Arrhythmia Burden in Elderly Patients with Severe Aortic Stenosis as Determined by Continuous ECG Recording: Towards a Better Understanding of Arrhythmic Events Following Transcatheter Aortic Valve Replacement

Background — This study aimed to evaluate the prevalence of previously undiagnosed arrhythmias in candidates for TAVR and to determine its impact on therapy changes and arrhythmic events following the procedure. Methods and Results — A total of 435 candidates for TAVR underwent 24-hour continuous electrocardiographic (ECG) monitoring the day before the procedure. Newly diagnosed arrhythmias were observed in 70 patients (16.1%) before TAVR: paroxysmal atrial fibrillation (AF)/atrial tachycardia (AT) in 28, advanced atrio-ventricular block (AVB) or severe bradycardia in 24, non-sustained ventricular tachycardia in 26, and intermittent left bundle branch block (LBBB) in 3 patients. All arrhythmic events but one were asymptomatic, and led to a therapy change in 43% of patients. In patients without known AF/AT, the occurrence of AF/AT during 24-hour ECG recording was associated with a higher rate of 30-day cerebrovascular events (7.1% vs 0.4%, P =0.030). Among the 53 patients with new-onset AF/AT after TAVR, 30.2% had newly diagnosed paroxysmal AF/AT before the procedure. In patients who needed permanent pacemaker implantation following the procedure (n=35), 31.4% had newly diagnosed advanced AVB or severe bradycardia before TAVR. New-onset persistent LBBB following TAVR occurred in 37 patients, 8.1% of whom had intermittent LBBB before the procedure. Conclusions — Newly diagnosed arrhythmias were observed in about a fifth of TAVR candidates, led to a higher rate of cerebrovascular events and accounted for a third of arrhythmic events following the procedure. This high arrhythmia burden highlights the importance of an early diagnosis of arrhythmic events in such patients in order to implement the appropriate therapeutic measures earlier on. surveillance by trained nurses or Holter monitors 14 in 407 (93.4%) and 28 (6.4%) patients, respectively. The occurrence of symptoms during arrhythmic events was assessed. All events were recorded and telemetry strips were further analyzed by a cardiologist at each center. All TAVR procedures were performed with ECG monitoring and arrhythmic events were prospectively collected. Patients were on continuous ECG monitoring at least 72 hours after TAVR 15 and an ECG was performed daily until hospital discharge. Physicians in charge of patients were aware of the ECG monitoring findings and were responsible for the changes in treatment if warranted. PPI was indicated if third-degree or advanced second-degree atrioventricular block (AVB) at any anatomical level occurred and was not expected to resolve, or in the presence of sinus node dysfunction and documented symptomatic bradycardia, according to current recommendations. 16 (cid:3) The indication and duration of anticoagulation therapy in newly detected AF was left at the discretion of the physician responsible for the patient. estimated glomerular filtration ratio; EuroSCORE: European System for Cardiac Operative Risk Evaluation; LBBB: left bundle branch block; LVEF: left ventricular ejection fraction; STS-PROM: Society of Thoracic Surgeons predicted risk of mortality