We are well aware of the benefits of TAVR in different scenarios, but the need for permanent pacemaker implantation (PPI) in self-expandable valves is between 15% and 30% according to different randomized and non-randomized studies.
This is why the higher implantation strategy or cusp overlap (COT) was developed and, though it has been shown to significantly reduce the need for PPI, so far, no randomized studies have looked into it.
This study included 2209 patients with severe symptomatic aortic stenosis receiving self-expandable supra-annular valves from Medtronic (Evolut R, Evolute Pro and Evolute Pro+). 1151 of these patients were treated with the standard three-cusp implantation technique (3CT) (52.1%) and 1058 with the COT strategy.
Primary end point was need for PPI at discharge.
Mean age was 82 and 54% of the population were women. After propensity score matching to balance for differences, 995 patients were left in each group.
STS score was 3.6%, 96% was femoral, 91% under conscious sedation.
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Procedural time was lower with COT, as was fluoroscopy time.
Pre and post-dilation were more frequent with COT, as was oversizing. Contrast volume was lower with COT.
PPI resulted in favor of COT in both the general and the matched population, 12.3% vs. 17% p=0.002 and 11.9% vs 17% p=0.001 respectively. New left bundle branch block was more frequent with COT (27.5% vs 22.6% p=0.01), and there were no differences in right bundle branch block.
There were no differences in major complications.
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Severe and moderate paravalvular regurgitation were significantly lower in patients treated with COT (4.6% vs. 2.4% p=0.006).
In multivariable logistic regression, right bundle branch block and diabetes resulted predictors of PPI and COT resulted protective.
Conclusion
COT was associated with significant reduction of PPI and paravalvular regurgitation with no increase in complications.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Cusp overlap versus standard three-cusp technique for selfexpanding Evolut transcatheter aortic valves.
Reference: Hendrik Wienemann, et al. EuroIntervention 2023;18-online publish-ahead-of-print April 2023.
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