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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Increased operator experience&#44; advances in transcatheter heart valve technologies and preprocedural planning are among the key factors that have improved outcomes in transcatheter aortic valve implantation &#40;TAVI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> TAVI is now performed not only in elderly&#44; high-risk patients&#44; but also in younger patients with lower surgical risk&#46; These patients have a longer life-expectancy and conduction disturbances such as new left-bundle branch block &#40;LBBB&#41;&#44; new atrioventricular &#40;AV&#41; block&#44; a need for a new permanent pacemaker and new-onset atrial fibrillation &#40;AF&#41; may become increasingly important for periprocedural management&#44; prognosis&#44; and costs&#46; Indeed&#44; several studies have now confirmed that new onset LBBB or the need for a permanent pacemaker have a significant&#44; detrimental association with prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#8211;5</span></a> However&#44; despite advances in biomedical engineering and increased operator experience&#44; the incidence of TAVI-associated new conduction disturbances remains high&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In this issue of the Portuguese Journal of Cardiology&#44; Manuel et al&#46; investigated the incidence and predictors of new conduction disturbances following TAVI&#46; After excluding patients with a preprocedural pacemaker&#44; a postprocedural new permanent pacemaker and those who were lost to follow-up&#44; they observed new-onset AF in 11&#37; and new LBBB in as many as 25&#37; of patients&#46; QRS duration &#40;permanently&#41; and PR interval &#40;transiently&#41; increased after TAVI&#46; This transient PR prolongation is also observed in the general population with normalization in 30&#37; of individuals&#44; without any prognostic relevance&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> They also found that deep &#40;ventricular&#41; valve implantation was significantly associated with new-onset LBBB&#46; This finding&#44; which corroborates previous studies&#44; should encourage operators to aim for a high implantation for most of the currently available transcatheter heart valves&#46; The exception is the ACURATE neo&#44; where an implantation with the inflow 7 mm below the annular level results in optimal sealing without a relevant increase in conduction disturbances&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#8211;9</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">New-onset atrial fibrillation</span><p id="par0015" class="elsevierStylePara elsevierViewall">Calcium deposits&#44; fibrosis and advanced age are risk factors common to severe aortic stenosis and AF&#46; Not surprisingly&#44; about a third of all patients undergoing TAVI have pre-existing AF&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10&#44;11</span></a> An additional 5-10&#37; may have pre-existing&#44; but undetected AF&#46; Previous studies have reported new-onset AF after transcatheter aortic valve replacement &#40;TAVR&#41; in about 7-8&#37; of patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">12&#44;13</span></a> similar to the 11&#37; reported in the study by Manuel et al&#46; Changes in volume state&#44; systemic inflammatory response and non-transfemoral access may all act as a trigger of new onset atrial fibrillation&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> Studies have consistently demonstrated an increased stroke risk in such patients&#46; Indeed&#44; new onset AF after TAVI has been linked to an absolute stroke increment as high as 3&#37; and to increased mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> Early diagnosis and proper treatment of new onset AF is of importance&#44; however scientific evidence guiding optimal anticoagulation management in TAVI patients is scarce&#46; Direct oral anticoagulants appear to be safe and effective in patients with bioprosthetic valves&#44; but not in patients with mechanical prostheses&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> Moreover&#44; data from our group suggest that continuation of oral anticoagulation may be equally safe and efficacious as the interruption of anticoagulation in patients with pre-existing AF undergoing TAVI&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">New-onset left bundle branch block</span><p id="par0020" class="elsevierStylePara elsevierViewall">During TAVR&#44; there is a direct interaction beetween the conduction system and the stiff wire&#44; the balloon&#44; the delivery catheter and the transcatheter heart valve itself&#46; New LBBB is most frequently observed and thus&#44; patients with a pre-existing right bundle branch block are at high risk for the development of an intra- or postprocedural high-grade AV block&#46; Identification of new LBBB is important as it may progress further to a delayed high-grade AVblock&#46; Also&#44; studies have consistently associated new LBBB with an increased risk for sudden cardiac death&#44; reduced left ventricular ejection fraction and heart failure&#44; especially in patients with a long QRS duration&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#8211;4</span></a> Choice of prosthesis&#44; depth of implantation and the degree of oversizing are the main predictors of new LBBB&#46; Indeed the risk of a new LBBB shows a relative increase of &#8764;20-30&#37; per 1 mm of implantation depth&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> To achieve a high implantation with self-expanding valves&#44; the cusp-overlap technique has become popular&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> With this technique &#40;often a right anterior oblique&#47;caudal projection&#41;&#44; the right and the left coronary cusps are overlapped and the non-coronary cusp is used as a reference for implantation depth&#46; This technique enables a high implantation and at the same time mitigates the risk of device pop-out&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">The continuing importance of postprocedural monitoring</span><p id="par0025" class="elsevierStylePara elsevierViewall">In recent years&#44; physicians have attempted to simplify and streamline the procedure and early discharge has been advocated to reduce the duration of hospitalization and healthcare costs&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> However&#44; this should not come at the price of patient safety and we should not forget that postprocedural conduction disorders are frequent complications&#46; Therefore&#44; it appears reasonable to monitor patients for 24-48 hours after TAVI&#46; Finally&#44; negative dromotropic medication such as betablockers&#44; verapamil&#44; amiodarone or digoxin should be discontinued periprocedurally to reduce the incidence of high-degree AV blocks and the need for a permament pacemaker&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;17</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">ST is a consultant and proctor for Boston Scientific&#44; New Valve Technology and Abbott Vascular&#46; He has received institutional research grants from <span class="elsevierStyleGrantSponsor" id="gs1">Boston Scientific</span> and <span class="elsevierStyleGrantSponsor" id="gs2">Fumedica</span>&#44; has received speaker honoraria from Medtronic&#46; He holds equity in Hi-D Imaging&#46;</p></span></span>"
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Editorial comment
Transcatheter aortic valve implantation-associated conduction disturbances are moving to center stage
Perturbações da condução associadas a implantação percutânea valvular aórtica: em trânsito para o palco central
Stefan Toggweiler
Autor para correspondência
stefan.toggweiler@luks.ch

Corresponding author.
, Benjamin Berte
Heart Center Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland
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    "titulo" => "Transcatheter aortic valve implantation-associated conduction disturbances are moving to center stage"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Increased operator experience&#44; advances in transcatheter heart valve technologies and preprocedural planning are among the key factors that have improved outcomes in transcatheter aortic valve implantation &#40;TAVI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> TAVI is now performed not only in elderly&#44; high-risk patients&#44; but also in younger patients with lower surgical risk&#46; These patients have a longer life-expectancy and conduction disturbances such as new left-bundle branch block &#40;LBBB&#41;&#44; new atrioventricular &#40;AV&#41; block&#44; a need for a new permanent pacemaker and new-onset atrial fibrillation &#40;AF&#41; may become increasingly important for periprocedural management&#44; prognosis&#44; and costs&#46; Indeed&#44; several studies have now confirmed that new onset LBBB or the need for a permanent pacemaker have a significant&#44; detrimental association with prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#8211;5</span></a> However&#44; despite advances in biomedical engineering and increased operator experience&#44; the incidence of TAVI-associated new conduction disturbances remains high&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In this issue of the Portuguese Journal of Cardiology&#44; Manuel et al&#46; investigated the incidence and predictors of new conduction disturbances following TAVI&#46; After excluding patients with a preprocedural pacemaker&#44; a postprocedural new permanent pacemaker and those who were lost to follow-up&#44; they observed new-onset AF in 11&#37; and new LBBB in as many as 25&#37; of patients&#46; QRS duration &#40;permanently&#41; and PR interval &#40;transiently&#41; increased after TAVI&#46; This transient PR prolongation is also observed in the general population with normalization in 30&#37; of individuals&#44; without any prognostic relevance&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> They also found that deep &#40;ventricular&#41; valve implantation was significantly associated with new-onset LBBB&#46; This finding&#44; which corroborates previous studies&#44; should encourage operators to aim for a high implantation for most of the currently available transcatheter heart valves&#46; The exception is the ACURATE neo&#44; where an implantation with the inflow 7 mm below the annular level results in optimal sealing without a relevant increase in conduction disturbances&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#8211;9</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">New-onset atrial fibrillation</span><p id="par0015" class="elsevierStylePara elsevierViewall">Calcium deposits&#44; fibrosis and advanced age are risk factors common to severe aortic stenosis and AF&#46; Not surprisingly&#44; about a third of all patients undergoing TAVI have pre-existing AF&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10&#44;11</span></a> An additional 5-10&#37; may have pre-existing&#44; but undetected AF&#46; Previous studies have reported new-onset AF after transcatheter aortic valve replacement &#40;TAVR&#41; in about 7-8&#37; of patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">12&#44;13</span></a> similar to the 11&#37; reported in the study by Manuel et al&#46; Changes in volume state&#44; systemic inflammatory response and non-transfemoral access may all act as a trigger of new onset atrial fibrillation&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> Studies have consistently demonstrated an increased stroke risk in such patients&#46; Indeed&#44; new onset AF after TAVI has been linked to an absolute stroke increment as high as 3&#37; and to increased mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> Early diagnosis and proper treatment of new onset AF is of importance&#44; however scientific evidence guiding optimal anticoagulation management in TAVI patients is scarce&#46; Direct oral anticoagulants appear to be safe and effective in patients with bioprosthetic valves&#44; but not in patients with mechanical prostheses&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> Moreover&#44; data from our group suggest that continuation of oral anticoagulation may be equally safe and efficacious as the interruption of anticoagulation in patients with pre-existing AF undergoing TAVI&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">New-onset left bundle branch block</span><p id="par0020" class="elsevierStylePara elsevierViewall">During TAVR&#44; there is a direct interaction beetween the conduction system and the stiff wire&#44; the balloon&#44; the delivery catheter and the transcatheter heart valve itself&#46; New LBBB is most frequently observed and thus&#44; patients with a pre-existing right bundle branch block are at high risk for the development of an intra- or postprocedural high-grade AV block&#46; Identification of new LBBB is important as it may progress further to a delayed high-grade AVblock&#46; Also&#44; studies have consistently associated new LBBB with an increased risk for sudden cardiac death&#44; reduced left ventricular ejection fraction and heart failure&#44; especially in patients with a long QRS duration&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#8211;4</span></a> Choice of prosthesis&#44; depth of implantation and the degree of oversizing are the main predictors of new LBBB&#46; Indeed the risk of a new LBBB shows a relative increase of &#8764;20-30&#37; per 1 mm of implantation depth&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> To achieve a high implantation with self-expanding valves&#44; the cusp-overlap technique has become popular&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> With this technique &#40;often a right anterior oblique&#47;caudal projection&#41;&#44; the right and the left coronary cusps are overlapped and the non-coronary cusp is used as a reference for implantation depth&#46; This technique enables a high implantation and at the same time mitigates the risk of device pop-out&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">The continuing importance of postprocedural monitoring</span><p id="par0025" class="elsevierStylePara elsevierViewall">In recent years&#44; physicians have attempted to simplify and streamline the procedure and early discharge has been advocated to reduce the duration of hospitalization and healthcare costs&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> However&#44; this should not come at the price of patient safety and we should not forget that postprocedural conduction disorders are frequent complications&#46; Therefore&#44; it appears reasonable to monitor patients for 24-48 hours after TAVI&#46; Finally&#44; negative dromotropic medication such as betablockers&#44; verapamil&#44; amiodarone or digoxin should be discontinued periprocedurally to reduce the incidence of high-degree AV blocks and the need for a permament pacemaker&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;17</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">ST is a consultant and proctor for Boston Scientific&#44; New Valve Technology and Abbott Vascular&#46; He has received institutional research grants from <span class="elsevierStyleGrantSponsor" id="gs1">Boston Scientific</span> and <span class="elsevierStyleGrantSponsor" id="gs2">Fumedica</span>&#44; has received speaker honoraria from Medtronic&#46; He holds equity in Hi-D Imaging&#46;</p></span></span>"
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Informação do artigo
ISSN: 08702551
Idioma original: Inglês
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2024 Outubro 44 28 72
2024 Setembro 55 24 79
2024 Agosto 44 29 73
2024 Julho 51 29 80
2024 Junho 42 23 65
2024 Maio 32 21 53
2024 Abril 34 27 61
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2024 Fevereiro 31 22 53
2024 Janeiro 34 23 57
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2023 Outubro 30 21 51
2023 Setembro 26 22 48
2023 Agosto 21 18 39
2023 Julho 31 11 42
2023 Junho 34 13 47
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2023 Abril 18 1 19
2023 Maro 24 24 48
2023 Fevereiro 26 19 45
2023 Janeiro 17 20 37
2022 Dezembro 21 26 47
2022 Novembro 36 28 64
2022 Outubro 28 19 47
2022 Setembro 28 31 59
2022 Agosto 23 26 49
2022 Julho 37 35 72
2022 Junho 33 31 64
2022 Maio 54 39 93
2022 Abril 37 28 65
2022 Maro 31 46 77
2022 Fevereiro 19 26 45
2022 Janeiro 22 25 47
2021 Dezembro 16 35 51
2021 Novembro 31 32 63
2021 Outubro 37 50 87
2021 Setembro 23 29 52
2021 Agosto 31 34 65
2021 Julho 20 34 54
2021 Junho 28 16 44
2021 Maio 31 38 69
2021 Abril 48 68 116
2021 Maro 42 40 82
2021 Fevereiro 27 22 49
2021 Janeiro 45 31 76
2020 Dezembro 37 35 72
2020 Novembro 37 32 69
2020 Outubro 50 39 89
2020 Setembro 88 62 150
2020 Agosto 51 35 86
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