Clinical Investigation
Valvular and Congenital Heart Disease
Incidence of strict versus nonstrict left bundle branch block after transcatheter aortic valve replacement

https://doi.org/10.1016/j.ahj.2014.12.011Get rights and content

Background

Up to one-third of patients diagnosed with left bundle branch block (LBBB) by conventional electrocardiographic (ECG) criteria are misdiagnosed. Strict LBBB shows decreased left ventricular pumping efficiency compared with nonstrict LBBB. However, no previous study has evaluated the frequency of strict LBBB after transcatheter aortic valve replacement (TAVR). The aim of this study was to determine the incidence of developing strict versus nonstrict LBBB after TAVR and test the hypothesis that preprocedure QRS duration does not predict strict LBBB but predicts development of nonstrict LBBB.

Methods

All patients receiving TAVR between 4/2011 and 2/2013 (n = 71) with no preexisting bundle branch block or permanent pacemaker were included. Twelve-lead ECGs were acquired preprocedure and both 1-day and 1-month postprocedure. All ECGs were classified as strict LBBB, nonstrict LBBB, or no LBBB.

Results

Sixty-eight patients had ECGs eligible for final analysis. On postprocedure day 1, 25 (37%) of 68 patients developed strict LBBB, and 2 patients (3%) developed nonstrict LBBB. At 1-month follow-up, the 2 patients diagnosed with nonstrict LBBB had resolved to normal, and 5 (20%) of 25 patients with strict LBBB had resolved to normal. Preprocedure QRS duration did not predict strict LBBB (P = .51). Because of the low incidence of nonstrict LBBB, QRS duration as a predictor of nonstrict LBBB could not be tested.

Conclusions

Almost all patients who developed evidence of LBBB after TAVR met the new strict criteria, indicating probable procedural injury to the left bundle branch. Preprocedural QRS duration did not predict the development of strict LBBB.

Section snippets

Study population

This study is a retrospective observational ECG analysis of 115 consecutive patients with severe symptomatic aortic stenosis who received TAVR at Duke University Medical Center (Durham, NC) between April 2011 and February 2013. Forthy-four patients were excluded for the following reasons: a preexisting permanent pacemaker with ventricular-paced rhythm (n = 16); preexisting right bundle branch block (RBBB) (n = 16); preexisting LBBB, either nonstrict or strict (n = 8); or missing ECGs, either

Results

Three patients had a paced rhythm on the ECG taken 1-day postprocedure due to the presence of a new pacing requirement post-TAVR. These ECGs could not be classified, and the 3 patients were not included in the analysis. A total of 68 patients were included in the final analysis. Baseline characteristics of these 68 patients are presented in the Table. In this table, baseline characteristics are also grouped according to development of strict LBBB, nonstrict LBBB, and no LBBB after TAVR. No

Discussion

The main finding of the current study is that more than one-third of patients developed a strict LBBB 24 hours after TAVR, whereas only 2 patients developed a nonstrict LBBB. In addition, 25% of the patients with a new strict LBBB at 24 hours had resolution of the LBBB at 30-day follow-up ECG. Both patients with nonstrict LBBB showed resolution of the QRS widening at 1 month. These findings are consistent with the conclusion that factors such as baseline LVH and/or LAFB do not explain the

Conclusions

We found that approximately one-third of patients developed strict LBBB 1 day after the TAVR procedure, and 3% developed nonstrict LBBB. Baseline QRS duration did not predict the procedural development of strict LBBB. In approximately 25% of patients who developed an LBBB 24 hours after the procedure, the LBBB resolved at 1-month follow-up. Factors that were expected to influence the accuracy of LBBB diagnosis such as LAFB and LVH were rarely seen in this study. Future prospective studies with

Acknowledgements

The mention of commercial products, their sources, or their use in connection with material reported herein is not to be construed as either an actual or implied endorsement of such products by the Department of Health and Human Services.

References (26)

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