Post-TAVI atrioventricular block: navigating the triple jeopardy of tricuspid regurgitation, pacemaker-induced heart failure, and left innominate vein obstruction

Abstract

Transcatheter aortic valve implantation (TAVI) has become a widely accepted therapeutic intervention for severe aortic stenosis, but it is frequently complicated by the development of atrioventricular block (AVB) that requires pacemaker implantation. This case report aims to present a 66-year-old male who developed a high-grade AVB after TAVI, requiring implantation of a dual-chamber pacemaker. Post pacing implantation, the patient presented with symptoms of heart failure (HF) and two-dimensional echocardiogram revealed severe tricuspid regurgitation (TR) and reduced left ventricular systolic function. Despite attempts to upgrade the pacemaker to a biventricular system, complications arose due to venous obstruction of the left brachiocephalic vein, which was overcome by tunneling the left ventricular lead from the right side. The patient achieved complete resolution of HF symptoms and marked improvement in both TR and left ventricular function after upgrading. This case illustrates the “triple jeopardy” of post-TAVI complications: pacemaker-induced HF, worsening of TR, and venous obstruction. It underlines the importance of thorough assessment of the patient and innovative management strategies for optimum results. The successful lead-tunneling techniques could become a solution for similar cases of venous obstruction when pacemakers are being replaced. Whereas TAVI saves life, management of complications such as AVB and TR with utmost care would prevent morbidity and enhance long-term outcome. This case emphasizes on the need for continuous monitoring post-TAVI and guided intervention that addresses both pacemaker-induced and venous complications.

Introduction

Transcatheter aortic valve implantation (TAVI), also referred to as transcatheter aortic valve replacement (TAVR) is one of the minimally invasive procedures developed to manage aortic stenosis (AS) in patients considered inoperable or at high surgical risk. TAVI has been developed since the early 1990 s, presenting it as a more advanced development than the limitations of traditional aortic balloon valvuloplasty. Therefore, from pioneers such as Cribier and Figulla (2020), came two obvious developments, balloon-expandable valve systems and self-expanding valve systems [1]. Moreover, TAVI has had great acceptance in reducing risks surgically and promoting excellence in patients’ outcomes, especially in the elderly. Clinical trials starting in 2005 established that TAVI provides results comparable with surgical aortic valve replacement (SAVR) and has therefore become the standard of care in cardiovascular medicine [2]. Ongoing advancements in device technology and delivery systems have minimized complications and paved the way for TAVI to be applied on lower risk patients as well as those with aortic regurgitation.

However, TAVI is frequently complicated by atrioventricular block atrio-ventricular block (AVB) and in that case, a permanent pacemaker must be inserted [3]. Such cardiac implantable electronic devices (CIED) lead to complexities which result in increase in morbidity. High-grade AV block (HAVB) is especially common following TAVI, with various studies using the term TAVR interchangeably with TAVI in literature. In a study with 953 patients, the incidence of any HAVB was extremely high as 8.2% of the patients reported a new first-degree AVB and 19.3% with left bundle branch block (LBBB). As a result, 16.8% of the patients required permanent pacemaker (PPM) implantation due to conduction abnormalities [4].These risks necessitate appropriate monitoring and prompt intervention to reduce the complications involved, including bradycardia and sudden cardiac death.

AVB is still a health-care concern, even with the advent of newer TAVI valves. Post PPM, patients might undergo pacemaker-induced cardiomyopathy (PIC) with significant morbidity and mortality. True incidence of PIC is not known, but it could reach as high as 20% [5]. A common complication that is not diagnosed or is being missed after a CIED includes tricuspid regurgitation (TR). The incidence of TR increases with an increase in the patients with CIED, with incidence up to 45% [6].

This case report will outline the complexities and challenges associated with complications occurring post-TAVI, focusing on a 66-year-old man requiring PPM implantation due to atrioventricular (AV) block. The patient developed heart failure (HF) symptoms primarily due to PIC and severe TR. The case management was complex due to the progression of HF associated with the need for upgrading to a biventricular pacemaker (Cardiac Resynchronisation Therapy Pacemaker - CRT-P). Obstruction in the left innominate vein was identified and a new technique required for the implementation of the new device. This allowed the left ventricular (LV) lead to be tunneled from the right side and resulted in satisfactory resolution of HF symptoms and marked improvement in LV function.

The triple jeopardy facing clinicians in the management of post-TAVI AV block is the risk of TR due to CIED implantation, the development of PIC, and challenges such as venous obstruction complicating device upgrades. Its prevalence is increasing, but the exact incidence and long-term outcome of such complications in post-TAVI patients are not well defined. However, management should be careful in such patients with an AV block, since intervention can greatly alter the course of a patient’s recovery. This case report focuses on the recognition of pacemaker-induced complications in post-TAVI patients, close monitoring of signs of TR and HF, and preparation for procedural challenges associated with the upgrade of the pacemaker. Moreover, the case report introduces the new concept of addressing venous obstruction to serve as a basis for future interventions. This is yet another reminder that TAVI may be life-saving, but it brings with it new and evolving risks and patients’ outcomes need to be optimized through innovative management strategies.

Case presentation

A 66-year-old man was admitted to the emergency department with a known history of coronary artery disease (CAD), previously treated with percutaneous coronary intervention (PCI) to the right coronary artery (RCA). He presented with chest pain of cardiac origin lasting for 2 h. There were no signs of HF such as leg edema or elevated jugular venous pressure. Cardiac auscultation demonstrated an ejection systolic murmur typical for AS.

Diagnosis was confirmed as non-ST elevation myocardial infarction (NSTEMI). Pre-invasive coronary angiogram transthoracic echocardiogram (TTE) had revealed normal left ventricular systolic function (LVSF) with an ejection fraction (EF) of 55%, concentric LV hypertrophy, and AS with a mean gradient of 35 mmHg across the valve. The severity of AS is typically classified as mild (mean gradient <20 mmHg), moderate (20–39 mmHg), and severe (≥40 mmHg). Since the patient’s mean gradient fell below the conventional severe threshold, additional parameters such as the aortic valve area (AVA <1.0 cm²) and peak velocity (≥4 m/s) were considered to confirm the severity of AS. Given that the patient had preserved LV ejection fraction, the classification of AS severity was carefully assessed in conjunction with these additional echocardiographic criteria.

Further assessment through left heart catheterization identified double vessel coronary disease involving the RCA and the left anterior descending (LAD) artery. Both vessels were treated with PCI. The patient’s case was extensively discussed in our Cardiology Multidisciplinary Team (MDT) meeting, which included consultant cardiologists from all cardiac subspecialties as well as cardiac surgeons. Considering the patient’s low surgical risk for TAVI, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was calculated to be 2.3%, indicating a low operative mortality risk but not negligible procedural risks. Additionally, the patient met the clinical indications for TAVI due to symptomatic severe AS with a mean transvalvular gradient of 35 mmHg and an AVA of 0.8 cm². The presence of significant CAD further justified early intervention, as untreated AS in such patients is associated with poor prognosis.

The decision for TAVI over SAVR was primarily influenced by the findings in the Cardio-Thoracic MDT discussion, where the patient’s procedural risk and anatomical challenges were reviewed. Despite the low EuroSCORE II, excessive aortic calcification led the cardiac surgeon to decline the patient for SAVR, as it increased the complexity and risk of surgical intervention. Additionally, before the MDT discussion, the patient had already expressed a preference for TAVI, even if the surgeon had accepted SAVR. Given these factors, a low but present surgical risk (EuroSCORE II 2.3%), excessive aortic calcification making SAVR unfavorable, and the patient’s preference the multidisciplinary team reached a consensus to proceed with TAVI for AS and PCI for CAD. The TAVI procedure was successfully performed 1 week after the PCI.

Although deferring TAVI might have been an option considering the absence of HF symptoms, the decision to proceed was based on several factors. The patient had already presented with NSTEMI, indicating significant CAD, and AS is known to contribute to myocardial ischemia. Additionally, the progression of AS is unpredictable, and delaying intervention could increase the risk of sudden deterioration, particularly in an elderly patient with concomitant CAD. Given these considerations, the multidisciplinary team concluded that early TAVI was the most appropriate course of action to prevent further cardiac complications.

Pre-TAVR CT analysis

A pre-TAVR computed tomography (CT) scan was performed to assess the anatomical suitability for valve implantation and evaluate vascular access. The CT protocol included gated thoracic computed tomography angiography (CTA) and non-gated aortic and iliac CTA.

Findings

• Cardiac findings: levocardia, AV, and ventriculoarterial (VA) concordance. Conventional drainage of the superior vena cava (SVC), inferior vena cava (IVC), and coronary sinus. Conventional pulmonary venous drainage into the left atrium. The left atrium, its atrial appendage, and the LV cavity showed uniform contrast enhancement. No significant pericardial effusion or calcification was observed.

• Coronary arteries: right dominant circulation. The left main coronary artery was 8.9 mm above the annulus, and the RCA was 9.8 mm above the annulus. This study was not optimized for coronary artery assessment. The coronary calcium score could not be measured due to the presence of a stent in the RCA.

• Aortic valve: severe calcification with an aortic valve calcium score of 1760. Two-dimensional maximum annulus measurements were 21.1 × 24.6 mm, corresponding to an annular area of 408.8 mm².

• Sinus of Valsalva: Measurements of 29.6 mm × 28.8 mm × 28.5 mm.

• 3-cusp tube projection angles: Initial projection 0L 9 right anterior oblique (RAO) 1 cranial (CRA), but corrected to 0L 17 left anterior oblique (LAO) 21 CRA due to overlaying of the aorta.

• Vascular dimensions

  • Sinotubular junction: 25.9 mm
  • Ascending aorta: mild calcification, 35.5 mm × 32.1 mm
  • Aortic arch: mild calcification with soft and hard plaque, 27.4 mm × 30.8 mm
  • Descending thoracic aorta: mild calcification, 31 mm × 26.9 mm
  • Descending abdominal aorta: mild to moderate atherosclerotic changes, including a penetrating atherosclerotic ulcer at the bifurcation (narrowest diameter, 12.9 mm × 17.5 mm)
• Iliac and femoral arteries

  • Right common iliac artery: mild calcification with mild tortuosity, 7.9 mm × 10.1 mm
  • Right external iliac artery: mild calcification with moderate tortuosity, 6.6 mm × 10.2 mm
  • Right femoral artery: no significant atherosclerotic changes, 7.8 mm × 9.8 mm
  • Left common iliac artery: mild atherosclerotic disease with moderate tortuosity, 9 mm × 11.1 mm
  • Left external iliac artery: mild calcification with mild tortuosity, 7.1 mm × 9.2 mm
  • Left femoral artery: no calcification or tortuosity, 7.7 mm × 8.9 mm

These findings were essential for procedural planning, confirming the feasibility of transfemoral TAVI while highlighting potential vascular challenges.

Management and treatment plan

The cardiac team had decided to manage the severe AS with TAVI, which was successfully performed 1 week after the PCI procedure. The decision was based on comprehensive risk assessment, including the patient’s EuroSCORE II, frailty status, and comorbid conditions. While the EuroSCORE II estimated a low surgical risk, the presence of CAD, advanced age, and AS severity warranted a minimally invasive approach.

A self-expanding EVOLUT PRO 29 mm Medtronic bio-prosthesis was implanted. The patient was on dual antiplatelet therapy consisting of ticagrelor 90 mg twice daily (BID) and aspirin 100 mg once daily (OD) post-PCI, and this regimen was not interrupted before the PPM implantation. Anticoagulation was initiated post-TAVI due to the presence of multiple thromboembolic risk factors, including atrial fibrillation and venous stasis. The patient was started on apixaban 5 mg BID in addition to dual antiplatelet therapy, following current clinical guidelines for post-TAVI anticoagulation strategies. Close monitoring for bleeding complications and thrombotic events was performed throughout the follow-up period.

Three days post-TAVI, the patient developed third-degree AVB (Fig. 1B) which was managed successfully with a dual-chamber PPM. The right ventricular (RV) lead was positioned at a basal septal location (Fig. 1D) with excellent lead parameters.

Fig. 1.

A Electrocardiogram (ECG) prior to transcatheter aortic valve implantation (TAVI) procedure showing sinus rhythm. B Electrocardiogram (ECG) post transcatheter aortic valve implantation (TAVI) procedure showing third-degree atrioventricular (AV) block. C Paced electrocardiogram (ECG) suggesting right ventricular at basal septal location, confirmed with chest X-ray (CXR) in D

Although a pre-TAVI CT scan was performed to assess anatomical suitability for valve implantation, a post-TAVI CT scan was not conducted as it is not our usual practice to perform post-TAVI CT imaging. However, following TAVI, the patient experienced recurrent episodes of dizziness and one syncopal episode, which correlated with electrocardiogram (ECG) findings showing narrow QRS and AV dissociation with a heart rate of approximately 70 bpm. Sixteen months later, the patient presented with HF symptoms including bilateral leg swelling up to the thighs. Pacemaker interrogation confirmed a high burden of RV pacing (82%), and repeat TTE showed deterioration of left ventricular ejection fraction (LVEF) to 25% and severe TR which was not present before the PPM implantation (Fig. 2). The decision was to upgrade the dual PPM to CRT-P and reposition the RV lead due to potentially severe TR likely caused by immobilization of tricuspid valve septal leaflet.

Fig. 2.

A Transthoracic echocardiography (TTE) before pacemaker implant; note no significant tricuspid regurgitation (TR). B Transthoracic echocardiography (TTE) post permanent pacemaker (PPM) showing severe tricuspid regurgitation (TR). C Transthoracic echocardiography (TTE) post upgrading permanent pacemaker (PPM) to cardiac resynchronization therapy pacemaker (CRT-P) showing trivial tricuspid regurgitation (TR)

Before proceeding with the upgrade to CRT-P, the patient was kept on guideline-directed optimal medical therapy and was evaluated multiple times to assess the necessity of the device upgrade. Despite adherence to medical therapy, the patient continued to have HF symptoms, warranting the decision to upgrade the device.

Figure 3 illustrates the overall course of treatment of the patient, including the development of significant clinical events from the initial TAVI procedure until pacemaker implantation and its upgrading. This stage was marked by developing complications concerning AV block and TR leading to full resolution of symptoms of HF after the introduction of a novel strategy focused on managing venous stenosis.

Fig. 3.

Flowchart illustrating the treatment progression and outcomes following transcatheter aortic valve implantation (TAVI), detailing the management of atrioventricular (AV), the development of tricuspid regurgitation (TR), and the successful upgrade to a cardiac resynchronization therapy pacemaker (CRT-P) following venous obstruction resolution

Outcomes post-TAVI and follow-up

During the CRT-P upgrade, the left subclavian vein and innominate vein were found to be obstructed. Several attempts to cross the obstruction using different types of angioplasty wires were unsuccessful. A right subclavian venogram confirmed that the right axillary, subclavian, and SVC were patent. Hence, the LV lead was positioned via the right subclavian approach and then tunneled subcutaneously to the left side using a Scanlan Tunneler sheath and Bullet Tip Ref-9009-22. In light of the obstruction in the left-sided venous system, repositioning the pre-existing RV lead was deemed too risky and was therefore left in situ. The new LV lead, along with the existing right atrial and RV leads, was connected to the new implanted CRT-P pulse generator.

At 16 months post-TAVI and post-PPM implantation, the patient presented with a reduction in LVEF. A repeat coronary angiography was performed to rule out new CAD, and no new flow-limiting lesions were identified. Two weeks later, the patient reported a complete resolution of all HF symptoms to the extent that he independently discontinued the diuretic therapy 3 days’ post CRT-P upgrade. Follow-up TTE demonstrated resolution of the previously significant TR and improvement in LV systolic function, with an EF of 50%.

Discussion

This case underscores the complex clinical challenges following AVB after TAVI, highlighting the necessity for comprehensive risk evaluation. Although the incidence of post TAVI AVB has declined with newer generation valves, it remains a significant concern. Clinicians must also consider complications associated with PPM implantation, such as TR and PIC. While the true incidence of these complications in the TAVI population remains uncertain, a higher prevalence may be anticipated due to the unique clinical characteristics of these patients. Abnormal depolarization of the right and left ventricles, combined with TR, can lead to reduced cardiac output and HF.

To mitigate the risk of PIC, our institution typically favors conduction system pacing (CSP) or basal septal positioning of the RV lead. In this case, due to unavailability of CSP equipment, we opted for basal septal pacing. Although a QRS duration of 120 ms was achieved, the intervention did not prevent PIC. This is consistent with prior evidence indicating inconclusive benefits of septal versus apical pacing [7]. In addition to improving LV systolic function and alleviating HF symptoms as demonstrated in the Budapest trial [8], this case also revealed a near-complete resolution of TR following upgrade to CRT-P, despite the septal RV lead remaining in place. This finding supports the hypothesis that TR was predominantly, if not exclusively, due to LV dyssynchrony.

Traditionally, TR following PPM implantation is attributed to mechanical disruption—either through leaflet impingement or damage such as laceration or perforation. Less commonly, TR results from asynchronous ventricular depolarization [9], which can impair valve leaflet coaptation. The resolution of TR following CRT-P upgrade in this case strongly suggests ventricular dyssynchrony as the primary mechanism.

Another significant procedural hurdle involved obstruction of the left subclavian and innominate veins, despite the patient being on dual antiplatelet therapy. To address this, we utilized a novel vascular tunneling system combined with an atraumatic subcutaneous dissection technique to route the LV lead from the right side to the left subclavicular PPM pocket. The LV lead was successfully connected to the CRT-P device along with the pre-existing right atrial (RA) and RV leads. To our knowledge, this is the first documented use of this tunneling method for such an application. Given its effectiveness and safety, we recommend this approach for other implanting physicians facing similar anatomical challenges.

Mangieri et al. (2018) conducted a study to investigate post-TAVI conduction disturbances, especially AVB and the need for PPM implantation [10]. They identified deep valve implantation and self-expandable valves as significant predictors of new conduction abnormalities, such as LBBB, often necessitating PPM placement. Similarly, in this case, post-TAVI AVB prompted dual-chamber PPM implantation, which subsequently led to PIC and TR. Issues related to ventricular dyssynchrony and mechanical interaction are commonalities between our case and the study. Furthermore, the procedural innovation in this case, namely, the novel LV lead tunneling, complements Mangieri et al.’s emphasis on the importance of procedural strategies and individualized care in managing the risks associated with PPM use [10].

Conclusion

This case illustrates the complex challenges that can arise after TAVI, particularly in managing AVB with pacemaker implantation. While pacemakers effectively treat AVB, complications such as PIC, severe TR, and venous obstructions can significantly impact patient outcomes. The novel approach of tunneling the LV lead to overcome left innominate vein obstruction exemplifies the innovative techniques required in complex cases. Careful monitoring and early intervention are crucial to mitigate risks such as HF and procedural complications. This case emphasizes the importance of personalized strategies in addressing the evolving challenges of post-TAVI care to optimize patient outcomes.

Author contribution

H.A, M.H.A, A.A.H.S, M.A.A, and H.S.H.H collectively contributed to the conception and design of this case report. They were all involved in data collection, analysis, and drafting of the manuscript. H.S.H.H supervised the entire project, provided expert guidance throughout, and critically reviewed the final version of the manuscript. All authors meet the ICMJE criteria for authorship and have approved the final version of the manuscript.

Funding

None.

Data availability

The data supporting this case report are available upon reasonable request from the corresponding author, Dr. H.S.H.H.

Declarations

Ethics approval

This is a case report with no ethical approval required before. The authors confirm that all procedures performed in this case report were in accordance with the ethical standards of the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Written informed consent was obtained from the patient for the publication of this case report and accompanying clinical data, including details related to tricuspid valve regurgitation.

Conflict of interest

The authors declare that they have no conflict of interest to disclose.