The impact of trans-catheter aortic valve replacement induced left-bundle branch block on cardiac reverse remodeling

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Abstract

Background

Left bundle branch block (LBBB) is common following trans-catheter aortic valve replacement (TAVR) and has been linked to increased mortality, although whether this is related to less favourable cardiac reverse remodeling is unclear. The aim of the study was to investigate the impact of TAVR induced LBBB on cardiac reverse remodeling.

Methods

48 patients undergoing TAVR for severe aortic stenosis were evaluated. 24 patients with new LBBB (LBBB-T) following TAVR were matched with 24 patients with a narrow post-procedure QRS (nQRS). Patients underwent cardiovascular magnetic resonance (CMR) prior to and 6 m post-TAVR. Measured cardiac reverse remodeling parameters included left ventricular (LV) size, ejection fraction (LVEF) and global longitudinal strain (GLS). Inter- and intra-ventricular dyssynchrony were determined using time to peak radial strain derived from CMR Feature Tracking.

Results

In the LBBB-T group there was an increase in QRS duration from 96 ± 14 to 151 ± 12 ms ( P < 0.001) leading to inter- and intra-ventricular dyssynchrony (inter: LBBB-T 130 ± 73 vs nQRS 23 ± 86 ms, p < 0.001; intra: LBBB-T 118 ± 103 vs. nQRS 13 ± 106 ms, p = 0.001). Change in indexed LV end-systolic volume (LVESVi), LVEF and GLS was significantly different between the two groups (LVESVi: nQRS -7.9 ± 14.0 vs. LBBB-T -0.6 ± 10.2 ml/m ², p = 0.02, LVEF: nQRS +4.6 ± 7.8 vs LBBB-T -2.1 ± 6.9%, p = 0.002; GLS: nQRS -2.1 ± 3.6 vs. LBBB-T +0.2 ± 3.2%, p = 0.024). There was a significant correlation between change in QRS and change in LVEF ( r = -0.434, p = 0.002) and between change in QRS and change in GLS ( r = 0.462, p = 0.001). Post-procedure QRS duration was an independent predictor of change in LVEF and GLS at 6 months.

Conclusion

TAVR-induced LBBB is associated with less favourable cardiac reverse remodeling at medium term follow up. In view of this, every effort should be made to prevent TAVR-induced LBBB, especially as TAVR is now being extended to a younger, lower risk population.

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Most cited references 18

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Cardiac dyssynchrony analysis using circumferential versus longitudinal strain: implications for assessing cardiac resynchronization.

Albert C. Lardo, Christophe Leclercq, P Faris … (2005)

QRS duration is commonly used to select heart failure patients for cardiac resynchronization therapy (CRT). However, not all patients respond to CRT, and recent data suggest that direct assessments of mechanical dyssynchrony may better predict chronic response. Echo-Doppler methods are being used increasingly, but these principally rely on longitudinal motion (epsilonll). It is unknown whether this analysis yields qualitative and/or quantitative results similar to those based on motion in the predominant muscle-fiber orientation (circumferential; epsiloncc). Both epsilonll and epsiloncc strains were calculated throughout the left ventricle from 3D MR-tagged images for the full cardiac cycle in dogs with cardiac failure and a left bundle conduction delay. Dyssynchrony was assessed from both temporal and regional strain variance analysis. CRT implemented by either biventricular (BiV) or left ventricular-only (LV) pacing enhanced systolic function similarly and correlated with improved dyssynchrony based on epsiloncc-based metrics. In contrast, longitudinal-based analyses revealed significant resynchronization with BiV but not LV for the overall cycle and correlated poorly with global functional benefit. Furthermore, unlike circumferential analysis, epsilonll-based indexes indicated resynchronization in diastole but much less in systole and had a lower dynamic range and higher intrasubject variance. Dyssynchrony assessed by longitudinal motion is less sensitive to dyssynchrony, follows different time courses than those from circumferential motion, and may manifest CRT benefit during specific cardiac phases depending on pacing mode. These results highlight potential limitations to epsilonll-based analyses and support further efforts to develop noninvasive synchrony measures based on circumferential deformation.

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Left bundle-branch block induced by transcatheter aortic valve implantation increases risk of death.

Patrick Houthuizen, Leen A F M Van Garsse, Thomas T Poels … (2012)

Transcatheter aortic valve implantation (TAVI) is a novel therapy for treatment of severe aortic stenosis. Although 30% to 50% of patients develop new left bundle-branch block (LBBB), its effect on clinical outcome is unclear.

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Left bundle branch block as a risk factor for progression to heart failure.

Philippe Ritter, Faiez Zannad, Paul van Helden … (2007)

The prevalence of conduction disturbances, particularly left bundle branch block (LBBB), is strongly correlated with age and with the presence of cardiovascular disease. LBBB has been reported to affect approximately 25% of the heart failure (HF) population and it is likely that the deleterious role of such conduction disorders in the progression to HF has been underestimated. The purpose of this article is to review the data from the literature indicating that LBBB may have a causative role, mediated through the resulting intra-ventricular asynchrony, in the deterioration of cardiac function and the development of cardiac remodelling and HF. It also aims to address the potential for future clinical therapies for this conduction disorder.

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Author and article information

Contributors

Laura E. Dobson: l.dobson@leeds.ac.uk

Tarique A. Musa: t.a.musa@leeds.ac.uk

Akhlaque Uddin: a.uddin@leeds.ac.uk

Timothy A. Fairbairn: timothy.fairbairn@lhch.nhs.uk

Owen J. Bebb: owenbebb@doctors.org.uk

Peter P. Swoboda: p.swoboda@leeds.ac.uk

Philip Haaf: Philip.haaf@usb.ch

James Foley: j.foley@leeds.ac.uk

Pankaj Garg: p.garg@leeds.ac.uk

Graham J. Fent: g.j.fent@leeds.ac.uk

Christopher J. Malkin: Christopher.malkin@nhs.net

Daniel J. Blackman: Daniel.blackman1@nhs.net

Sven Plein: s.plein@leeds.ac.uk

John P. Greenwood: +44113 3925909 , j.greenwood@leeds.ac.uk

Journal

Journal ID (nlm-ta): J Cardiovasc Magn Reson

Journal ID (iso-abbrev): J Cardiovasc Magn Reson

Title: Journal of Cardiovascular Magnetic Resonance

Publisher: BioMed Central (London )

ISSN (Print): 1097-6647

ISSN (Electronic): 1532-429X

Publication date (Electronic): 22 February 2017

Publication date PMC-release: 22 February 2017

Publication date Collection: 2017

Volume: 19

Electronic Location Identifier: 22

Affiliations

[1 ]ISNI 0000 0004 1936 8403, GRID grid.9909.9, Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), , University of Leeds, ; Clarendon Way, Leeds, LS2 9JT UK

[2 ]ISNI 0000 0000 9965 1030, GRID grid.415967.8, Department of Cardiology, , Leeds Teaching Hospitals NHS Trust, ; Leeds, LS1 3EX UK

Article

Publisher ID: 335

DOI: 10.1186/s12968-017-0335-9

PMC ID: 5320804

PubMed ID: 28222749

SO-VID: 882ad5a5-695e-4d4e-866d-17341cd5fb77

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 24 January 2017

Date accepted : 2 February 2017

Custom metadata

ScienceOpen disciplines: Cardiovascular Medicine

Keywords: aortic valve stenosis,trans-catheter aortic valve implantation,left bundle branch block,ventricular ejection fraction,ventricular remodeling,cardiovascular magnetic resonance

Data availability:

ScienceOpen disciplines: Cardiovascular Medicine

Keywords: aortic valve stenosis, trans-catheter aortic valve implantation, left bundle branch block, ventricular ejection fraction, ventricular remodeling, cardiovascular magnetic resonance

The impact of trans-catheter aortic valve replacement induced left-bundle branch block on cardiac reverse remodeling

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Karger: Cardiovascular System

Most cited references 18

Cardiac dyssynchrony analysis using circumferential versus longitudinal strain: implications for assessing cardiac resynchronization.

Left bundle-branch block induced by transcatheter aortic valve implantation increases risk of death.

Left bundle branch block as a risk factor for progression to heart failure.

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