Prospective Validation of a Pre-Specified Algorithm for the Management of Conduction Disturbances Following TAVR (PROMOTE)

Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Quebec

Status: Enrolling

Conditions: Conduction Disturbances; Transcatheter Aortic Valve Replacement; Permanent Pacemaker Implantation

Study type: Observational

Funder types: Other

Identifiers

NCT04139616

PROMOTE

Details and patient eligibility

About

The high incidence and variety of conduction disturbances post-TAVR represents a major challenge in the periprocedural management of TAVR recipients. Despite the growing body of knowledge on this topic, the large variability in the management of these complications has translated into a high degree of uncertainty regarding the most appropriate treatment of a large proportion of such patients. The implementation of a pre-specified treatment strategy translating into a more uniform practice regarding the management of conduction disturbances post-TAVR applied to a large cohort of patients would permit to identify the benefits and drawbacks of each specific aspect of the treatment algorithm proposal. This may also help to improve both the management and clinical outcomes of the complex group of patients with conduction disturbances associated with TAVR. In the end, the final objective of a pre-specified strategy for managing conduction disturbances post-TAVR should be to obtain a low rate of PPM without increasing the risk of sudden death or life threatening arrhythmic events following hospital discharge, and all this while avoiding an excessive prolongation of the hospitalization period following the TAVR procedure.

Full description

The objectives of the study are:

• Feasibility: to validate and determine the applicability of a pre-specified algorithm for managing conduction disturbances in consecutive patients undergoing TAVR, also evaluating the percentage of patients included in each group of the algorithm strategy.
• Efficacy: (i) to evaluate the rate of permanent pacemaker implantation in-hospital and at 30 days compared to that of the year prior to the implementation of the protocol, (ii) to determine the incidence of sudden death at 30 days and at 1-year follow-up.

Enrollment: 2,000 estimated patients

Sex: All

Ages: 18+ years old

Volunteers: Accepts Healthy Volunteers

Inclusion criteria

-Patients with aortic valve disease undergoing transcatheter aortic valve replacement

Exclusion criteria

• Prior permanent pacemaker
• Failure to provide signed informed consent for data collection
• Impossibility for a follow-up
• Unwillingness to follow the pre-specified strategy for the management of conduction disturbances

Trial design

2,000 participants in 5 patient groups

No ECG changes in patients without pre-existing RBBB

Description:

Patients with no new conduction disturbances on the ECG performed immediately post-TAVR (and no episodes of HAVB/CHB during the procedure) have a very low risk of developing HAVB/CHB or any conduction disturbance within the hours-days following the procedure. In these cases, temporary pacing will be discontinued at the end of the procedure. However, continuous ECG monitoring until hospital discharge is recommended. A 12-lead ECG is recommended 24 hours after the procedure. If no arrhythmic episodes and no ECG changes occur within the 24 hours post-procedure, the patient can be safely discharged (the day after TAVR) with no other monitoring measures in case of otherwise uneventful clinical course (absence of other TAVR related adverse events). If the patient has to remain hospitalized because of other reasons or TAVR complications, telemetry would be recommended (but no strictly required) for the detection of post-TAVR tachyarrhythmias or late ECG changes.

Patients with pre-existing RBBB

Description:

A temporary pacing wire is recommended to be maintained for 24 hours (or at least overnight) in all patients with prior RBBB, along with telemetry and daily ECG during the entire hospitalization period (minimum of 2 days). If any ECG changes occur during the initial 2-3 days, patients can be managed according to the proposed strategy (see management strategies for groups 3 and 5). If no ECG changes or significant bradyarrythmias occur within the 2-3 days following the procedure, the patient can be discharged. Considering that the increased risk of life threatening bradyarrhythmias in these patients may extend beyond the hospitalization period, the use of continuous ECG monitoring systems (minimum of 48 hours, up to 4 weeks) may be considered.

ECG changes in patients with prior conduction disturbances

Description:

Any significant increase in PR or QRS interval will indicate to continuing the temporary pacing for 24 hrs, with daily ECG and telemetry for 1-2 days. If the ECG changes regress in \<24 hrs, an earlier removal of the temporary pacing may be considered. Also, a strategy of multiple ECGs during the first 24 hrs may be considered. If ECG changes regress or no further changes occur the patient can be discharged with no PPM at 2 days post-TAVR. If 24 hrs post-TAVR, the PR and QRS interval remain stable but \>240 or \>150 ms, respectively, and ≥20 ms longer than baseline, maintaining the temporary pacing wire for another 24 hrs is recommended. If no decrease in the PR or QRS duration occurs at day 2, the patient can be considered at risk for more advanced conduction disturbances requiring PPM. The use of an EP study may be a reasonable option for deciding PPM in those patients with prior conduction disturbances with worsening of ECG changes post-TAVR

New-onset LBBB

Description:

Temporary pacing for 24 hrs is recommended, in all patients with new-onset LBBB post-TAVR. Earlier removal of the temporary pacing and discharged at day 1 can be considered if LBBB resolves in \<24 hrs. If LBBB persists but no further progression of the duration of the QRS or PR interval is observed at day 1, temporary pacing can be discontinued. If no further ECG changes are observed up to day 2-3 post-TAVR, the patient can be discharged. These patients are however at increased risk of HAVB/CHB requiring PPM, and continuous ECG monitoring and/or EP studies may be considered. If further prolongation of the QRS or PR interval is observed at day 1, the temporary pacing is recommended for an additional 24 hrs. If the prolongation of the QRS or PR intervals continues at day 2, evaluation with EP studies or PPM implantation may be considered. The occurrence of any episode of HAVB/CHB following TAVR in a patient with new-onset LBBB will be considered an indication for PPM

HAVB/CHB during the periprocedural period

Description:

Maintaining temporary pacing in patients with procedural persistent HAVB/CHB, and monitoring in intensive care unit are recommended. If HAVB/CHB persists at 24 hrs, PPM is recommended. If HAVB/CHB recovers the day after TAVR, the temporary pacing can be removed and the patient can remain hospitalized for 1 day. If another episode of HAVB/CHB occurs, PPM is recommended. If no other episode of HAVB/CHB occurs, and no other features potentially justifying PPM exist the patient can be discharged. Temporary pacing is recommended for 24 hrs in patients with transient HAVB during the procedure, with telemetry and daily ECG for 2 days. Discontinuing temporary pacing may be considered in those cases with brief episodes of HAVB/CHB and normal ECG. If no recurrent episodes of HAVB/CHB occur, and the patient has no other potential indications for PPM the patient can be discharged at day 2. PPM would be indicated if any recurrent episode of HAVB/CHB occurs during the hospitalization period.