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Archives of cardiovascular diseases
Volume 110, n° 12
pages 667-675 (décembre 2017)
Doi : 10.1016/j.acvd.2017.03.007
Received : 17 November 2016 ;  accepted : 22 Mars 2017
Predictors and prognostic impact of new left bundle branch block after surgical aortic valve replacement
Facteurs prédictifs et impact pronostique du bloc de branche gauche acquis après remplacement valvulaire aortique
 

Moukda Khounlaboud a, b, , Erwan Flécher c, d, e, Maxime Fournet a, Hervé Le Breton a, d, e, Erwan Donal a, d, e, Christophe Leclercq a, d, e, Philippe Mabo a, d, e, Alain Leguerrier c, d, e, Claude Daubert d, e
a Service de cardiologie et maladies vasculaires, hôpital Pontchaillou/CHU, 35000 Rennes, France 
b Service de cardiologie, centre hospitalier, 10, rue Marcel-Proust, 22000 Saint-Brieuc, France 
c Service de chirurgie cardiaque, thoracique et vasculaire, hôpital Pontchaillou/CHU, 35000 Rennes, France 
d Faculté de médecine, université de Rennes 1, 35000 Rennes, France 
e LTSI Inserm U1099, 35000 Rennes, France 

Corresponding author. Service de cardiologie, centre hospitalier, 10, rue Marcel-Proust, 22000 Saint-Brieuc, France.
Summary
Background

Left bundle branch block (LBBB) induces mechanical dyssynchrony that may lead to left ventricular systolic dysfunction.

Aims

To evaluate the incidence, predictors and clinical impact of new LBBB in patients undergoing surgical aortic valve replacement (SAVR).

Methods

After exclusion of patients with pre-existing LBBB, a previous pacemaker or a paced rhythm at hospital discharge, 547 consecutive patients undergoing SAVR were included. All-cause death, cardiovascular death and the combined outcome of all-cause death or a first heart failure event were assessed at 3months and 1year. Patients with and without new LBBB were compared.

Results

New LBBB occurred in 4.6% of patients after SAVR (compared with 16.4% of patients treated by transcatheter aortic valve implantation during the study period). Previous valve surgery and an immediate postoperative paced rhythm were independent predictors of new LBBB. At 1-year follow-up, there were no significant differences in all-cause death, cardiovascular death, or the combined outcome of all-cause death or a first heart failure event between patients with and without new LBBB. However, new LBBB was associated with a trend towards functional deterioration and more heart failure events at 1year.

Conclusion

At 1-year follow-up, new LBBB did not have a significant impact on clinical outcome, but was associated with worse functional status and more heart failure events.

The full text of this article is available in PDF format.
Résumé
Contexte

Le bloc de branche gauche (BBG) induit un asynchronisme mécanique pouvant provoquer une dysfonction systolique ventriculaire gauche.

Objectifs

Évaluer l’incidence, les facteurs prédictifs et les conséquences cliniques d’un BBG acquis suite à un remplacement valvulaire aortique (RVA) chirurgical.

Méthodes

Après avoir exclu les patients ayant un BBG préexistant ou porteurs d’un stimulateur cardiaque avant le RVA chirurgical et les patients ayant un rythme électro-entraîné à la sortie d’hospitalisation, 547 patients consécutifs opérés d’un RVA ont été inclus. La mortalité toute cause, la mortalité cardiovasculaire et le critère combiné mortalité toute cause ou premier événement d’insuffisance cardiaque ont été évalués à 3mois et 1an. Les patients avec et sans BBG acquis ont été comparés.

Résultats

Un BBG acquis est retrouvé chez 4,6 % des patients opérés d’un RVA (pour comparaison, sur la même période, un BBG est retrouvé chez 16,4 % des patients après TAVI). Les facteurs prédictifs indépendants de BBG acquis sont un antécédent de chirurgie valvulaire et un rythme électro-entraîné en postopératoire immédiat. À 1 an de suivi, il n’y pas de différence entre les patients ayant un BBG acquis et ceux n’ayant pas de BBG pour la mortalité toute cause, la mortalité cardiovasculaire et le critère combiné mortalité toute cause ou premier événement d’insuffisance cardiaque. Toutefois, les patients avec BBG acquis avaient un plus mauvais statut fonctionnel et davantage d’événements d’insuffisance cardiaque à 1an.

Conclusion

À 1an de suivi, un BBG acquis n’a pas d’influence pronostique significative.

The full text of this article is available in PDF format.

Keywords : Left bundle branch block, Aortic valve replacement, Clinical outcome

Mots clés : Bloc de branche gauche, Remplacement aortique valvulaire, Pronostic

Abbreviations : ECG, LBBB, LVEF, NYHA, SAVR, TAVI


Background

Animal studies have shown that in normal hearts, the acute onset of left bundle branch block (LBBB) induces immediate and persistent asynchronous ventricular activation and mechanical dyssynchrony [1]. It leads to a redistribution of myocardial blood flow, with septal hypoperfusion and, thereafter, left ventricular remodelling, with ventricular dilatation, asymmetric hypertrophy and reduction of left ventricular ejection fraction (LVEF). In animal models of chronic isolated LBBB, left ventricular dysfunction can be reverted by electrical resynchronization, with normalization of left ventricular end-diastolic volume, left ventricular wall mass and left ventricular pump function [2].

In humans, surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) can induce new LBBB. It is reasonable to assume that the sudden onset of LBBB in pathological hearts with left ventricular dysfunction will have immediate and long-term adverse consequences. There is abundant literature on LBBB after TAVI. The reported incidence is high, ranging from 10 to 20% with balloon-expandable valves [3, 4, 5, 6, 7, 8, 9, 10, 11, 12] and from 30 to 50% with self-expandable valves [3, 4, 6, 7, 12, 13, 14, 15, 16]. Clinical implications remain unclear, with inconsistent results across studies [4, 5, 6, 7, 8, 9, 10, 11, 13, 16]. By contrast, very few data exist on new LBBB after SAVR. An incidence of 6.4% has been reported in one study [17]. The clinical implications are unknown.

The aims of this study were to better evaluate the incidence and predictors of new LBBB in patients undergoing SAVR, and to assess the impact of new LBBB on clinical, functional and echocardiographic outcomes.

Methods
Study population

From January 2013 to December 2013, 626 consecutive patients underwent SAVR in our institution. During the same period, 109 patients had a TAVI procedure. Patients with pre-existing LBBB, a previous pacemaker or paced rhythm at hospital discharge were excluded. The final study population consisted of 547 patients who underwent SAVR (Figure 1).



Figure 1


Figure 1. 

Study flow chart. LBBB: left bundle branch block.

Zoom

Data collection

Pre-, peri- and early postoperative data were collected at the time of hospital discharge, and were entered into a computerized database.

Baseline clinical characteristics

Demographics, cardiovascular risk factors and co-morbidities were collected. Neurological dysfunction was defined as any clinical neurological impairment. Peripheral vascular disease included peripheral artery disease and aortic aneurysm. Chronic renal failure was defined as a creatinine clearance rate<60mL/min according to the Modification of Diet in Renal Disease (MDRD) equation. Chronic pulmonary disease was defined as abnormal pulmonary function tests or the chronic use of bronchodilators or inhaled steroids. The logistic EuroSCORE I was calculated to estimate the operative risk of death [18]. Echocardiographic data (LVEF, left ventricular dimensions, left ventricular thickness, aortic valve variables, valvular regurgitations, systolic pulmonary arterial pressure and right ventricle function) were collected.

Perioperative data

Delay to surgery was defined as ‘salvage’ for surgery performed immediately, ‘emergency’ for surgery within 24hours, ‘urgent’ for surgery within a few days and ‘elective’ for planned surgery. Inotropic support was defined as the use of dobutamine in the operating room. Mechanical support was defined as weaning from cardiopulmonary bypass requiring more than 30minutes or the use of a temporary mechanical circulatory support. Immediate postoperative paced rhythm meant a paced rhythm in the operating room, after the surgical procedure. Operative death was defined as a death within 30days after surgery. Reoperation was defined as repeat cardiac surgery with cardiopulmonary bypass during the same hospitalization.

Electrocardiographic data

A 12-lead surface electrocardiogram (ECG) was recorded at admission before surgery, after the procedure and at hospital discharge. All ECG recordings were reviewed and analysed by the same investigator (M.K.). Complete LBBB was defined according to the criteria of Strauss et al. [19], including a negative terminal deflection in leads V1 and V2 (QS or rS), a minimum QRS duration of 140ms in men or 130ms in women, and the presence of mid-QRS notching or slurring in at least two of leads V1, V2, V5, V6, I and aVL. New LBBB was defined as any new LBBB documented during the hospitalization period on at least one ECG. Other ECG criteria were analysed according to American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society recommendations for the standardization and interpretation of the ECG [20].

Follow-up

Follow-up was carried out during outpatient visits and/or by telephone call to the cardiologist or the general practitioner within 3months after SAVR, at 1year and yearly thereafter. Mortality data were available for 100% of the patients, clinical data (heart failure events and New York Heart Association [NYHA] class) for 80% of the patients and ECG data for 70% of the patients at 1-year follow-up.

Outcomes

All-cause death, cardiovascular death, and the combined outcome of all-cause death or a first heart failure event were assessed at 3months and 1year. Cardiovascular death included coronary death, heart failure death, cerebrovascular death, presumed arrhythmic death and other cardiovascular death (acute pulmonary embolism, aortic aneurysm dissection, cardiovascular surgery, bleeding). A first heart failure event was defined as a first hospitalization for decompensated heart failure or worsening symptoms needing initiation of diuretic treatment or an increased diuretic dosage. Other monitored variables were functional status (NYHA class, improvement by at least one class), need for pacemaker implantation and LVEF. Patients with new LBBB were compared with patients without new LBBB.

Statistical analysis

Continuous variables are presented as means±standard deviations, and were compared with Student's t test. Categorical variables are presented as counts and percentages, and were compared with the χ2 test or Fisher's exact test. A logistic regression model was used for the multivariable analysis. Pre- and perioperative covariates for multivariable analysis were selected on the basis of clinical relevance and statistical association at a threshold of P <0.10 by univariate analysis. Survival curves were constructed using Kaplan–Meier estimates, and the log-rank test was used to compare groups. All reported P values were two-sided and a P value<0.05 was considered significant. Statistical analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).

Results
Patient baseline characteristics

A total of 547 consecutive patients undergoing SAVR were included, with a mean age of 71 years. Indication for SAVR was severe aortic stenosis for 487 (89.0%) patients, severe aortic regurgitation for 18 (3.3%) patients and both severe aortic stenosis and regurgitation for 42 (7.7%) patients (Table 1).

New LBBB occurred in 25 patients (4.6%) after SAVR. By comparison, during the study period, new LBBB was observed in 16.4% patients after TAVI (31.6% after self-expandable valve implantation and 11.1% after balloon-expandable valve implantation).

The baseline clinical and echocardiographic characteristics of patients with or without new LBBB are shown in Table 1. There were no significant differences between subgroups, except a higher proportion of previous cardiac surgery in patients with new LBBB (16.0% vs 5.2%; P =0.046).

Regarding baseline and postoperative ECG findings: there were no significant differences between patients with or without new LBBB. There was only a non-significant trend towards a wider QRS duration at baseline in patients with new LBBB (92.7±20.2 vs 86.3±10.6ms; P =0.12).

Perioperative data

Thirty-day data are shown in Table 2. Patients with new LBBB had a higher proportion of paced rhythm in the operating room (48.0% vs 18.4%; P =0.001), a higher 24-hour postoperative bleeding (952.6±943.5 vs 592.7±441.8; P <0.001), and a significantly longer postoperative hospital stay (15.0±9.3 vs 11.4±6.7 days; P =0.012). Other perioperative data were similar between patients with and without new LBBB. The operative mortality rate was 3.6% in patients without new LBBB and 0% in patients with new LBBB (P =0.33).

Regarding postoperative ECG changes, new LBBB was associated with greater QRS widening (144.6±19.3ms vs 96.2±22.4ms; P <0.001) and more left axis QRS deviation (n =19 [76.0%] vs n =192 [37.0%]; P <0.001) compared with no LBBB. The rates of postprocedural atrial fibrillation and first-degree atrioventricular block were similar in patients with or without new LBBB.

Follow-up
Three-month follow-up

Three months after SAVR, all-cause death (0% vs 4.8%; P =0.62), cardiovascular death (0% vs 3.6%; P =1.00) and the composite of all-cause death or a first heart failure event (12.0% vs 7.7%; P =0.44) were not significantly different between patients with and without new LBBB, respectively. There were significantly more heart failure events in patients with new LBBB (14.3% vs 3.4%; P =0.043) and more postdischarge pacemaker implantations (n =2 [8.0%] vs n =0 [0%]; P =0.002).

1-year follow-up

At 1year, all-cause death (0% vs 6.7%; P =0.39), cardiovascular death (0% vs 5.4%; P =0.62) and the composite of all-cause death or a first heart failure event (20.0% vs 13.0%; P =0.36) were not significantly different between patients with and without new LBBB, respectively (Table 3). The mean NYHA functional class was higher in patients with new LBBB (1.6±0.8 vs 1.3±0.5 in the no LBBB group; P =0.029), and this group had significantly more heart failure events (23.8% vs 8.8%; P =0.041). LVEF was similar in the two groups (61.5±8.9% vs 62.1±8.5%; P =0.78). There were no new pacemaker implantations after 3months in the two groups.

Survival curves for all-cause death and the combined outcome of all-cause death or a first heart failure event are shown in Figure 2. Event rates were significantly greater in patients with new LBBB with regard to the combined outcome of all-cause death or a first heart failure event (log rank=0.023). The combined outcome was mainly driven by heart failure events.



Figure 2


Figure 2. 

Event-free survival curves in patients with and without new left bundle branch block (LBBB). A. All-cause death. B. All-cause death or a first heart failure event.

Zoom

Predicting factors of new LBBB

Univariate and multivariable predictors of new LBBB are shown in Table 4 and in online Appendix A. Previous valve surgery, an immediate postoperative paced rhythm and a higher 24-hour postoperative bleeding were independent predictors of new LBBB after SAVR.

Predictors of all-cause death

Univariate and multivariable predictors of all-cause death are shown in Table 4 and in online Appendix A. Age, history of malignancy, preoperative moderate-to-severe mitral regurgitation, need for cardiac reoperation during hospitalization and low postoperative LVEF analysed as a continuous variable were independently associated with an increased risk of all-cause death.

Predictors of the combined outcome of all-cause death or a first heart failure event

Univariate and multivariable predictors of all-cause death or a first heart failure event are shown in Table 4 and in online Appendix A. Age, high logistic EuroSCORE I, high preoperative NYHA class, a paced rhythm in the operating room, need for cardiac reoperation during hospitalization, low postoperative LVEF and longer hospitalization duration were independent predictors of all-cause death or a first heart failure event.

New LBBB was not an independent predictor of clinical outcomes at 3-month and 1-year follow-up. However, event-free survival curves with longer follow-up showed an increased risk of all-cause death or a first heart failure event in patients with new LBBB (Figure 2). The difference was driven mainly by heart failure events.

Discussion

Our main findings are that the incidence of new LBBB after SAVR is low (4.6%) and is much lower than after TAVI; that previous valve surgery is an independent predictor of new LBBB; and that new LBBB does not have an impact on early and 1-year clinical outcomes, but there is a trend towards worsened symptoms and more heart failure events in patients with new LBBB.

In animal models, isolated LBBB induced by radiofrequency ablation induces left ventricular asynchronous electrical activation and mechanical dyssynchrony that, in the long run, lead to left ventricular remodelling and reduced LVEF [1]. In these models, electrical resynchronization has been shown to reverse the process [2].

In humans, there are consistent data suggesting that progressive left ventricular systolic dysfunction may develop in patients with isolated LBBB, and can be similarly reversed after cardiac resynchronization therapy [21, 22, 23]. The term “LBBB-induced cardiomyopathy” has been used to qualify this pathological entity [21, 23]. The prevalence, natural history and predicting factors of left ventricular dysfunction remain unclear. Studies suggest that a long time (up to 10years) may be necessary before clinical heart failure occurs [23]. The delay to left ventricular dysfunction and the clinical impact may be different in the setting of diseased hearts.

LBBB induced by SAVR or TAVI is a unique model of acute dyssynchrony in diseased hearts. It occurs abruptly, similar to animal models with radiofrequency ablation of the left bundle branch, but affects a particular population of ageing hypertrophied hearts. It can be reasonably assumed that new LBBB after SAVR or TAVI may have a particularly negative impact both acutely and in the long term.

Our study was designed to better assess the incidence and prognostic impact of new LBBB after SAVR. At 1-year follow-up, new LBBB was not associated with an increase in death, but patients with new LBBB had worse functional status and more heart failure events compared with patients without new LBBB. Furthermore, event-free survival curves suggest a potential negative effect of LBBB in the long run, with a trend towards more deaths and heart failure events with longer follow-up. However, the role of new LBBB in this possibly increased risk of major clinical events is uncertain. In our series, most patients with postoperative heart failure events had a preserved ejection fraction.

There are very few data in the literature on the prognostic impact of new LBBB after SAVR [17]. This contrasts with abundant literature in recent years on the impact of new LBBB after TAVI on clinical outcome. Results of studies are not consistent: some showed increased mortality after 1 year [5, 6, 7, 11, 24]; others showed no significant influence [4, 7, 8, 9, 10, 16]. In studies that analysed heart failure status and the risk of new heart failure events, no significant difference was observed between patients with and without new LBBB [7, 9, 10, 16]. Regarding functional status, worsening of NYHA class was reported by Urena et al. [7, 9, 10], but no difference was found by Testa et al. [16].

Study limitations

This study has the limitations of a retrospective observational study with missing data. At 1-year follow-up, NYHA functional class and heart failure events were available in 80% of patients, and echocardiographic data were available in 70% of patients. The number of patients with new LBBB was small (n =25). No patients died among those without new LBBB; this can be viewed as an effect of chance, and the duration of the follow-up was relatively short. Finally, there were relatively few events in the overall population, which may have led to an underestimation of the impact of new LBBB.

Conclusions

In this study, new LBBB after SAVR does not appear to be an independent predictor of death or the combined outcome of all-cause death or a first heart failure event at 1year. However, there was a trend towards more heart failure events and worsening NYHA class. Longer follow-up and a larger population will be necessary to assess the real clinical impact of new LBBB after SAVR.

Funding

None.

Disclosure of interest

The authors declare that they have no competing interest.


Acknowledgments

The authors thank Anne Ingels for conducting the statistical analyses.


Appendix A. Supplementary data

(87 Ko)
  
References

Vernooy K., Verbeek X.A., Peschar M., and al. Left bundle branch block induces ventricular remodelling and functional septal hypoperfusion Eur Heart J 2005 ;  26 : 91-98 [cross-ref]
Vernooy K., Cornelussen R.N., Verbeek X.A., and al. Cardiac resynchronization therapy cures dyssynchronopathy in canine left bundle-branch block hearts Eur Heart J 2007 ;  28 : 2148-2155 [cross-ref]
Aktug O., Dohmen G., Brehmer K., and al. Incidence and predictors of left bundle branch block after transcatheter aortic valve implantation Int J Cardiol 2012 ;  160 : 26-30 [cross-ref]
Franzoni I., Latib A., Maisano F., and al. Comparison of incidence and predictors of left bundle branch block after transcatheter aortic valve implantation using the CoreValve versus the Edwards valve Am J Cardiol 2013 ;  112 : 554-559 [inter-ref]
Houthuizen P., van der Boon R.M., Urena M., and al. Occurrence, fate and consequences of ventricular conduction abnormalities after transcatheter aortic valve implantation EuroIntervention 2014 ;  9 : 1142-1150 [cross-ref]
Houthuizen P., Van Garsse L.A., Poels T.T., and al. Left bundle-branch block induced by transcatheter aortic valve implantation increases risk of death Circulation 2012 ;  126 : 720-728 [cross-ref]
Massoullie G., Bordachar P., Ellenbogen K.A., and al. New-onset left bundle branch block induced by transcutaneous aortic valve implantation Am J Cardiol 2016 ;  117 : 867-873 [cross-ref]
Nazif T.M., Williams M.R., Hahn R.T., and al. Clinical implications of new-onset left bundle branch block after transcatheter aortic valve replacement: analysis of the PARTNER experience Eur Heart J 2014 ;  35 : 1599-1607 [cross-ref]
Urena M., Mok M., Serra V., and al. Predictive factors and long-term clinical consequences of persistent left bundle branch block following transcatheter aortic valve implantation with a balloon-expandable valve J Am Coll Cardiol 2012 ;  60 : 1743-1752 [cross-ref]
Urena M., Webb J.G., Cheema A., and al. Impact of new-onset persistent left bundle branch block on late clinical outcomes in patients undergoing transcatheter aortic valve implantation with a balloon-expandable valve JACC Cardiovasc Interv 2014 ;  7 : 128-136 [cross-ref]
Urena M., Webb J.G., Eltchaninoff H., and al. Late cardiac death in patients undergoing transcatheter aortic valve replacement: incidence and predictors of advanced heart failure and sudden cardiac death J Am Coll Cardiol 2015 ;  65 : 437-448 [cross-ref]
van der Boon R.M., Houthuizen P., Urena M., and al. Trends in the occurrence of new conduction abnormalities after transcatheter aortic valve implantation Catheter Cardiovasc Interv 2015 ;  85 : E144-E152 [cross-ref]
Carrabba N., Valenti R., Migliorini A., and al. Impact on left ventricular function and remodeling and on 1-year outcome in patients with left bundle branch block after transcatheter aortic valve implantation Am J Cardiol 2015 ;  116 : 125-131 [inter-ref]
Khawaja M.Z., Rajani R., Cook A., and al. Permanent pacemaker insertion after CoreValve transcatheter aortic valve implantation: incidence and contributing factors (the UK CoreValve Collaborative) Circulation 2011 ;  123 : 951-960 [cross-ref]
Nuis R.J., Van Mieghem N.M., Schultz C.J., and al. Timing and potential mechanisms of new conduction abnormalities during the implantation of the Medtronic CoreValve System in patients with aortic stenosis Eur Heart J 2011 ;  32 : 2067-2074 [cross-ref]
Testa L., Latib A., De Marco F., and al. Clinical impact of persistent left bundle-branch block after transcatheter aortic valve implantation with CoreValve Revalving System Circulation 2013 ;  127 : 1300-1307 [cross-ref]
El-Khally Z., Thibault B., Staniloae C., and al. Prognostic significance of newly acquired bundle branch block after aortic valve replacement Am J Cardiol 2004 ;  94 : 1008-1011 [inter-ref]
Roques F., Michel P., Goldstone A.R., Nashef S.A. The logistic EuroSCORE Eur Heart J 2003 ;  24 : 881-882
Strauss D.G., Selvester R.H., Wagner G.S. Defining left bundle branch block in the era of cardiac resynchronization therapy Am J Cardiol 2011 ;  107 : 927-934 [inter-ref]
Surawicz B., Childers R., Deal B.J., and al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology J Am Coll Cardiol 2009 ;  53 : 976-981 [cross-ref]
Blanc J.J., Fatemi M., Bertault V., Baraket F., Etienne Y. Evaluation of left bundle branch block as a reversible cause of non-ischaemic dilated cardiomyopathy with severe heart failure. A new concept of left ventricular dyssynchrony-induced cardiomyopathy Europace 2005 ;  7 : 604-610 [cross-ref]
Lee S.J., McCulloch C., Mangat I., Foster E., De Marco T., Saxon L.A. Isolated bundle branch block and left ventricular dysfunction J Card Fail 2003 ;  9 : 87-92 [inter-ref]
Vaillant C., Martins R.P., Donal E., and al. Resolution of left bundle branch block-induced cardiomyopathy by cardiac resynchronization therapy J Am Coll Cardiol 2013 ;  61 : 1089-1095 [cross-ref]
Schymik G., Tzamalis P., Bramlage P., and al. Clinical impact of a new left bundle branch block following TAVI implantation: 1-year results of the TAVIK cohort Clin Res Cardiol 2015 ;  104 : 351-362 [cross-ref]



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