Alternating Bundle Branch Block With Paroxysmal Atrioventricular Block 22 Months After Valve-in-Valve Transcatheter Aortic Valve Replacement
Article ID: CJ-21-0600
Details
Article ID: CJ-21-0600
A 72-year-old woman underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (Figure A,B). Preoperative computed tomography [CT] revealed no calcification in the membranous septum, which was 4.5 mm long. ECG indicated that the PR interval (190 ms) and QRS interval (99 ms) were within normal limits. During the procedure, because the 1st self-expandable valve (CoreValve; Medtronic, MN, USA) popped up and failed to deploy, a 2nd self-expandable valve was deployed after placing the 1st valve in the ascending aorta (Figure C). Postoperative CT showed that the transcatheter heart valve (THV) position was as deep as 7.1 mm below the native annulus. The patient developed 1st-degree atrioventricular block (AVB) and complete left bundle branch block (LBBB) after surgery (Figure D,E). However, pacemaker implantation was deferred because the continuous ECG did not show episodes of more than 2nd-degree AVB for 14 days. At 22 months later, she complained of frequent syncope. Holter ECG revealed alternating bundle branch block (ABBB) followed by paroxysmal AVB, in agreement with her symptoms (Figure F,G). Nevertheless, CT showed that the valve position and THV depth remained unchanged. The patient underwent pacemaker implantation and had an uneventful clinical course thereafter. Previous reports suggest that conduction disturbance following TAVR recovers with time.1,2 However, this patient developed paroxysmal and complete AVB during the very late phase after surgery. ABBB, in which RBBB and LBBB coexist on successive ECGs, is a rare ECG pattern and has a high risk of progression to complete AVB. In this patient, the deep position of the THV could induce 1st-degree AVB with LBBB. Furthermore, complicated RBBB might have triggered complete AVB. Clinicians should be vigilant against complete AVB at long-term follow-up of patients developing both 1st-degree AVB and LBBB after TAVR.
(A) Pre- and (B) postoperative computed tomography images of the aortic valve. (C) 3D reconstruction of the deployed valves. (D) Pre- and (E) postoperative 12-lead ECGs. (F,G) Waveforms in the Holter ECG. Red and black arrows indicate right bundle branch block and left bundle branch block, respectively, in the insets.
M.Y. is a member of Circulation Journal’s Editorial Team.
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