TAVI : qui et quand mettre un pace-maker ? C. GUENANCIA SERVICE DE - PowerPoint PPT Presentation

TAVI :à qui et quand mettre un pace-maker ? C. GUENANCIA SERVICE DE CARDIOLOGIE CHU DIJON

Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une rémunération ou des redevances ou des octrois de recherche d'une société commerciale : I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Affiliation/Financial Relationship None

Conduction disorders : why ? Nicolo Piazza et al, JACC: Cardiovascular Interventions, Volume 1, Issue 3, 2008, 310 – 316

Auffret, V. et al. J Am Coll Cardiol. 2017;70(1):42 – 55.

Permanent pacemaker implantation : predictive factors Siontis et al. JACC 64:129-140 (2014)

PPI : prognostic value Mohananey et al. Circ Cardiovasc Interv 2017;10

2 critical questions ! ? What ar are th the con onduction ab abnormali litie ies th that ab absolutely require th the plac lacement of of a a devi vice? = = who ? ? ? When is is it it reas asonable to o pla lace a a pac acing devic ice? = When is is th the in inju jury ry to o th the conduction system con onsid idered irr irreversib ible le?

Pacemakers after TAVI : who ? AV block LBBB • RBBB

High degree AV block 50 to 70 % of patients will (at least partly) recover …

Why ? Bjerre Thygesen et al. J Invasive Cardiol 2014;26(2):94-99

Predictors of long-term persistence of complete AVB 102 patients PPI after TAVI for CAVB 22% persistent CAVB at 1 year ◦ Previous RBBB ◦ Post dilatation ◦ Higher mean aortic valve gradient prior to implantation 27% Vpace <5% ◦ Degree of acute AV block Gaede et al. Clin Res Cardiol. 2018; 107:60 – 69

QRS duration and delayed AVB 39% vs 0% ! Takahashi et al. http://dx.doi.org/10.1016/j.amjcard.2017.05.050

Left bundle branch block and pacemaker Ando et al. Clin Cardiol. 39,9:544 – 550 (2016)

Left bundle branch block : evolution Nishiyamaet al. Int J Cardiol. 227:25 – 29 (2017)

LBBB and Delta PR >20 ms EPS was performed a median of 6 (range 2 – 210, mean 13.3 ±38) days after TAVI Tovia-Brodie et al. J Interv Card Electrophysiol (2017) 48:121 – 130

LBBB and Electro Physiologic Study Delta-HV ≧ 13 ms HV after TAVI >65 ms Rivard et al. Heart Rhythm 12:321 – 329 (2015)

Permanent pacemaker implantation : predictive factors of PM indication at 1 year Naveh et al. J Cardiovasc Electrophysiol. 2016 Dec 12. doi: 10.1111/jce.13147

RBBB without PM implantation Auffret et al. JACC: Cardiovascular Interventions 2017

Pacemaker after TAVI : when ? Preexisting conductive disturbances (RBBB!): ◦ Before ? ◦ Early if additional conductive troubles Auffret et al. Circulation. 2017;136:1049 – 1069.

LBBB Auffret et al. Circulation. 2017;136:1049 – 1069.

AV BLOCK > 48 h in ICU Auffret et al. Circulation. 2017;136:1049 – 1069.

Take-home messages LBBB is associated with higher PPI rates and lower LVEF ◦ Watchful waiting ◦ Delta PR and QRS length ! ◦ EP study ? RBBB without PM : careful !

Take-home messages High Degree AVB ◦ Preexisting conductive disturbances (RBBB++) ? ◦ Post dilatation ? ◦ Low rate of escape rhythm ? If none of these criteria, wait at least 48 hours before PPI