Baseline bundle branch block and clinical outcomes after surgical aortic valve replacement: A nationwide Danish digital electrocardiogram cohort study

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Severe aortic stenosis or aortic regurgitation requiring surgical aortic valve replacement (SAVR) (n=7433). Intervention: Baseline right bundle branch block (RBBB) vs. No bundle branch block. Primary outcome: Permanent pacemaker implantation at 30 days (aHR 2.50, 95% CI 1.67-3.67).

Q: What does this research mean for the field?

Pre-existing right bundle branch block increases the risk of 30-day permanent pacemaker implantation by 2.5-fold following surgical aortic valve replacement compared to no bundle branch block. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

Daniel Kjærgaard Steiner; Maria Lukács Krogager; Christoffer Polcwiartek; Claus Graff; Mikkel Porsborg Andersen; Helle Collatz Christensen; Carsten S. Simonsen; Emil Loldrup Fosbøl; Ivy Susanne Modrau; Lars Peter Riber; Christian Lildal Carranza; Ole De Backer; Gintautas Bieliauskas; Michael Vinther; Jacob Moesgaard Larsen; Christian Juhl Terkelsen; Jens Cosedis Nielsen; Henrik Nissen; Christian Torp-Pedersen; Kristian Hay Kragholm; Ashkan Eftekhari

doi:10.1016/j.ijcard.2026.134937

Key result

Pre-existing right bundle branch block increased the risk of permanent pacemaker implantation at 30 days following surgical aortic valve replacement by 2.5-fold compared to no bundle branch block.

Why the study?

Baseline bundle branch block is a known predictor of atrioventricular block requiring permanent pacemaker after TAVI, but its impact after surgical aortic valve replacement is unclear.

Does pre-existing bundle branch block increase the risk of permanent pacemaker implantation in patients undergoing surgical aortic valve replacement?

Key Points

To evaluate the association between baseline right or left bundle branch block and clinical outcomes, including pacemaker implantation, mortality, and heart failure, in patients undergoing surgical aortic valve replacement.
Nationwide Danish digital electrocardiogram cohort study of N=7433 first-time surgical aortic valve replacement patients (mean age 71 years, 70% males).
Pre-existing bundle branch block was assessed on the latest preoperative electrocardiogram, identifying 479 patients (6%) with right bundle branch block and 425 (6%) with left bundle branch block.
Outcomes included 30-day permanent pacemaker implantation, all-cause mortality, and new-onset heart failure (evaluated in N=6037 patients without baseline heart failure), analyzed using cause-specific Cox regression.
Permanent pacemaker implantation at 30 days occurred in 6.9% (33/479) of patients with right bundle branch block (aHR 2.50; 95% CI: 1.67–3.67) and 5.4% (23/425) with left bundle branch block (aHR 2.02; 95% CI: 1.30–3.14).

Study Design

Type

Cohort (n=7,433)

Multicenter

Yes

Structured PICO

Does pre-existing bundle branch block increase the risk of permanent pacemaker implantation in patients undergoing surgical aortic valve replacement?

P

Population

7,433 adults (mean age 71, 30% female) undergoing first-time surgical aortic valve replacement with an available preoperative ECG, followed for up to 1 year.

E

Exposure

Pre-existing bundle branch block (RBBB or LBBB) on preoperative electrocardiogram

C

Comparator

No baseline bundle branch block on preoperative electrocardiogram

O

Outcome

Postoperative permanent pacemaker (PM) implantation at 30, 90, and 365 dayshard clinical

Main Result

Hazard Ratio: 2.5 (95% CI 1.67–3.67)

Absolute Event Rate: 6.9% vs 2.7%

Limitations

Lack of detailed intraoperative variables (e.g., valve size, cross-clamp time, cardiopulmonary bypass duration)
Potential residual confounding despite multivariable adjustment
Lack of detailed information on pacing indication and device dependency
ECG diagnoses were based on automated interpretation without systematic physician overread
Exclusion of patients without baseline ECG data may introduce temporal differences
Lack of detailed intraoperative variables (valve size, bypass duration)
Residual confounding cannot be excluded
Information on pacing indication and device dependency was not available
Automated ECG interpretation without systematic physician overread
Excluding patients without baseline ECG data introduced temporal differences

Implication

Baseline bundle branch block in patients undergoing surgical aortic valve replacement predicts an increased risk for postoperative permanent pacemaker implantation, with left bundle branch block also conferring a higher risk for new-onset heart failure.

Abstract

Surgical aortic valve replacement (SAVR) is an established treatment option for patients with severe aortic stenosis and remains the definitive treatment in patients with aortic regurgitation when intervention is needed [1–3]. In most of the pivotal randomized trials of transcatheter aortic valve implantation (TAVI), SAVR was associated with lower rates of permanent pacemaker (PM) implantation [4–6]. In the TAVI population, baseline right bundle branch block (RBBB) has been established as a strong predictor of atrioventricular block (AVB) with need for subsequent permanent PM [7–10].

Discussion

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Cite This Study

Steiner et al. (2026) conducted a cohort in Severe aortic stenosis or aortic regurgitation requiring surgical aortic valve replacement (SAVR) (n=7,433). Baseline right bundle branch block (RBBB) vs. No bundle branch block was evaluated on Permanent pacemaker implantation at 30 days (aHR 2.50, 95% CI 1.67-3.67). Pre-existing right bundle branch block increased the risk of permanent pacemaker implantation at 30 days following surgical aortic valve replacement by 2.5-fold compared to no bundle branch block.

synapsesocial.com/papers/6ad0fd4715427f6a84040638 https://doi.org/10.1016/j.ijcard.2026.134937

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Baseline bundle branch block and clinical outcomes after surgical aortic valve replacement: A nationwide Danish digital electrocardiogram cohort study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Baseline bundle branch block and clinical outcomes after surgical aortic valve replacement: A nationwide Danish digital electrocardiogram cohort study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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