October 21, 2020Journal of the American College of Cardiology
2020 ACC Expert Consensus Decision Pathway on Management of Conduction Disturbances in Patients Undergoing Transcatheter Aortic Valve Replacement
Why the study?
A consensus strategy for managing cardiac conduction disturbances after TAVR has been elusive due to lack of adequately powered randomized trials and evolving technologies.
Key Points
- Standardized care pathways define clinical surveillance for cardiac conduction disturbances after transcatheter aortic valve replacement, addressing disparate practice styles.
- Expert consensus decision pathway synthesizes available clinical data on electrophysiological testing and pacemaker implantation, filling evidence gaps with expert opinion.
- Highlights the critical need for unified post-procedural protocols in valvular heart disease, establishing institutional guidance for cardiovascular implantable electrical devices.
Structured PICO
P
Population
Patients undergoing transcatheter aortic valve replacement (TAVR) who develop cardiac conduction disturbances
I
Intervention
Management strategies for conduction disturbances (including prolonged observation, electrophysiological testing, and pre-emptive pacemaker implantation)
Limitations
- Absence of adequately powered, randomized controlled trials
- Transient nature of the conduction disturbances
- Evolving technologies
- Interplay of cardiology subspecialties involved
- absence of adequately powered, randomized controlled trials
- often transient nature of the conduction disturbances
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Conduction disturbances after TAVR are common and there is currently heterogeneity in how they're managed, ranging from a casual observational approach to invasive electrophysiological studies and preemptive pacemaker implantation. We felt this kind of collaborative effort to review what little research there is on this topic and come to [an] expert consensus was long overdue.”
Implication
This document provides a US-based expert consensus decision pathway for managing conduction disturbances following TAVR, addressing a gap in current guidelines.
Abstract
Consensus regarding a reasonable strategy to manage cardiac conduction disturbances after transcatheter aortic valve replacement (TAVR) has been elusive. This is due to the absence of adequately powered, randomized controlled trials; the often transient nature of the conduction disturbances; evolving technologies; and the interplay of cardiology subspecialties involved. In the absence of high-quality trials, numerous practice styles have been developed, and prolonged observation, electrophysiological testing, and pre-emptive pacemaker implantation have been described. Although the 2013 European Society of Cardiology guidelines address pacing post-TAVR, they do not provide in-depth discussion of this topic. Furthermore, a summary and proposed strategy for this problem have not been published by cardiovascular societies in the United States, despite an interest in establishing best practices in TAVR, valvular heart disease, and cardiovascular implantable electrical devices. This document reviews existing data and experience regarding the management of conduction disturbances after TAVR and proposes an evidence-based expert consensus decision pathway for their management. Where evidence is lacking or insufficient, the recommendations herein are based on expert opinion.
Coverage & sources
Journal, society, and media accounts. Useful signal, not independent expert judgment.
Discussion
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Cite This Study
Lilly et al. (2020) conducted a review in Cardiac conduction disturbances after transcatheter aortic valve replacement. Management of conduction disturbances was evaluated. An evidence-based expert consensus decision pathway was developed for the management of cardiac conduction disturbances after transcatheter aortic valve replacement.