TAVR is a well-established course of treatment, increasingly indicated in lower risk populations. However, one of the challenges associated with self-expanding TAVR, compared against balloon expandable TAVR and SAVR, is the frequent need for definite permanent pacemaker implantation (PPI).
High implantation, also known as cusp overlapping (COT), has been shown to reduce the need for definite PPI by preventing conduction disturbances at the lowest part of the membranous septum.
Transjugular intracardiac echocardiography (ICE) might contribute to reduce the need for definite PPI in self-expandable TAVR, even though its efficacy is yet to be determined.
446 patients undergoing TAVR were divided in three groups: 211 (47.3%) treated with coplanar projection of 3 cusps without ICE (3 cusps no ICE); 129 with COT without ICE (28.9%); and 106 with COT and ICE (23.8%). They received Medtronic’s Evolut R and Evolut PRO/PRO+.
Primary end point was need for PPI at 30 days after procedure.
The groups were comparable, with mean age 86, 40% men and 6% STS. The prevalence of conditions such as hypertension, dyslipidemia, diabetes, atrial fibrillation and others was similar between groups. The presence of AV block was 20% and RBBB 10%.
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There were no differences in aortic valve area or gradient, and ejection fraction was 62%. Neither were there differences in angioCT between the groups.
The transfemoral approach was used in 90% of cases and there were no significant differences in access site, valve diameter, pre or post-dilation between the groups.
Primary end point resulted in favor of patients receiving COT with ICE (14.2% vs. 7.0% vs. 0.9% for 3 cusps no ICE, vs. COT no ICE vs. COT + ICE, respectively, p < 0.001). Implantation depth was also lower with COT + ICE (4.3 mm vs. 2.2 mm vs. 1.9 mm, p < 0.001). it was also associated to lower prior AV block progress, AB block and LBBB.
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There were no differences in mortality at 30 days.
The echocardiographic analysis showed the 3 cusps no ICE group presented a lower indexed orifice area and greater prosthesis mismatch, with no significant differences in the presence of leaks.
The multivariable analysis showed the use of COT + ICE was associated with a reduction in definite PPI.
Conclusion
In conclusion, this novel approach to TAVR using transjugular intracardiac echocardiography capable of real time viewing of the membranous septum, allows high prosthesis positioning, which results in a remarkable reduction of conduction disturbances and therefore a lower need for pacemaker implantation after TAVR.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Reference: Kenichi Ishizu, et al.
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