Arrhythmias Associated with Aortic Stenosis

Ventricular Arrhythmias

Ventricular tachycardia and ventricular fibrillation are the predominant life-threatening arrhythmias in aortic stenosis, with Holter monitoring demonstrating ventricular tachyarrhythmias in 6 of 7 patients who died suddenly, while only 1 patient had bradyarrhythmia 1, 2, 3
The frequency and severity of ventricular arrhythmias decrease significantly after transcatheter aortic valve implantation (TAVI), with complex arrhythmias reducing from 48.6% pre-procedure to 16.4% at 12 months post-procedure 4

Ventricular overload from aortic stenosis creates the substrate for arrhythmias, even when peripheral blood pressure is low 4
Multiple mechanisms contribute to sudden cardiac death in aortic stenosis: abnormal Betzold-Jarisch reflex, ventricular tachyarrhythmias, and atrioventricular conduction disturbances 1, 2, 3

Conduction disorders in the His bundle and trifascicular system are associated with aortic stenosis, with more extensive involvement when the valve is calcified 1, 2, 3
These conduction abnormalities can lead to bradyarrhythmias, though this is a less common mechanism of sudden death compared to ventricular tachyarrhythmias 1, 2, 3

Atrial fibrillation has adverse effects on atrial pump function and ventricular rate in aortic stenosis, and prompt cardioversion or pharmacological rate control is essential if cardioversion is unsuccessful 5

Sudden cardiac death risk is low in asymptomatic patients with aortic stenosis, and prospective data show no sudden deaths occurred in 123 asymptomatic patients followed for 2.5 years 1, 2, 3
Once symptoms develop, the incidence of sudden cardiac death increases dramatically to 8-34% in different studies, with approximately 20% of all deaths in AS being sudden 1, 2, 3

History of syncope, previous cardiac arrest, and rapid sustained ventricular tachycardia on Holter monitoring or exercise testing are regarded as predictors of major arrhythmic events 1, 2

Restriction of physical activity should be advised in patients with moderate and especially severe aortic stenosis to reduce arrhythmia risk 1, 2, 3
Patients presenting with sustained ventricular tachycardia or fibrillation should be considered for ICD implantation, particularly if inducible at electrophysiological study 1, 2, 3
Beta blockers may be appropriate for patients with aortic stenosis who have reduced ejection fraction, prior MI, arrhythmias, or angina pectoris 6, 7