Transcatheter Aortic Valve Replacement

Cardiac Resynchronization Therapy Improved Heart Failure After Left Bundle Branch Block During Transcatheter Aortic Valve Implantation

Kentaro Meguro, MD, PhD, Nicolas Lellouche, MD, PhD, Emmanuel Teiger, MD, PhD

Kentaro Meguro, MD, PhD, Nicolas Lellouche, MD, PhD, Emmanuel Teiger, MD, PhD

Abstract: After transcatheter aortic valve implantation (TAVI) in a 75-year-old male, chronic wide left bundle branch block (LBBB) developed. He experienced repeated episodes of decompensated systolic heart failure with severe systolic left ventricular dysfunction. After cardiac resynchronization therapy, his heart function improved substantially and he had no further admissions for heart failure. Cardiac resynchronization therapy can be effective in systolic heart failure associated with LBBB developing after TAVI.

J INVASIVE CARDIOL 2012;24:132–133

Key words: heart failure, valvular heart disease, cardiac resynchronization therapy

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Electrical conduction abnormalities are common following transcatheter aortic valve implantation (TAVI). Among them, left bundle branch block (LBBB) develops in approximately 30% of cases1-4 and requires a permanent pacemaker in up to one-third of patients.1,5-7 Moreover, LBBB can worsen systolic left ventricular (LV) function, leading to systolic heart failure.8,9 The potential benefits of cardiac resynchronization therapy (CRT) in this situation remain unclear. We describe successful CRT therapy in a patient with symptomatic systolic heart failure and LBBB after TAVI.

Case Report

A 75-year-old man presented with angina and dyspnea (New York Heart Association III). He had a history of acute anterior wall myocardial infarction and was treated with drug-eluting stents in the proximal left anterior descending, proximal left circumflex (LCX), and proximal right coronary artery (RCA) two years ago because the LCX and RCA also showed severe stenosis.

No restenosis was found by coronary angiography, but transthoracic echocardiography revealed severe aortic valve stenosis (mean gradient, 37 mm Hg; peak gradient, 58 mm Hg; and aortic valve surface area, 0.7 cm2) and decreased left ventricular ejection fraction (LVEF; 30%). He was referred to our center for aortic valve stenosis management.

Despite moderate values for the Logistic Euroscore (13.94%), conventional open-chest aortic valve replacement was considered unsafe by two cardiac surgeons because the patient had a history of acute mesenteric infarction in 2003 and comorbidity of Parkinson’s disease. TAVI was therefore performed with a 29 mm self-expanding CoreValve ReValving System (Medtronic) implanted via the left femoral artery. Immediately after TAVI, LBBB occurred (QRS duration increased from 118 to 180 msec, Figures 1A and 1B). The patient was discharged from our unit 7 days after the procedure.

However, 1 month after the index procedure, the patient was admitted for acute decompensated heart failure (HF). Transthoracic echocardiography revealed normal prosthesis function (mean gradient, 6 mm Hg; peak gradient, 12 mm Hg; and aortic valve surface area, 2.3 cm2), severe LV dysfunction (LVEF, 25%), and abnormal diastolic indices indicating high left-chamber filling pressures. 

Over the next 9 months, he was admitted 3 times for acute pulmonary edema. Electrocardiogram (ECG) still showed LBBB and LVEF was unchanged despite optimal medical therapy. A CRT defibrillator (CRT-D) device (Concerto II; Medtronic) was implanted, according to international guidelines.10,11 We placed an atrial lead in the right atrial appendage, a right ventricular lead in the right ventricular septum, and an LV lead (Attain OTW; Medtronic) in the posterolateral coronary sinus branch. The pacemaker was programmed in DDD mode with a short atrioventricular delay to maximize the percentage of biventricular stimulations. The atrioventricular and interventricular delays were programmed during transthoracic echocardiography to optimize diastolic and systolic LV function. QRS duration decreased to 145 msec under biventricular stimulation (Figure 1C). The N-Terminal Pro-B Type natriuretic peptide concentration, LV diastolic diameter (LVDd), and LVEF, which had not changed after TAVI, improved 3 months after CRT-D implantation (Figure 2). The New York Heart Association class improved from III to II and no admissions were required over the next 10 months.

Discussion

TAVI is effective for high-risk surgical patients with severe symptomatic aortic stenosis.12-15 However, the mid- and long-term outcomes of TAVI remain unclear and need to be evaluated in prospective randomized studies.

In this case, the patient didn’t require hospitalization after implantation of CRT, and CRT seemed to be effective to improve cardiac function. It is also possible that TAVI was effective for the improvement of cardiac function because LVDd and LVEF improved slightly prior to CRT placement. Therefore, it is reasonable to think that the combination therapy of CRT and TAVI was effective for the treatment of heart failure in this patient.

Electrical conduction disturbances are common after TAVI. Among them, LBBB has been reported in 3%-45% of cases.1-4 Additionally, the main cause of death following TAVI is the occurrence of cardiovascular complications such as heart failure.13,16 The prognostic significance of post-TAVI LBBB is unclear. However, after surgical aortic valve replacement, LBBB is independently associated with an increased risk of adverse cardiac events.17,18 LBBB is also a strong independent predictor of mortality and morbidity in patients with systolic heart failure.9,19,20 Thus, the high rate of LBBB after TAVI would be expected to contribute to a deterioration in systolic LV function, particularly in patients with preexisting LV dysfunction.15,21 The pathophysiology of LBBB development after TAVI is obscure, but may involve deeper prosthesis implantation2,4 responsible for intraventricular conduction disturbances.

The course of post-TAVI LBBB is not well known, but cases of spontaneous resolution have been described.2,4 However, our patient had stable LBBB 10 months after TAVI, indicating that the disorder was chronic. CRT is a recognized treatment modality for symptomatic systolic heart failure and LBBB.11,22-24 Thus, CRT may hold promise for improving long-term outcomes in TAVI patients. However, LBBB can resolve shortly after TAVI, and CRT should be considered only in patients with chronic LV dysfunction and LBBB. The best time for CRT and the potential contribution of CRT to post-TAVI management need to be evaluated.

Conclusion

CRT was performed successfully in a patient with repeated admissions for decompensated systolic heart failure after post-TAVI LBBB. The exact indications of CRT following TAVI need to be clarified.

References

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From the Interventional Cardiology Unit, Henri Mondor University Hospital, Val-de-Marne University, Creteil, France.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted October 28, 2011, provisional acceptance given November 1, 2011, final version accepted November 7, 2011.
Address for correspondence: Kentaro Meguro, MD, PhD, Interventional Cardiology Unit, Henri Mondor University Hospital, Val-de-Marne University, 51 Avenue du Marechal de Lattre de Tassigny, 94010 Creteil, France. Email: meguro@med.email.ne.jp