Podcast 1004: Sinus Arrest Post TAVR

Contributor: Taylor Lynch, MD

Educational Pearls:

Conduction abnormalities are a common and clinically significant complication in patients who undergo transcatheter aortic valve replacement (TAVR)

Clinical Features

• The most common abnormalities include high grade AV block and new onset LBBB

• Due to the close proximity of the aortic annulus to the AV node and His-Purkinje system

• More common in males, the elderly, and those with pre-existing conduction disease (RBBB or LBBB)

• Sinus pauses and sinus arrest are a rare post-TAVR rhythm disturbances

• Temporary failure of sinus node firing with absent P waves, followed by return of sinus rhythm

• Sinus Pauses: Typically last < 3 seconds

• Sinus Arrest: Typically last > 3 seconds

• Not due to direct mechanical injury from the valve, but may occur in patients as a result of pre-existing disease or other external factors:

• Medications

• Beta blockers, calcium channel blockers, digoxin

• Pre-existing damage to the SA node

• Fibrosis from a previous MI

Treatment

• If the patient is asymptomatic, provide ongoing surveillance

• If the patient is symptomatic, treatment should be aimed at the underlying cause:

• For medication-induced abnormalities, stop the offending medication

• For acute, unstable bradycardia:

• Medications: Atropine, Dopamine Infusion, Epinephrine Infusion

• If cardiology is not immediately available, initiate transcutaneous pacing or insert a temporary transvenous pacemaker

• Definitive treatment: Pacemaker

• ~10–15% of patients may develop a bradyarrhythmia post TAVR, with ~8-15% later requiring a pacemaker

Due to the risk of conduction abnormalities post TAVR, many patients are discharged with ambulatory rhythm monitoring such as a ZioPatch or Holter monitor, and may present to the emergency department for evaluation of rhythm disturbances.

References:

1. Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. Heart Rhythm. 2019;16(9):e128-e226.

2. Lilly, S, Deshmukh, A, Epstein, A. et al. 2020 ACC Expert Consensus Decision Pathway on Management of Conduction Disturbances in Patients Undergoing Transcatheter Aortic Valve Replacement: A Report of the American College of Cardiology Solution Set Oversight Committee. JACC. 2020 Nov, 76 (20) 2391–2411.

https://doi.org/10.1016/j.jacc.2020.08.050

1. Sammour, Y, Krishnaswamy, A, Kumar, A. et al. Incidence, Predictors, and Implications of Permanent Pacemaker Requirement After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol Intv. 2021 Jan, 14 (2) 115–134.

https://doi.org/10.1016/j.jcin.2020.09.063

1. Tarakji KG, Patel D, Krishnaswamy A, et al. Bradyarrhythmias detected by extended rhythm recording in patients undergoing transcatheter aortic valve replacement (Brady-TAVR Study). Heart Rhythm. 2022;19(3):381-388.

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P

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