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Minimizing Permanent Pacemaker After Repositionable Self-Expanding TAVR
Study Questions:
Does modified positioning of self-expanding transcatheter aortic valve replacement (TAVR) lead to lower risk of permanent pacemaker implantation (PPMI)?
Methods:
At a single center, 248 consecutive patients with severe aortic stenosis (AS) underwent TAVR with repositionable self-expanding TAVR with a standard approach to device implantation. A detailed analysis of multiple factors contributing to was performed; this was used to generate an anatomically guided MIDAS (MInimizing Depth According to the membranous Septum) approach to device implantation, aiming for pre-release depth in relation to the noncoronary cusp of less than the length of the membranous septum.
Results:
Right bundle branch block, membranous septum length, largest device size (Evolut 34 XL) and implant depth > membranous septum length predicted PPMI. On multivariate analysis, only implant depth > membranous septum length (odds ratio [OR], 8.04; p < 0.001) and use of Evolut 34 XL valve (OR, 4.96; p = 0.004) were independent predictors of PPMI. The MIDAS approach was applied prospectively to a consecutive series of 100 patients, with operators aiming to position the device at a depth of less than the membranous septum length whenever possible. This reduced the new PPMI rate from 10% in the standard cohort to 3% (p = 0.035); the rate of new left bundle branch block (LBBB) went down from 26% to 9% (p < 0.001).
Conclusions:
Using a patient-specific MIDAS approach to device implantation, repositionable self-expanding TAVR achieved very low and predictable rates of PPMI and LBBB, which are significantly lower than previously reported with self-expanding TAVR.
Perspective:
A very small difference in device positioning can exert dramatic differences in the need for PPMI. The MIDAS approach to device implantation using repositionable self-expanding TAVR, as described by the authors, appears to mitigate the risk of PPMI. This is consistent with prior reports showing a lower risk with higher (less ventricular) depth of deployment. A caveat here is that this is a short-term study and it does not provide outcomes data following the procedure, although there may be additional advantages of the higher placement not related to the risk of PPMI. Of note, the membranous septum length in the present study is a bit of a misnomer, as it is not the actual membranous septum length, but rather its co-axial caudal length in relation to the basal annular plane, which is used intraprocedurally for TAVR device positioning.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and ACS, Interventions and Structural Heart Disease
Keywords: Acute Coronary Syndrome, Arrhythmias, Cardiac, Aortic Valve Stenosis, Bundle-Branch Block, Geriatrics, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Pacemaker, Artificial, Risk, Secondary Prevention, Transcatheter Aortic Valve Replacement
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