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Response to Letter Regarding Article, ''Clinical Impact of Persistent Left Bundle-Branch
Block After Transcatheter Aortic Valve Implantation With CoreValve Revalving System''
Francesco Bedogni, Azeem Latib, Federico De Marco, Mauro Agnifili, Jacopo Oreglia, Samuele
Pizzocri, Roberto A. Latini, Stefania Lanotte, Anna Sonia Petronio, Marco De Carlo, Federica
Ettori, Claudia Fiorina, Arnaldo Poli, Silvia Cirri, Stefano De Servi, Angelo Ramondo,
Giuseppe Tarantini, Antonio Marzocchi, Rosario Fiorilli, Silvio Klugmann, Gian Paolo Ussia,
Corrado Tamburino, Francesco Maisano, Nedy Brambilla, Antonio Colombo and Luca Testa
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Circulation. 2013;128:e444
doi: 10.1161/CIRCULATIONAHA.113.005705
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Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2013 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539
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The online version of this article, along with updated information and services, is located on the
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http://circ.ahajournals.org/content/128/22/e444
An erratum has been published regarding this article. Please see the attached page for:
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http://circ.ahajournals.org/content/129/5/e327.full.pdf
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Correspondence
Article Type
Federico De Marco, MD
Niguarda Ca Granda Hospital
Milan, Italy
Response to Letter Regarding Article, “Clinical
Impact of Persistent Left Bundle-Branch Block
After Transcatheter Aortic Valve Implantation
With CoreValve Revalving System”
Mauro Agnifili, MD
Department of Cardiology
Istituto Clinico S. Ambrogio
Milan, Italy
Jacopo Oreglia, MD
Niguarda Ca Granda Hospital
Milan, Italy
Samuele Pizzocri, MD
Roberto A. Latini, MD
Stefania Lanotte, MD
Department of Cardiology
Istituto Clinico S. Ambrogio
Milan, Italy
Federica Ettori, MD
Claudia Fiorina, MD
Cardiothoracic Department
Spedali Civili
Brescia, Italy
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Anna Sonia Petronio, MD
Marco De Carlo, MD
Cardiothoracic and Vascular Department
Azienda Ospedaliero-Universitaria Pisana
Pisa, Italy
Arnaldo Poli, MD
Azienda Ospedaliera Legnano
Legnano, Italy
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We appreciate the interest of Prinzen et al about our article,1 but
some of their comments need to be addressed.
Prinzen et al analyzed a mixed population of patients treated with
CoreValve or Edwards Sapien prostheses.2 Of note, their different
influence on the cardiac conduction system is well known,3 with the
CoreValve being more prone to determine conduction disturbances as
a consequence of the larger frame.
Accordingly, we decided to specifically focus on the CoreValve,
pooling >800 patients, which is more than double the population considered by Prinzen et al. It is clear that the internal and external validity (ie, the extent of systematic biases and the generalizability of the
results) are highly affected by the sample size.
Prinzen et al excluded patients who underwent pacemaker
implantation within 30 days after transcatheter aortic valve replacement, which, in our opinion, makes little sense because the left
bundle-branch block (LBBB) usually develops immediately and its
short-term effect was unclear. The latter was one of the aims of our
study.
We excluded those who were implanted urgently within 48 hours,
and, among the remaining patients, those showing a new-onset LBBB
had a higher risk of pacemaker implantation within the first month after
transcatheter aortic valve replacement. As for these points, Prinzen et al
suggest that a considerable proportion of patients with LBBB was protected against bradyarrhithmic death. The logical consequence of this
hypothesis is that the very tight follow-up we implemented for those
patients was very successful and should be advocated on a routine basis.
As for the diagnostic issue, the citation from Prinzen et al has little
to do with the transcatheter aortic valve replacement scenario, and the
criteria we used are accepted worldwide.
With respect to the QRS duration in patients with LBBB, we found
that the widening of the QRS was remarkable, reaching a mean duration of 142 ms (range of 130–155 ms). Prinzen et al probably interpreted 130 ms as the 25th percentile; it was instead the lower limit.
Thus, their doubts seem groundless.
Prinzen et al probably misinterpreted also the percentage of LBBB in
our study: it was 43.2% (ie, close to the 51% they reported). This percentage decreased afterward, which is consistent with data from the literature.
In conclusion, logistic EuroSCORE in our study was higher: this
is a consequence of the fact that only patients at a very high or prohibitive risk for surgery were included. In such a population, which is
supposed to be the real transcatheter aortic valve replacement population, it is conceivable that other predictive factors play a critical role
in determining the prognosis.
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Silvia Cirri, MD
Department of Cardiology
Istituto Clinico S. Ambrogio
Milan, Italy
Disclosures
Dr Bedogni is a medical proctor for Medtronic. Dr Ussia, Dr Petronio,
and Dr Ramondo are TAVI medical proctors for Medtronic. The other
authors report no conflicts.
Stefano De Servi, MD
Azienda Ospedaliera Legnano
Legnano, Italy
Angelo Ramondo, MD
Ospedale di Bassano del Grappa
Vicenza, Italy
Giuseppe Tarantini, MD
Department of Cardiac Thoracic
and Vascular Sciences
University of Padova
Padova, Italy
Antonio Marzocchi, MD
Institute of Cardiology
St. Orsola/Malpighi Hospital
Bologna University
Bologna, Italy
Francesco Bedogni, MD
Department of Cardiology
Istituto Clinico S. Ambrogio
Milan, Italy
Rosario Fiorilli, MD
Ospedale San Camillo
Rome, Italy
Azeem Latib, MD
Interventional Cardiology Unit
San Raffaele Hospital and
EMO-GVM Centro Cuore Columbus
Milan, Italy
Silvio Klugmann
Niguarda Ca Granda Hospital
Milan, Italy
(Circulation. 2013;128:e444-e445.)
© 2013 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.113.005705
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Correspondence e445
Luca Testa, MD, PhD
Department of Cardiology
Istituto Clinico S. Ambrogio
Milan, Italy
Gian Paolo Ussia, MD
Corrado Tamburino, MD
Ferrarotto Hospital
Catania, Italy
Francesco Maisano, MD
Interventional Cardiology Unit
San Raffaele Hospital and
EMO-GVM Centro Cuore Columbus
Milan, Italy
References
1. Testa L, Latib A, De Marco F, De Carlo M, Agnifili M, Latini RA, Petronio
AS, Ettori F, Poli A, De Servi S, Ramondo A, Napodano M, Klugmann S,
Ussia GP, Tamburino C, Brambilla N, Colombo A, Bedogni F. Clinical impact
of persistent left bundle-branch block after transcatheter aortic valve implantation with CoreValve Revalving System. Circulation. 2013;127:1300–1307.
2. Houthuizen P, Van Garsse LA, Poels TT, de Jaegere P, van der Boon
RM, Swinkels BM, Ten Berg JM, van der Kley F, Schalij MJ, Baan J Jr,
Cocchieri R, Brueren GR, van Straten AH, den Heijer P, Bentala M, van
Ommen V, Kluin J, Stella PR, Prins MH, Maessen JG, Prinzen FW. Left
bundle-branch block induced by transcatheter aortic valve implantation
increases risk of death. Circulation. 2012;126:720–728.
3. Erkapic D, De Rosa S, Kelava A, Lehmann R, Fichtlscherer S, Hohnloser
SH. Risk for permanent pacemaker after transcatheter aortic valve
implantation: a comprehensive analysis of the literature. J Cardiovasc
Electrophysiol. 2012;23:391–397.
Nedy Brambilla, MD
Department of Cardiology
Istituto Clinico S. Ambrogio
Milan, Italy
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Antonio Colombo, MD
Interventional Cardiology Unit
San Raffaele Hospital and
EMO-GVM Centro Cuore Columbus
Milan, Italy
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Correction
In the article by Bedogni et al, “Response to Letter Regarding Article, ‘Clinical Impact of
Persistent Left Bundle-Branch Block After Transcatheter Aortic Valve Implantation With
CoreValve Revalving System’,” which was published in the November 26, 2013 issue of the journal
(Circulation. 2013;128:e444), the order of authors was incorrect. The author list should have read:
Stefano De Servi, MD
Azienda Ospedaliera Legnano
Legnano, Italy
Francesco Bedogni, MD
Department of Cardiology
Istituto Clinico S. Ambrogio
Milan, Italy
Angelo Ramondo, MD
Ospedale di Bassano del Grappa
Vicenza, Italy
Azeem Latib, MD
Interventional Cardiology Unit
San Raffaele Hospital and EMO-GVM
Centro Cuore Columbus
Milan, Italy
Giuseppe Tarantini, MD
Department of Cardiac Thoracic and Vascular Sciences
University of Padova
Padova, Italy
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Federico De Marco, MD
Niguarda Ca Granda Hospital
Milan, Italy
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Mauro Agnifili, MD
Department of Cardiology
Istituto Clinico S. Ambrogio
Milan, Italy
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Jacopo Oreglia, MD
Niguarda Ca Granda Hospital
Milan, Italy
Samuele Pizzocri, MD
Roberto A. Latini, MD
Stefania Lanotte, MD
Department of Cardiology
Istituto Clinico S. Ambrogio
Milan, Italy
Rosario Fiorilli, MD
Ospedale San Camillo
Rome, Italy
Silvio Klugmann
Niguarda Ca Granda Hospital
Milan, Italy
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Gian Paolo Ussia, MD
Corrado Tamburino, MD
Ferrarotto Hospital
Catania, Italy
Francesco Maisano, MD
Interventional Cardiology Unit
San Raffaele Hospital and EMO-GVM
Centro Cuore Columbus
Milan, Italy
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Anna Sonia Petronio, MD
Marco De Carlo, MD
Cardiothoracic and Vascular Department
Azienda Ospedaliero-Universitaria Pisana
Pisa, Italy
Federica Ettori, MD
Claudia Fiorina, MD
Cardiothoracic Department
Spedali Civili
Brescia, Ital
Antonio Marzocchi, MD
Institute of Cardiology
St. Orsola/Malpighi Hospital
Bologna University
Bologna, Italy
Nedy Brambilla, MD
Department of Cardiology
Istituto Clinico S. Ambrogio
Milan, Italy
Arnaldo Poli, MD
Azienda Ospedaliera Legnano
Legnano, Italy
Antonio Colombo, MD
Interventional Cardiology Unit
San Raffaele Hospital and EMO-GVM Centro Cuore
Columbus
Milan, Italy
Silvia Cirri, MD
Department of Cardiology
Istituto Clinico S. Ambrogio
Milan, Italy
Luca Testa, MD, PhD
Department of Cardiology
Istituto Clinico S. Ambrogio
Milan, Italy
The current online version of the article has been corrected.
(Circulation. 2014;129:e327.)
© 2014 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIR.0000000000000014
e327
15/08/2014
