 0.11. The secondary outcome of new PPM implantation at 1 year was reported by 5 studies, and NOP-RBBB was significantly associated with an increase in pacemaker implantation at 1 year: overall RR 4.68 (95% CI 3.60-6.08) with high heterogeneity: I2 = 67%, p < 0.01 (Figure 6). Other secondary outcomes were not reported in the available studies and were therefore not included in the meta-analysis.
Figure 5.
Meta-analysis of primary outcome of all-cause mortality at 1 year after new-onset persistent RBBB.
Abbreviation: RBBB, right bundle branch block.
Figure 6.
Meta-analysis of secondary outcome of new permanent pacemaker at 1 year after new-onset persistent RBBB.
Abbreviation: RBBB, right bundle branch block.
Discussion
This systematic review and meta-analysis offers the most up-to-date and comprehensive evaluation of the prognostic implications of a NOP-LBBB or NOP-RBBB after TAVI. The key results can be summarized as follows: (1) NOP-LBBB after TAVI is associated with a greater risk of all-cause mortality at 1 year compared to patients without NOP-LBBB; (2) NOP-LBBB after TAVI is associated with a greater risk of cardiovascular mortality and heart failure-related rehospitalization at mid- to long-term follow-up; (3) Both NOP-LBBB and NOP-RBBB after TAVI are associated with a greater risk of PPM implantation at 1 year.
Our study found the incidence of NOP-LBBB after TAVI to be significantly higher than NOP-RBBB. This is explained by the anatomical proximity of the native conduction pathway to the aortic valve. The bundle of His is thought to emerge and bifurcate at the inferior margin of the membranous septum, exposing the left bundle branch and leaving it susceptible to interference from the inflow of an implanted THV. This mechanism also helps to explain the higher observed incidence of NOP-LBBB with taller framed SEVs,10 which have may impart a greater radial force on the membranous septum. Whilst this study did not stratify the analysis on valve type, Figure 2 illustrates that the study with the highest incidence of NOP-LBBB (%) included only SEV patients, whereas the 2 studies with the lowest incidence of NOP-LBBB (%) included only balloon-expandable valve patients.
Of further interest in Figure 2 is that the incidence of NOP-LBBB is not only variable across studies, but it has not reduced with modern implant techniques and valve designs. This contrasts to the falling incidence of PPM implantation, even in SEVs, owing mostly to higher implantation depth using the cusp-overlap technique.11 The cusp-overlap technique facilitates higher implantation of the SEV by elongating the left ventricular outflow tract and isolating the noncoronary cusp. However, a meta-analysis published in 2023 by Sa et al.,12 did not show any difference in NOP-LBBB when the cusp-overlap technique was compared to standard coplanar implantation, which appears consistent with our findings.
The development of NOP-RBBB is more uncommon and cannot be explained as intuitively as the fibers are located on the right ventricular aspect of the ventricular septum. However, His-Bundle fibers are believed to be predestined for the left and right bundle,13 and thus one proposed theory14 is that a THV may interrupt the right bundle much more proximally via direct or indirect means (calcium translocation). Another proposed etiology is via septal ischemia from embolic debris during THV deployment, although this requires validation.14
On analysis of our primary outcome, we found NOP-LBBB increased the risk of all-cause mortality at 1 year, compared to those without a LBBB (RR 1.41, 95% CI 1.12-1.78), with moderate heterogeneity (I2 = 49%). One outlier in our results was Eschalier et al. (2019)15 where the RR of all-cause mortality after NOP-LBBB was 0.25 (95% CI 0.03-2.14). This discrepant result is potentially explained by the study’s small sample size (n = 80), and its design, as it was conducted as a subanalysis of a concurrently running separate prospective study which was powered to investigate for changes in left ventricular function, rather than mortality at 1 year.
We also noted an increase in cardiovascular mortality and heart failure-related rehospitalizations in patients with NOP-LBBB. The adverse prognostic outcome of NOP-LBBB may at least partly explained by electrical and mechanical dyssynchrony, causing decreased cardiac output, higher residual left ventricle volumes, and negative cardiac remodeling.16 To date, there have been 3 prior meta-analyses assessing the prognostic impact of NOP-LBBB after TAVI. The first, published by Regueiro et al.17 in 2016, found that NOP-LBBB increased cardiovascular death and PPM at 1 year and trended towards worse all-cause mortality at 1 year without reaching statistical significance. In 2020, Faroux et al.18 published that NOP-LBBB increased risk of all-cause and cardiovascular mortality, as well as heart failure rehospitalization and PPM at 1 year. These results were further substantiated most recently by Wang et al. (2022)19 and are also similar to our results19 which also include an additional 5 studies which were published after Wang et al. (2022)’s work.
Our study did not find a correlation between NOP-LBBB and mid-term all-cause mortality, which included follow-up from 1 to 5 years. Whilst this may partly be attributed to varying follow-up periods, a physiological explanation may be from conduction system recovery. Whilst immediate LBBB after TAVI is very common, occurring in in up to 40% of patients due to transient localized inflammation, up to a third of patients recover their conduction by hospital discharge, and close to two-thirds recover in 12 months.20 Thus, when studying the longer-term impacts of THV-induced LBBB, a “persistent” LBBB should perhaps be defined as manifesting past 12 months.
Our study is the first to meta-analyze the currently available prognostic data on NOP-RBBB after TAVI. Whilst we did not find an association between NOP-RBBB and all-cause mortality at 1 year, it must be noted that only 2 studies were available for analysis, both of which were retrospective with significant heterogeneity.
The evaluation of NOP-RBBB and the risk of pacemaker at 1 year was a more robust and clinically relevant analysis, with 5 available retrospective studies. We found that NOP-RBBB increased the risk of PPM 5-fold (RR 4.68) at 1 year, even more so than with NOP-LBBB (RR 3.08). Whilst there was still notable heterogeneity in the data (I2 = 67%), the strength of this association may warrant further prospective research.
Regardless, implanters who note the development of a new bundle branch block may rightfully opt for longer ambulatory or invasive (implantable loop recorder) rhythm monitoring, although there is limited data available to recommend the duration of monitoring that would be sufficient. The role of a prophylactic pacemaker in patients with a new bundle branch block is also controversial, although a recently published French study demonstrated that in patients with a NOP-LBBB after TAVI, a His-Ventricle interval >70 milliseconds21 conferred a greater risk of progression of complete heart block, and in such patients a preventative pacemaker may be justified.
Limitations
As a meta-analysis of observational studies, limited to the English language, we may have unintentionally introduced elements of bias. Our analysis of NOP-RBBB had high levels of heterogeneity, as did our analysis of NOP-LBBB and cardiovascular mortality, which influences the overall interpretation of these results. The likely drivers include varying definitions of “persistent” bundle branch blocks, valve types used and cohort surgical risk scores. Furthermore, the duration of the QRS interval in both NOP-LBBB and NOP-RBBB populations may influence the likelihood of future high-grade atrioventricular conduction disease but was not available for analysis in the included studies. Finally, it should be noted that our search strategy and filtration of studies was based on our primary outcome, and secondary outcomes were reported from these included studies and were not specifically searched.
Conclusion
Patients with a NOP-LBBB after TAVI have greater risk of all-cause mortality at 1 year, as well as greater cardiovascular mortality, heart failure hospitalizations and PPM implantation. Whilst NOP-RBBB after TAVI is not as well studied, the results suggest a significantly increased risk of new pacemaker implantation at 1 year. Recognizing the prognostic impact of bundle branch block after TAVI can help to guide implanters in preprocedural planning, as well as postprocedural follow-up care.
Ethics Statement
This manuscript adheres to the relevant ethical guidelines.
Funding
This is an investigator initiated and funded project. No external funding was sought. Karan Rao is supported through a National Health and Medical Research Council (NHMRC) and Heart Research Australia Postgraduate Scholarship.
Disclosure Statement
The authors report no conflict of interest.
References
- 1.Popma J.J., Deeb G.M., Yakubov S.J., et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med. 2019;380(18):1706–1715. doi: 10.1056/NEJMoa1816885. [DOI] [PubMed] [Google Scholar]
- 2.Mack M.J., Leon M.B., Thourani V.H., et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med. 2019;380(18):1695–1705. doi: 10.1056/NEJMoa1814052. [DOI] [PubMed] [Google Scholar]
- 3.Carroll J.D., Mack M.J., Vemulapalli S., et al. STS-ACC TVT registry of transcatheter aortic valve replacement. J Am Coll Cardiol. 2020;76(21):2492–2516. doi: 10.1016/j.jacc.2020.09.595. [DOI] [PubMed] [Google Scholar]
- 4.Vora A.N., Gada H., Manandhar P., et al. National variability in pacemaker implantation rate following TAVR: insights from the STS/ACC TVT registry. JACC Cardiovasc Interv. 2024;17(3):391–401. doi: 10.1016/j.jcin.2023.12.005. [DOI] [PubMed] [Google Scholar]
- 5.Singh N. TCT; San Francisco: 2023. Outcomes of Patients with New LBBB after TAVR: Insights from the NCDR STS/ACC TVT Registry. CA2023. [Google Scholar]
- 6.Baldasseroni S., Opasich C., Gorini M., et al. Left bundle-branch block is associated with increased 1-year sudden and total mortality rate in 5517 outpatients with congestive heart failure: a report from the Italian network on congestive heart failure. Am Heart J. 2002;143(3):398–405. doi: 10.1067/mhj.2002.121264. [DOI] [PubMed] [Google Scholar]
- 7.Zegard A., Okafor O., de Bono J., et al. Prognosis of incidental left bundle branch block. Europace. 2020;22(6):956–963. doi: 10.1093/europace/euaa008. [DOI] [PubMed] [Google Scholar]
- 8.Witt C.M., Wu G., Yang D., Hodge D.O., Roger V.L., Cha Y.-M. Outcomes with left bundle branch block and mildly to moderately reduced left ventricular function. JACC Heart Fail. 2016;4(11):897–903. doi: 10.1016/j.jchf.2016.07.002. [DOI] [PubMed] [Google Scholar]
- 9.Lee S.J., McCulloch C., Mangat I., Foster E., De Marco T., Saxon L.A. Isolated bundle branch block and left ventricular dysfunction. J Card Fail. 2003;9(2):87–92. doi: 10.1054/jcaf.2003.19. [DOI] [PubMed] [Google Scholar]
- 10.Houthuizen P., van der Boon R.M.A., Urena M., et al. Occurrence, fate and consequences of ventricular conduction abnormalities after transcatheter aortic valve implantation. Eurointervention. 2014;9(10):1142–1150. doi: 10.4244/eijv9i10a194. [DOI] [PubMed] [Google Scholar]
- 11.Grubb K.J., Gada H., Mittal S., et al. Clinical impact of standardized TAVR technique and care pathway: insights from the Optimize PRO study. JACC Cardiovasc Interv. 2023;16(5):558–570. doi: 10.1016/j.jcin.2023.01.016. [DOI] [PubMed] [Google Scholar]
- 12.Sá M.P., Van den Eynde J., Jacquemyn X., et al. Cusp-overlap versus coplanar view in transcatheter aortic valve implantation with self-expandable valves: a meta-analysis of comparative studies. Catheter Cardiovasc Interv. 2023;101(3):639–650. doi: 10.1002/ccd.30562. [DOI] [PubMed] [Google Scholar]
- 13.Narula O.S. Longitudinal dissociation in the His bundle. Bundle branch block due to asynchronous conduction within the his bundle in man. Circulation. 1977;56(6):996–1006. doi: 10.1161/01.CIR.56.6.996. [DOI] [PubMed] [Google Scholar]
- 14.Tan N.Y., Adedinsewo D., El Sabbagh A., et al. Incidence and outcomes of new-onset right bundle branch block following transcatheter aortic valve replacement. Circ Arrhythm Electrophysiol. 2024;17(2) doi: 10.1161/circep.123.012377. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Eschalier R., Massoullié G., Nahli Y., et al. New-onset left bundle branch block after TAVI has a deleterious impact on left ventricular systolic function. Can J Cardiol. 2019;35(10):1386–1393. doi: 10.1016/j.cjca.2019.05.012. [DOI] [PubMed] [Google Scholar]
- 16.Tan N.Y., Witt C.M., Oh J.K., Cha Y.-M. Left bundle branch block: current and future perspectives. Circ Arrhythm Electrophysiol. 2020;13(4) doi: 10.1161/CIRCEP.119.008239. [DOI] [PubMed] [Google Scholar]
- 17.Regueiro A., Abdul-Jawad Altisent O., Del Trigo M., et al. Impact of new-onset left bundle branch block and periprocedural permanent pacemaker implantation on clinical outcomes in patients undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis. Circ Cardiovasc Interv. 2016;9(5) doi: 10.1161/CIRCINTERVENTIONS.115.003635. [DOI] [PubMed] [Google Scholar]
- 18.Faroux L., Chen S., Muntané-Carol G., et al. Clinical impact of conduction disturbances in transcatheter aortic valve replacement recipients: a systematic review and meta-analysis. Eur Heart J. 2020;41(29):2771–2781. doi: 10.1093/eurheartj/ehz924. [DOI] [PubMed] [Google Scholar]
- 19.Wang J., Liu S., Han X., et al. Prognostic outcome of new-onset left bundle branch block after transcatheter aortic valve replacement in patients with aortic stenosis: a systematic review and meta-analysis. Front Cardiovasc Med. 2022;9 doi: 10.3389/fcvm.2022.842929. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Urena M., Mok M., Serra V., et al. Predictive factors and long-term clinical consequences of persistent left bundle branch block following transcatheter aortic valve implantation with a balloon-expandable valve. J Am Coll Cardiol. 2012;60:1743–1752. doi: 10.1016/j.jacc.2012.07.035. [DOI] [PubMed] [Google Scholar]
- 21.Massoullié G., Ploux S., Souteyrand G., et al. Incidence and management of atrioventricular conduction disorders in new-onset left bundle branch block after TAVI: a prospective multicenter study. Heart Rhythm. 2023;20:699–706. doi: 10.1016/j.hrthm.2023.01.013. [DOI] [PubMed] [Google Scholar]