Should we implant a permanent pacemaker in patients with left bundle branch block and PQ prolongation following transcatheter aortic valve implantation?

Introduction

Transcatheter aortic valve implantation (TAVI) includes the risk for development of heart block. The presence of left bundle branch block (LBBB) after TAVI with PQ interval prolongation is not clearly defined as an indication for pacemaker implantation.

Case report

A 76-year-old woman with a combined aortic valve disease, with a predominance of severe aortic stenosis, who had been previously disqualified from the classical cardiac surgery of aortic valve replacement because of the high risk of the procedure, was qualified for transcatheter aortic valve implantation (TAVI) due to increasing symptoms of heart failure. Moreover, she had a history of long-term arterial hypertension, symptomatic heart failure (NYHA II/III), rheumatoid arthritis (RA) and degeneration of the spine in the thoracic-lumbar part and lumbar scoliosis limiting her mobility. Baseline ECG revealed: regular sinus rhythm 70 bpm, the mean electrical axis in the frontal plane = ‘–20’, PQ interval = 170 ms, QRS = 98 ms, QTc = 410 ms. The baseline echocardiography examination revealed left ventricular (LV) hypertrophy (LV = 42 mm, posterior wall (PW) of LV = 14 mm, interventricular septum (IVS) = 15 mm), significantly stenotic, extremely calcified aortic valve (peak pressure gradient (PPG) = 174 mm Hg, mean PG (MPG) = 101.2 mm Hg, and Vmax = 6.6 m/s) with good ejection fraction (EF) of the LV (EF – 65%). Computed tomography scans disclosed multiple calcifications of the aortic valve (Figure 1 A) and within the coronary sinus area (aortic valve area 417 mm2, perimeter 23.4 mm). Operative mortality was estimated using the following scoring systems: Euro SCORE standard = 7 p., logistic [%] = 6.19%, EUROSCORE II = 2.11%, STS score mortality [%] = 11.12%, mortality & morbidity = 58.526. The TAVI was carried out in general anesthesia from a femoral approach using the Prostar system. Before valve implantation balloon aortic valvuloplasty using Numed Z-Med II-X 18 mm × 50 mm was performed. Following that a CoreValve 29 mm was implanted (the depth of implantation calculated on computed tomography scan was 4 mm), which resulted in a complete elimination of the transvalvular gradient with a trace of paravalvular aortic regurgitation. There were no complications of the procedure.
On the first day after TAVI the patient’s general condition was good. ECG revealed: regular sinus rhythm 86 bpm, new onset of left bundle branch block (LBBB) with QRS complex...


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