Definite Pacemaker Implantation Predictors in TAVR High Implant Using Cusp Overlap

TAVR has been shown beneficial but one of the current challenges especially in low risk populations is the need for pacemaker implantation (PPMI) after self-expanding TAVR. This situation has been associated with higher costs and potential complications at followup, such as endocarditis and tricuspid failure. 

Implanting these valves in a very high position, known as “cusp overlap”, has been shown to reduce the need for PPMI. However, we are yet to determine whether PPMI predictors are the same as those for the conventional three cusp technique. 

261 TAVR patients receiving cusp overlap were analyzed. 314 of these patients (11,9%) required PPMI. Patients receiving balloon expanding valves were excluded, also aortic stenosis patients with bicuspid valve, aortic failure, prior pacemaker, V-in-V and TAVI-in-TAVI. 

Study patients were similar. Mean age was 81, and over half were men. STS score was 6.9. Hypertension prevalence was 95%, diabetes 26.4%, MI 10.3%, CABG 9.3%, PCI 42.1%, stroke 1.5%, kidney function deterioration 49% and dialysis 1.5%.

Mean ejection fraction was 56%, aortic valve area (AVAO) 0.69 cm² and mean gradient 49 mmHg.

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Regular sinus rhythm was more frequent among patients not requiring PPMI, while those who did need it more often presented first and second degree AV block, trifascicular and complete RBBB, vs those not requiring PPM. 

98,7% of procedures were done via femoral approach, 5.4% required brain protection; pre-dilation was done in 79% and post-dilation in 37%. 22% of cases required recapturing, implantation depth was 2.18 mm, there were no valve embolization cases and nearly 99% of cases used a percutaneous closing system. 

The most used valve was EVOLUTE R/PRO (83,9%), followed by Accurate Neo (10%) and, less frequently the Portico, Vitaflow and Navitor.

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At 30 days, all proceudres were technically successful. There were no differences in mortality (2,3%), MI (0,4%), stroke (0,4%), major or minor bleeding, major or minor vascular complications, moderate or severe leak, reintervention, emergency surgery or transient or permanent complete LBBB. However, hospitalization was longer among those requiring PPMI. 

When implantation depth was over 4 mm, there was a need for PPMI in 63% in the presence of complete RBBB, 25% in first or second degree AV block, 13% in complete RBBB, but not in those with sinus rhythm with no conduction abnormalities. 

Independent predictors of PPM were implantation depth >4 mm and conduction abnormalities, being complete RBBB the most relevant, followed by first and second degree AV block and incomplete LBBB. 

Conclusion:

Deep implantation and prior conduction abnormalities are the main predictors of need for PPMI in patients undergoing TAVR with self-expanding valves, even in the era of cusp overlap. Patients with high implantation and no conduction abnormalities might be good candidates for early discharge after TAVR with self-expanding valves, while the rest, despite high implantation, might require continued monitoring. The need of PPMI was associated with longer hospital stay. 

Original Title: Predictors of permanent pacemaker implantation for transcatheter self‐expandable aortic valve implant in the cusp overlap era.

Reference: Oscar A. Mendiz,  et al. Catheter Cardiovasc Interv. 2024;1–8. DOI: 10.1002/ccd.31176.