Utilization of cusp-overlap projection affects the occurrence of 30-day conduction disturbances and the need for permanent pacemaker implantation following TAVR.

Mostafa Salem (Kiel)1, D. Frank (Kiel)1, H. Seoudy (Kiel)1, J. Voran (Kiel)1, J. Frank (Kiel)1, R. H. Rangel (Kiel)1, M. Saad (Kiel)1

1Universitätsklinikum Schleswig-Holstein Innere Medizin III mit den Schwerpunkten Kardiologie, Angiologie und internistische Intensivmedizin Kiel, Deutschland


Objective: This study aimed to evaluate the safety and effectiveness of the different implantation techniques for aortic transcatheter heart valve replacement (TAVR). We compare the classic implantation technique, the 3 Cusp view Technique (3CT), with the newest version, the cusp overlap technique (COT). Self-expanding aortic protheses have been associated with an increased risk of new permanent pacemaker implantation (PPMI). The deeper the implantation, the more conduction system damage and the more the potential for higher PPMI rates. Using COT aims to achieve a lower implantation depth and, as a result, reduces the occurrence of postprocedural new conduction disturbance and PMI.

Methods: Between March 2018 and April 2020, 194 patients were consecutively enrolled in our study. 101 patients underwent TAVR using the COT, while the other 93 received the 3CT. The implantation depth was assessed using the distance from the deepest edge distance from the left coronary cusp and the noncoronary cusp to the TAVR-prothese. The primary endpoint was the 30-day incidence of PPMI after TAVI. Secondary endpoints were the post-procedural occurrence of general conduction disturbance and the incidence and degree of paravalvular leak (PVL) after the TAVI, according to the VARC-3 definitions.

Results: The COT group exhibited a significantly lower implantation depth compared to the classic technique group (3CT) (Depth from LCC; 8.7 mm ± 3.6 vs 10 mm ± 6; P = 0.6; Depth from NCC; 8.1 mm ± 4.2 vs. 9 mm ± 6.7; P = 0.8 ). Moreover, 44 patients (22.7%) required a new PPMI during the 30-day follow-up period. However, the COT group showed a significantly lower PPMI rate than the 3CT group (17.8% vs. 28%, P = <0.09). The general conduction disturbance was lower in the COT than in the 3CT (36.6% vs 55.5%; 0.007). The COT consistently demonstrated protective effects against PPMI while maintaining similar procedural success rates and complication occurrences.

Conclusions: The COT, a simple modification of the standard protocol, facilitates a lower implantation depth for TAVRs, leading to a reduction in the new conduction disturbances and PMI rates.

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