My elderly patient developed a new left bundle branch block following transcatheter aortic valve replacement. Is this a frequent occurrence?

Yes, conduction abnormalities, particularly left bundle branch block (LBBB), frequently complicate transcatheter aortic valve replacement (TAVR).

A 2016 systematic review and meta-analysis reported new-onset LBBB following TAVR and persisting at hospital discharge in 13.3%-37% of patients1; the incidence may be higher or lower depending on the type of prosthesis used.2,3 In the same systematic review, new-onset LBBB was associated with a higher risk of permanent pacemaker placement (PPI) and cardiac death during 1-year followup.   In another study, persistence of LBBB post-TAVR without PPM placement was associated with an increased risk of syncope, complete AV node block, and PPI, but not overall mortality.4

The underlying anatomy of the conduction system may help explain post-TAVR conduction complications. The AV node is located adjacent to the membranous septum, closely associated with the subaortic region and LV outflow track, giving rise to the LBB.5 Protrusion of TAVR prostheses into the LV outflow tract, the mechanical injury occurring during the predilation or the positioning of the valve, and potential trauma to the conduction system by the catheters and guidewires used in TAVR may all contribute to these complications.3,5

References

  1. Regueiro A, Altisent OA, Del Trigo M, et al. Impact of new-onset left bundle branch block and periprocedural permanent pacemaker implanation on clinical outomces in patients undergoing transcatheter aortic valve replacement: A systematic review and meta-analysis. Circ Cardiovasc Interv 2016;9:e003635. http://circinterventions.ahajournals.org/content/9/5/e003635.long
  2. Nazif, T.M., Williams, M.R., Hahn, R.T., Kapadia, S., Babaliaros, V. et al. Clinical implications of new-onset left bundle branch block after transcatheter aortic valve replacement: analysis of the PARTNER experience. Eur. Heart J. 2014;21:1599-1607. https://www.ncbi.nlm.nih.gov/pubmed/24179072
  3. Bourantas CV, Serruys PW. Evolution of transcatheter aortic valve replacement. Circ Res 2014;114:1037-1051. http://circres.ahajournals.org/content/114/6/1037
  4. Urena, M., Mok, M., Serra, V., Dumont, E., Nombela-Franco, L. 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. https://www.ncbi.nlm.nih.gov/pubmed/23040577
  5. Piazza, N., Jaegere, P., Schultz, C., Becker, A.E., Serruys, P.W., Anderson, R.H. Anatomy of the aortic valve complex and its implications for transcatheter implantation of the aortic valve. Circ Cardiovasc Interv. 2008;1:74-81. https://www.ncbi.nlm.nih.gov/pubmed/20031657

Contributed by Salvatore D’Amato MD, Mass General Hospital, Boston, MA

My elderly patient developed a new left bundle branch block following transcatheter aortic valve replacement. Is this a frequent occurrence?

My elderly patient with aortic stenosis has iron deficiency in the setting of Heyde’s syndrome. Can surgical or transcatheter aortic valve replacement (SAVR, TAVR) reduce her risk of future gastrointestinal bleeding?

Yes! Heyde’s syndrome, characterized by aortic stenosis and GI angiodysplasia1, appears to respond to SAVR or TAVR by reducing future risk of GI bleed.

Cessation of bleeding following SAVR or TAVR with gradual disappearance of angiodysplasia has been reported, in some cases despite long-term anticoagulant therapy2,3In fact, GI bleed may cease in 95% of cases following AVR vs 5% in cases controlled with laparotomy with or without bowel resection.  Further supporting the potential role of valve replacement is the observation that in patients who have undergone SAVR, aortic valve restenosis usually leads to the recurrence of GI bleeding which again resolves after redo surgery.

The pathophysiology of Heyde’s syndrome involves not only increased number of angiodysplasias but higher risk of bleeding from them.  Although its exact  physiological link is unclear, hypo-oxygenation of intestinal mucosa—possibly related to cholesterol emboli with resultant vasodilatation—has been hypothesized, among many others.4   Bleeding from angiodysplasias appears related to the high shear stress across the stenotic aortic valve, leading to acquired von Willebrand’s disease (Type 2AvWF disease) and coagulopathy.4

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References

    1. Heyde EC. Gastrointestinal bleeding in aortic stenosis. N Engl J Med 1958;259:196. https://www.nejm.org/doi/full/10.1056/NEJM200209123471122
    2. Abi-akar R, El-rassi I, Karam N et al. Treatment of Heyde’s syndrome by aortic valve replacement. Curr Cardiol Rev 2011;  7:47–49. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3131716/
    3. Pyxaras, SA, Santangelo S. Perkan A et al. Reversal of angiodysplasia-derived anemia after transcatheter aortic valve implantation. J Cardiol Cases 2012; 5: e128–e131. https://www.sciencedirect.com/science/article/pii/S187854091100079X
    4. Kapila A, Chhabra L, Khanna A. Valvular aortic stenosis causing angiodysplasia and acquired von Willebrand’s disease: Heyde’s syndrome. BMJ Case Rep 2014 doi:10.1136/bcr-2013-201890. http://casereports.bmj.com/content/2014/bcr-2013-201890.full.pdf

 

Contributed by Biqi Zhang, Medical Student,  Harvard Medical School

 

My elderly patient with aortic stenosis has iron deficiency in the setting of Heyde’s syndrome. Can surgical or transcatheter aortic valve replacement (SAVR, TAVR) reduce her risk of future gastrointestinal bleeding?