Influence of cusp-overlap and three-cusp coplanar techniques on new-onset conduction disturbances after TAVI

New-onset conduction disturbances remain one of the most frequent complications after transcatheter aortic valve implantation (TAVI), being associated with worse long-term clinical outcomes. Among the main determinants is the implantation depth of the prosthesis in relation to the length of the membranous septum. In this context, the cusp-overlap (COL) technique emerged as an alternative angiographic strategy to the conventional three-cusp coplanar (TCC) projection, aiming to reduce parallax and facilitate higher and more controlled valve implantation.

This single-center retrospective study evaluated whether the COL technique truly reduces conduction disturbances or whether its benefit mainly depends on achieving a lower implantation depth relative to the membranous septum. The primary endpoint was the composite of high-grade atrioventricular block or permanent pacemaker implantation at 30 days. Secondary endpoints included persistent left bundle branch block, implantation depth, and clinical events during follow-up.

A total of 501 patients undergoing TAVI between 2020 and 2023 were included. Mean age was 80.3 ± 7.4 years, 46.5% were women, and the mean EuroSCORE II was 11.2 ± 9.1%. Femoral access was used in 89% of cases and left carotid access in 11%. Balloon-expandable valves were implanted in 75.6% of patients and self-expanding valves in 24.4%. The COL technique was used in 177 patients (35.3%) and the TCC technique in 324 (64.7%), with a progressive increase in COL use over time.

The primary endpoint occurred in 90 patients (18%), with no significant differences between COL and TCC (15% vs 19%; p=0.24). Likewise, no differences were observed in the incidence of persistent left bundle branch block (26% vs 25%; p=0.92). However, the COL technique achieved significantly higher implantations: 4.0 ± 1.95 mm versus 5.54 ± 2.6 mm from the non-coronary cusp (p<0.01).

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In addition, a greater distance between the membranous septum and the final implantation depth was independently associated with a lower risk of conduction disturbances (OR 0.78; 95% CI 0.71–0.85; p<0.001), suggesting less interaction between the device and the conduction system. Other independent predictors of the primary endpoint were advanced age, baseline first-degree AV block, complete right bundle branch block, and the use of Portico/Navitor valves.

During a median follow-up of 525 days, the occurrence of high-grade AV block or the need for permanent pacemaker implantation was associated with higher mortality and heart failure hospitalization.

Conclusion: The cusp-overlap technique did not reduce conduction disturbances after TAVI.

The cusp-overlap technique did not independently reduce post-TAVI conduction disturbances, although it facilitated higher implantation relative to the membranous septum, reinforcing the concept that the relationship between implantation depth and individual patient anatomy is the main determinant of conduction disturbance risk after the procedure.

Original Title: Influence of the Cusp-Overlap and Three Cusps Coplanar Techniques on New-Onset Conduction Disturbances Following Transcatheter Aortic Valve Implantation.