Transesophageal echocardiographic predictors of intraventricular conduction delay in patients undergoing transcatheter aortic valve replacement

Abstract

Introduction Patient anatomical features, such as shorter membranous septum (MS) length, on computed tomography have been shown to predict conduction abnormalities after transcatheter aortic valve replacement (TAVR). This relationship has not yet been evaluated using transesophageal echocardiography (TEE). Our hypothesis is that the distance from the aortic annulus to the septal bulge, a surrogate of MS distance and length, will be associated with a new interventricular conduction delay and heart block post-TAVR. Likewise, we hypothesize an implantation depth of the valve closer to the septal bulge will also predict post-TAVR interventricular conduction delay. Methods Comprehensive intraprocedural echocardiographic data were analyzed retrospectively on 88 patients who underwent TAVR under general anesthesia with TEE. Pre-procedural MS distance and post-procedural implantation depth (quantified as the inferior border of valve to septal bulge) were measured in the mid-esophageal long axis view of the aortic valve in mid-systole. EKGs were evaluated pre-TAVR and immediately post-valve deployment. Univariate logistic regression was used to identify predictors of a need for post-operative pacemaker (PM) implantation and new bundle branch block (BBB). Results The population consisted of 88 patients undergoing TAVR with TEE from 2017-2018 at our institution. The median age was 84, 45/88 (51.1%) were female. After TAVR, 7/88 (7.9%) had PPM placed and 21/88 (23.8%) had a new bundle branch block, transient or permanent. MS length was inversely associated with the risk of developing an interventricular conduction delay after TAVR (OR=0.19, CI 0.05-0.75, p=0.018). As shown in Table 1, the implantation distance was inversely associated with the need for a pacemaker or developing a new interventricular conduction delay after TAVR (OR=0.19, Cl 0.06-0.6, p=0.006). Discussion MS length and valve implantation depth on intraprocedural TEE are inversely associated with the risk of developing conduction abnormalities post-TAVR. TEE assessment may be comparable to CT in predicting post-TAVI high-grade atrioventricular block, and has the additional benefit of being performed intraprocedurally in selected patients.