Accelerated Idioventricular Rhythm Following Transcatheter Self-Expandable Aortic Valve Implantation

An 82-year-old woman with symptomatic severe aortic stenosis was admitted to Shimane University Hospital. The patient had a history of hypertension and was using only azelnidipine. On admission, 12-lead electrocardiography (ECG) revealed sinus rhythm and left ventricular hypertrophy; however, atrioventricular conduction was normal (Figure A). Echocardiography showed a calcified tricuspid aortic valve with a peak pressure gradient of 95 mmHg. Other valvular lesions were absent. The patient underwent transcatheter aortic valve implantation (TAVI) using an Evolut PRO valve (Medtronic, Dublin, Ireland) via the transfemoral approach. During the procedure, no conduction disturbances were observed. Forty-eight hours after TAVI, the ECG showed ventricular rhythm at a heart rate of 65 beats/min and complete left bundle branch block, suggesting accelerated idioventricular rhythm (AIVR; Figure B). There were no electrolyte imbalances or myocardial ischemia. Because the patient did not have any symptoms, she was not prescribed any medications, including antiarrhythmic drugs. AIVR continued intermittently for 2 days, and spontaneously returned to normal sinus rhythm; the patient was discharged.

Figure.

(A) The initial 12-lead electrocardiogram (ECG) shows sinus rhythm and left ventricular hypertrophy. (B) Forty-eight hours after transcatheter aortic self-expandable valve implantation, the ECG shows ventricular rhythm and complete left bundle branch block.

AIVR is a ventricular rhythm comprising 3 or more consecutive monomorphic beats. Patients undergoing TAVI with a self-expandable valve may have delayed conduction disturbances, such as left bundle branch block or complete atrioventricular block, and subsequently require pacemaker implantation.^1,2 Mechanical compression applied by a self-expandable valve is one of the possible mechanisms of AIVR, but further studies are needed to clarify this. Knowing that AIVR can occur following TAVI with a self-expandable valve is important.

Sources of Funding

This study was supported by scholarship funds from Otsuka Pharmaceutical Co., Ltd.

Disclosures

K.T. is a member of Circulation Reports’ Editorial Team. The remaining authors have no conflicts of interest to declare.

IRB Information

This study was approved by the Institutional Review Board of Shimane University Faculty of Medicine (No. 5385).

Human Rights

All procedures were performed in accordance with the ethical standards and the 1964 Declaration of Helsinki.

References

• 1.   Faroux L, Muntané-Carol G, Urena M, Nombela-Franco L, Amat-Santos I, Kleiman N, et al. Late electrocardiographic changes in patients with new-onset left bundle branch block following transcatheter aortic valve implantation. Am J Cardiol 2020; 125: 795–802.
• 2.   Sasaki K, Izumo M, Kuwata S, Ishibashi Y, Kamijima R, Watanabe M, et al. Clinical impact of new-onset left bundle-branch block after transcatheter aortic valve implantation in the Japanese population: A single high-volume center experience. Circ J 2020; 84: 1012–1019.