Risk Of Permanent Pacemaker Implantation Research Articles

Mean compression ratio of a self-expandable valve is associated with the need for pacemaker implantation after transcatheter aortic valve replacement

BackgroundThe risk and timing of permanent pacemaker implantation (PPMI) after transcatheter aortic valve replacement (TAVR) is still hard to predict. We aimed to analyze the relationship between the compression ratio of a self-expandable valve (SEV) and the need for PPMI after TAVR.MethodsA total of 106 patients who were implanted with the VitaFlow transcatheter aortic valve system and for whom complete imaging information was available were included in this retrospective cohort study. Eight lines perpendicular to the long axis of the SEV were drawn (the top and bottom of the SEV and the intersection of each row of wires) for measurement purposes. The compression ratio was calculated as 1 − (in vivo meridian/in vitro meridian) and compared between patients undergoing and those not undergoing PPMI after adjusting for implantation depth. Multivariable logistic regression and Cox proportional hazards models were used to assess factors associated with the risk and timing of the need for PPMI.ResultsFifteen (14.2%) patients underwent PPMI after TAVR. Patients with a higher mean compression ratio (20%, odds ratio [OR] = 214.82; p < 0.001) and prior right bundle branch block (OR = 51.77; p = 0.015) had a higher risk of the need for PPMI after TAVR. These two factors were also associated with the timing of PPMI, according to the Cox proportional hazards model.ConclusionsThe compression ratio of the SEV was positively associated with the risk of PPMI after TAVR, and the association was most significant in the annular and supravalvular planes. The compression ratio may also affect the time to PPMI.

Prevalence and predictors of pacemaker implantation in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: TAVI-NOR study

Abstract Background The transcatheter aortic valve implantation (TAVI) in patients with aortic stenosis (AS) asserts mechanical forces during valve expansion both on the aortic root and conduction system. TAVI is therefore frequently associated with the development of conduction abnormalities requiring a permanent pacemaker implantation (PMI). Purpose To identify predictors of new PMI in unselected patients with severe AS undergoing TAVI. Methods Among the 600 patients consecutively enrolled in TAVI-NOR study, 52 had PMI prior to TAVI and were excluded, remaining 548 patients eligible for this analysis. Predictors of PMI were identified in binary logistic regression analyses. Results A total of 189 patients (31.5%) required a new PMI post TAVI, evenly distributed between females and males (30.1% vs 32.9%, p=0.456). Higher age, comorbidities such as hypertension, chronic kidney disease, coronary artery disease, diabetes, and left ventricular hypertrophy on ECG or echocardiography, and the severity of AS had no association with the risk of PMI after TAVI (Table 1). In univariate logistic regression analyses, larger aortic root diameter was associated with a higher risk of new PMI (OR 1.66; 95% 1.07-2.58, p=0.024), but was no longer significant in multivariate model, and bioprosthesis size had no association with the need for a PMI following TAVI. Bundle branch block (BBB) (OR 1.52; 95% 1.00-2.31, p= 0.051), and especially right BBB (RBBB) (OR 2.05; 95% 1.14-3.70, p= 0.017) showed increased risk of a new PMI, also in a multivariable-adjusted analysis (OR 2.67; 95% 1.39-5.11, p=0.003). Lotus bioprosthesis with mechanical expansion was associated with an increased risk of PMI (OR 2.92; 95% CI 1.92-4.45, p&amp;lt;0.001), while balloon expandable Sapiens had a lower risk for PMI (OR 0.15; 95% CI 0.06-0.37, p&amp;lt;0.001). In a multivariable-adjusted analysis, the use of Lotus valve (OR 2.23; 95% CI 1.44-3.46, p&amp;lt;0.001) was still associated with a higher risk, and use of Sapien with a lower risk of PMI (OR 0.15; 95% CI 0.06-0.40, p&amp;lt;0.001) independent of non-significant association with atrial fibrillation (p=0.067), lower heart rate (0.077), aortic root (p=0.225) and stroke volume index (p=0.097). Adding age and gender to the same primary multivariable-adjusted model did not change our conclusions: Lotus (OR 2.28; 95% CI 1.46-3.57, p&amp;lt;0.001) and RBBB (OR 2.63; 95% CI 1.37-5.04, p=0.004) and Edward Sapien (OR 0.15; 95% 0.06-0.39, p&amp;lt;0.001) of post-procedural PMI. Conclusion Our data from less selected patients with severe AS patients show that pre-intervention RBBB and the use of bioprosthesis with mechanic expansion (Lotus) were associated with a higher risk, and the use of balloon expandable bioprothesis (Sapiens) with a lower risk of PMI after TAVI. We found no gender differences in risk of PMI.

Reevaluation of the indications for permanent pacemaker implantation after cardioneuroablation

Abstract Background Cardioneuroablation(CNA) is promising and innovative method to cure vagally mediated bradycardia.However, according to current ESC2021 guidelines patients may have indications for permanent pacing. CNA is still referred to patients as an experimental and alternative method,not being recommended in guidelines due to too small amount of evidence.The study sought to validate criteria for permanent pacemaker(PPM) implantation,discontinuation of PPM therapy(PPMT) and risk of PPM implantation after CNA in a large population of patients qualified for electrophysiologic study(EPS),Extracardiac vagal nerve stimulation(ECVS) and CNA. Methods Data were collected from POLish prospective multicentre CardioneuroAblation registry(POLCA) with comprehensive management, interdisciplinary consultations, state-of-art autonomic tests, atropine tests, EPS as well as ECVS. Shared-decision making was used to developed patient-oriented therapy with clear declaration of fulfilling indications for PPMT according to ESC guidelines,(when applicable) and CNA only as alternative and developing technique. Results A total of 195 consecutive adult patients(mean age:55,6+/-14,3 years; min 20,0 Q1 44,96-Q2 58,4 - Q3 67,2; max 82;107(54%)females,) underwent first CNA. Out of them, 17(8,2%) had already PPM. According to current guidelines 100/178(51%) patients had de novo indications for PPM implantation prior to CNA including: SND(n=88,45%), AVB(n=21, 10%), TBS (n=26, 13%), CI-VVS(n=41; 21%),M-VVS(n=1;0,5%), CI-CCS(n=41;21%) or mixed etiologies (n=45;23%). Indications for de novo PMT were present in 32(37%) patients above age 60. During moderate-term (23,7+/-10,3 months), no patient died, and only 10 had syncope (which was diagnosed as orthostatic or vasodepressive). Despite preprocedural positive atropine test and positive ECVS, 6 out of 195 patients (had early and elective PPM implantation due to coexistence of functional and structural bradycardia(n=3) or bradycardia recurrences(n=2) or severe sinus chronotropic incompetence(n=1). There were 7(3,5%) major complications (tamponade (n=2), pericarditis(n=2), pericardial effusion(n=1), femoral aneurysm(n=1), pneumothorax(n=1) of CNA. Only 4 of patients with indications for PPM implantation before CNA still had those indications during follow-up. Out of 6 patients with late PPM implantations after CNA, 1 patient had syncope due to development of AVB. Conclusions About 51%patients referred for CNA had indications for PPM therapy. CNA in subgroup of patients with functional bradycardia is becoming alternative choice to PPMT and allowed to give up PPM implantation at least temporarily in 96%patients without prior PPMT. However some patients require PMT due to failed CNA or reinnervation,but also co-existence or development of complex structural bradyarrhythmias.

Pacemaker implantation after cardiac surgery: a contemporary analysis

Abstract Background Cardiac surgery entails an increased risk for bradyarrhythmias. Currently known rates for permanent pacemaker (PPM) implantation after cardiac surgery are derived from non-contemporary studies. Purpose We sought to explore the one-year incidence and indications for PPM implantation after different cardiac surgical procedures in the modern era. Methods All patients in Sweden from 2006 to 2020 who underwent first-time cardiac surgery without previous PPM or implantable cardioverter-defibrillator (ICD) were included in this nationwide population-based study using data from three national registries (SWEDEHEART, National Patient Registry and Swedish ICD &amp; Pacemaker Registry). Patients who received an ICD (n=1,714) and patients undergoing heart transplantation (n=376) were excluded. Sex- and age-matched controls from the general population were used for comparison. Results A total number of 83,484 patients and 82,921 controls were included. Median follow-up was 6.3 years (range 0-15 years). A PPM was implanted in 8.0% (n= 6,707) of the patients, out of these 46.2% (n= 3,101) had pacemaker implanted during the first postoperative year. Atrioventricular block was the main indication in 1,988 (64.1%) of the patients and 1,113 (35.9%) received a PPM due to sinoatrial disease. The incidence rate per 100 patient-years for PPM implantation during the first postoperative year was 1.4 (95% confidence interval 1.3-1.5) for those who underwent coronary artery bypass grafting (CABG), 15.8 (14.6-18.4) following mitral valve surgery, 7.0 (6.6-7.5) after aortic valve surgery and 9.6 (8.6-10.3) for those with combined CABG and valve surgery. The median time from surgery to PPM implantation was 10 days (IQR 7 – 28, Figure 1A and Figure 1B). Compared to the control population, the risk for PPM implantation after cardiac surgery was higher even beyond the first post-operative year. Conclusions The need for PPM after cardiac surgery is highest during the first 30 postoperative days and mostly due to atrioventricular block. The incidence rate for PPM implantation after mitral valve surgery was higher than that following CABG, aortic valve, or combined CABG and/or valvular surgery.Figure 1AFigure 1B

Self-expanding or balloon-expandable transcatheter aortic valve replacement in a German comparison

Abstract Background Studies demonstrated that results for self-expanding vs balloon-expandable transcatheter aortic valve replacement (TAVR) are similar, with larger subgroup analyzes missing. Methods We identified 46,243 self-expanding (SE) and balloon-expandable (BE) transfemoral TAVR for aortic stenosis in German hospitals in 2019 or 2020. Both in-hospital outcomes as well as subgroups for in-hospital mortality were analyzed. Results Regarding baseline characteristics, the logistic EuroSCORE was higher in SE (SE 13.6% - BE 12.7%; p&amp;lt;0.001), which also applied to age (SE 81.6a - BE 80.0a; p&amp;lt;0.001). There was a comparable in-hospital mortality rate in both groups (BE 2.37% - SE 2.35%; p=0.916). Risk adjusted in-hospital mortality was also not significantly different (OR=0.98, p=0.799). The SE group presented a significantly lower risk of major bleeding events (OR=0.83, p=0.006), however, there was a significantly higher risk of stroke (OR=1.38, p&amp;lt;0.001), risk of delirium (OR=1.15, p=0.001) as well as risk of permanent pacemaker implantation (OR=1.29, p&amp;lt;0.001). No difference has been found for acute kidney injury, mechanical ventilation &amp;gt;48h, length of hospital stay, and reimbursement. In addition, the subgroups showed no significant differences for in-hospital mortality regarding age, logistic EuroSCORE, gender, heart failure NYHA III/IV, previous coronary artery bypass graft, peripheral vascular disease, chronic obstructive pulmonary disease, pulmonary hypertension, renal disease GFR &amp;lt;30ml/min or diabetes mellitus. Conclusion Self-expanding or balloon-expandable TAVR did not show significant differences for in-hospital mortality in a subgroup analysis in Germany.

Pacemaker implantation following tricuspid valve annuloplasty

ObjectiveTricuspid annuloplasty is associated with increased risk of atrioventricular block and subsequent implantation of a permanent pacemaker. However, the exact incidence of permanent pacemaker, associated risk factors, and outcomes in this frame remain debated. The aim of the study was to report permanent pacemaker incidence, risk factors, and outcomes after tricuspid annuloplasty from nationwide databases. MethodsBy using data from multiple Swedish mandatory national registries, all patients (n = 1502) who underwent tricuspid annuloplasty in Sweden from 2006 to 2020 were identified. Patients who needed permanent pacemaker within 30 days from surgery were compared with those who did not. The cumulative incidence of permanent pacemaker implantation was estimated. A multivariable logistic regression model was fit to identify risk factors of 30-day permanent pacemaker implantation. The association between permanent pacemaker implantation and long-term survival was evaluated with multivariable Cox regression. ResultsThe 30-day permanent pacemaker rate was 14.2% (214/1502). Patients with permanent pacemakers were older (69.8 ± 10.3 years vs 67.5 ± 12.4 years, P = .012). Independent risk factors of permanent pacemaker implantation were concomitant mitral valve surgery (odds ratio, 2.07; 95% CI, 1.34-3.27), ablation surgery (odds ratio, 1.59; 95% CI, 1.12-2.23), and surgery performed in a low-volume center (odds ratio, 1.85; 95% CI, 1.17-2.83). Permanent pacemaker implantation was not associated with increased long-term mortality risk (adjusted hazard ratio, 0.74; 95% CI, 0.53-1.03). ConclusionsThis nationwide study demonstrated a high risk of permanent pacemaker implantation within 30 days of tricuspid annuloplasty. However, patients who needed a permanent pacemaker did not have worse long-term survival, and the cumulative incidence of heart failure and major adverse cardiovascular events was similar to patients who did not receive a permanent pacemaker.

Native aortic leaflets and permanent pacemaker implantation risk following balloon-expandable transcatheter aortic valve implantation

ObjectivePermanent pacemaker implantation (PPI) risk is higher following transcatheter aortic valve implantation (TAVI) than surgical valve replacement. Native aortic leaflets are retained in patients undergoing TAVI, unlike in surgical valve replacement. Whether the retained leaflets influence PPI risk because of their proximity to the conduction system is unknown. The study sought to determine the association between infra-annular extension of native right coronary cusp/noncoronary cusp (RCC/NCC) post balloon-expandable TAVI and PPI risk. MethodsWe performed a retrospective analysis of 190 patients undergoing balloon-expandable TAVI at a single center. Manifestation of infra-annular extension of RCC/NCC was considered to be present when part of leaflet extended below aortic–annular plane on post-implantation aortic-root angiography. ResultsInfra-annular extension of RCC/NCC was observed in 33 patients (17.37%). PPI incidence post-TAVI was higher in patients with infra-annular extension of RCC/NCC than in those without (36.36% versus 8.92%, relative-risk: 4.08, p˂0.0001). On logistic-regression analysis, preexisting right bundle-branch block (RBBB) (odds-ratio: 12.73, 95% confidence-interval: 2.16–74.93, p = 0.005), and infra-annular extension of RCC/NCC (odds-ratio: 5.63, 95% confidence-interval: 2.17–14.58, p < 0.0001) were independently associated with PPI risk. Preexisting RBBB (φ = +0.25, p = 0.001) and infra-annular extension of RCC/NCC (φ = +0.30, p < 0.0001) showed a positive-correlation with PPI risk. Infra-annular extension of RCC/NCC was a significant predictor of PPI risk on receiver-operating-characteristic curve analysis (area under-the-curve 0.67; 95% confidence-interval: 0.54–0.79, p = 0.006). ConclusionThe retained native aortic leaflets play a significant role in PPI risk following balloon-expandable TAVI. Infra-annular extension of RCC/NCC is a novel predictor, and is associated with a four-fold higher risk of PPI.

Transcatheter versus surgical aortic valve replacement in patients with aortic regurgitation: A propensity-matched analysis

This study aimed to analyze in-hospital and early-to-interim outcomes of pure aortic regurgitation (AR) using transcatheter aortic valve replacement (TAVR) vs. surgical aortic valve replacement (SAVR). BackgroundFew studies have discussed and compared the safety and short-term prognosis of TAVR and SAVR in pure AR patients. As such, we looked to the National Readmissions Database (NRD) for records between 2016 and 2019 in order to identify patients diagnosed with pure AR who underwent SAVR or TAVR. We used the propensity score matching to minimize disparities between two groups. We included 23,276 pure AR patients: 1983 (8.5%) who underwent TAVR and 21,293 (91.5%) who underwent SAVR. We found 1820 matched pairs using propensity score matching. In the matching cohort, TAVR was associated with a low risk of in-hospital mortality. Although TAVR had lower incidences of 30-day all-cause readmission (hazard ratio (HR):0.73, 95% confidence interval (CI): 0.61–0.87; P < 0.01) and 6-month all-cause readmission (HR: 0.81, 95% CI: 0.67–0.97; P = 0.03), while TAVR had high incidences of 30-day permanent pacemaker implantation incidence (HR: 3.54, 95% CI: 1.62–7.74; P < 0.01) and 6-month permanent pacemaker implantation incidence (HR: 4.12, 95% CI: 1.17–14.4; P = 0.03).In conclusion, TAVR and SAVR had similar risks of hospital death and lower rates of 30-day and 6-month all-cause and cardiovascular readmission. But TAVR had a higher risk of permanent pacemaker implantation than SAVR in AR patients, suggesting that TAVR can be performed safely in pure AR patients.

Auditing the safety and efficacy of interventional septal reduction therapies in hypertrophic obstructive cardiomyopathy at a specialized tertiary centre

Abstract Funding Acknowledgements Type of funding sources: None. Background Hypertrophic cardiomyopathy (HCM) is a recognized cause of sudden cardiac death and dysrhythmias. Patients with HCM and marked left ventricular outflow tract obstruction (LVOTO) may benefit from invasive therapies such as septal myectomy or alcohol septal ablation (ASA) (1). This study aimed to compare patient outcomes post-ASA and post-septal myectomy within a specialized tertiary centre. Purpose To establish the efficacy and safety outcomes of septal reduction therapies. Postoperative conduction abnormalities are the most common long-term postoperative complications in this population (2); however, specific patient outcomes at our tertiary heart centre were previously unknown. Methods This retrospective analysis included patients who underwent ASA (n= 66) or septal myectomy (n=151) between 2015 and 2021. Ethical approval was obtained before commencing the study. Two independent investigators extracted the preoperative and postoperative data from echocardiograms, electrocardiograms, clinic letters, and discharge forms. Normally distributed variables were reported as mean and standard deviation and analysed using an unpaired T-test with Welch's correction. Non-normally distributed variables were reported as median and interquartile range and analysed using the Mann-Whitney U test. Results The mean follow-up time was 2.69 ±1.37 years in the ASA cohort and 1.38 ±1.18 years in the myectomy cohort. There were no differences in gender or ethnic composition; however, on average, patients in the ASA cohort were 10.40 ± 1.82 years older than those in the myectomy cohort (95% CI: 13.99 to 6.81, p&amp;lt; 0.0001). Significant improvements in New York Heart Association (NYHA) class occurred across both cohorts (p&amp;lt; 0.0001). Post-ASA resting LVOT gradients decreased from 54.00 to 13.00 mmHg (95% CI: -45.00 to -21.00, p&amp;lt; 0.0001). Post-myectomy resting LVOT gradients decreased from 60.00 to 4.90 mmHg (95% CI: -57.00 to -41.00, p&amp;lt; 0.0001) and were significantly lower than post-ASA (p= 0.0007). In addition, re-intervention rates were higher post-ASA compared to post-myectomy 40% vs 1.32% respectively, (p&amp;lt; 0.0001). ASA also carried a greater risk of permanent pacemaker implantation 18% vs. 8% (p=0.0270), complete heart block 22% vs. 6% (p= 0.0016), and right bundle branch block 28% vs 0% (p&amp;lt; 0.0001) compared to septal myectomy. In contrast, septal myectomy had a greater risk of postoperative atrial fibrillation 20% vs 1.5% (p= 0.0004), and left bundle branch block 60% vs 7% (p&amp;lt; 0.0001) compared to ASA. Perioperative mortality was 0 (0%) in both cohorts. Conclusion In conclusion, both interventions were safe and provided significant symptomatic relief and effective gradient reduction. However, conduction abnormalities remain a considerable risk of septal reduction therapies and may contribute to patient morbidity. More research is needed to minimize intervention risks and further improve patient outcomes.

Transcatheter Valve Implantation in Patients with Multivalvular Heart Disease

Free AccessTranscatheter Valve Implantation in Patients with Multivalvular Heart DiseaseTranskatheter-Klappenimplantation bei Personen mit multivalvulärer HerzerkrankungOjuola Boris Adjibodou, Miriam Brinkert, and Laurent HaegeliOjuola Boris AdjibodouDr. med. Ojuola Boris Adjibodou, Kantonsspital Aarau AG, Tellstrasse 25, 5001 Aarau, Switzerlandojuola.adjibodou@ksa.ch Department of Cardiology, Cantonal Hospital Aarau, Aarau, Switzerland Search for more papers by this author, Miriam Brinkert Department of Cardiology, Cantonal Hospital Aarau, Aarau, Switzerland Search for more papers by this author, and Laurent Haegeli Department of Cardiology, Cantonal Hospital Aarau, Aarau, Switzerland Search for more papers by this authorPublished Online:February 01, 2023https://doi.org/10.1024/1661-8157/a003983PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreTranscatheter aortic valve replacement (TAVR) has increased during the last two decades as an alternative to surgery across all risk profiles for patients with symptomatic aortic stenosis (AS), the most common valvular disease in western countries. Although the prevalence of degenerative multivalvular disease is growing with advancing age, little randomized data exist to guide therapy in this population. Mitral regurgitation (MR) is the most common valve impairment in patients undergoing TAVR (near to 20%), followed by tricuspid regurgitation (TR), mitral stenosis (MS) and aortic regurgitation (AR). The prognostic impact and the changes of severity of MR combined to AS in TAVR patients has been well studied, but there are several underlying limitations not allowing a definitive conclusion. In general, the impact of multivalvular disease on mortality after TAVR remains uncertain [1, 2].In this issue of the journal "Praxis", Fritschi et al. [3] review the evidence currently supporting a comprehensive pathophysiology, the clinical implications and treatment of multivalvular disease in patients undergoing TAVR. They highlight the challenge of quantifying and assessing the severity of these multivalvular disease, pointing out that it is essential not only to have a good knowledge of the pathophysiological interactions they induce, but also to use new imaging modalities (3D-echocardiography, multi-slice CT imaging) and right/left heart catheterisation in order to avoid underestimation of the disease and enhance the comprehension of the underlying mechanism before the heart team decision. Indeed, because the evolution of the combined valve disease is not always predictable after successful TAVR, the authors emphasise the central role of the multidisciplinary heart team bearing on the decision to propose the most appropriate and therefore individualised treatment for each patient, considering the plethora of clinical, hemodynamic, and imaging data as well as physiological and psychological considerations. The authors also provide three scenarios inspired by Khan et al. 2020 [4], covering the most frequent clinical situations occurring in our daily practise. They nicely illustrated the topic with a clinical case description.Siddiqi et al. recently published a meta-analysis and systematic review on the same topic with covariate-adjusted risk of mortality associated with concomitant valve disease. They demonstrated that moderate to severe MR was associated with increased mortality at 30 days and one year. An increased risk of 1-year mortality was observed in patients with severe MS compared with patients without MS. Moderate-to-severe TR was also at higher risk of all-cause mortality at one year compared with no or mild TR [5].Regarding the pathophysiological and prognostic considerations, a staging of aortic stenosis has been proposed by Généreux et al. [6] based on anatomical, haemodynamic, or echocardiographic criteria. The disease can therefore be divided into four stages: 1. signs of left ventricular overload, decreased left ventricular function; 2. mitral valve damage and left atrial deformation; 3. increased pulmonary pressure and tricuspid valve damage; 4. impairment of right ventricular function. Based on this staging, Okuno et al. were later able to document the impressive clinical correlate in a clinical survey: the 1-year mortality rate was five times higher in TAVI patients at stage-4 compared to stage-1 patients (25.8 vs 5.3%), highlighting how relevant it is to treat aortic stenosis at an early stage and not to miss the optimal time for intervention before an irreversible left or right ventricle damage occurs [7].That is the reason why the following principles were suggested by the European Society of Cardiology [8] to facilitate the heart team decision: – It is important to understand the pathophysiological interactions between the different valve diseases. – The indication for intervention should only be made after a thorough review of the haemodynamic and functional impact of the valve diseases (e.g., symptoms, dilatation or dysfunction of the left ventricle). – In case of multivalvular disease, treat the predominant disease. – The risk of intervention on multiple valves must be weighed against the risk of untreated disease. – For interventional treatment procedures, particularly in the association between aortic stenosis and functional mitral regurgitation, a staged approach should be evaluated.Future and perspectiveWith the aging population, the prevalence of patients with multivalvular disease will inexorably increase in the future. Although TAVR procedure is well standardised, several issues need to be addressed to propose more broadly this option across all risk profiles: specific anatomical characteristics (bicuspid aortic valve, aortic regurgitation), device durability, risk of permanent pacemaker implantation, paravalvular aortic regurgitation and coronary access). As transcatheter treatment option is rapidly increasing for both mitral and tricuspid valve impairment with substantial improvement of the transcatheter edge-to-edge repair (TEER) technology and the progressive expansion of transcatheter mitral valve replacement (TVMR), the role of the multidisciplinary heart team becomes more central in the complex decision-making process that must be patient-oriented, based on a lifetime approach and take into account patient preferences. More research is needed to evaluate the optimal use of mitral and tricuspid transcatheter procedures in TAVR patients with concomitant mitral and tricuspid valve disease and determine the resulting physiological and clinical implications.Bibliography Alkhouli M , Alqahtani F , Ziada KM , Aljohani S , Holmes DR , Mathew V . Contemporary trends in the management of aortic stenosis in the USA. Eur Heart J . 2020; 41 (8):921–928. First citation in articleCrossref Medline, Google Scholar Unger P , Pibarot P , Tribouilloy C , et al. European Society of Cardiology Council on Valvular Heart Disease. Multiple and mixed valvular heart diseases. Circ Cardiovasc Imaging . 2018; 11 (8): e007862. First citation in articleCrossref Medline, Google Scholar Fritschi D , Oechslin L , Biaggi L , Wenavesser P . Transkatheter-Aortenklappenimplantation (TAVI) bei multivalvulären Herzerkrankungen. Praxis (Bern 1994) . 2023; 112 :65–73. First citation in articleAbstract, Google Scholar Khan F , Okuno T , Malebranche D , et al. Transcatheter aortic valve replacement in patients with multivalvular heart disease. JACC Cardiovasc Interv . 2020; 13 (13):1503–1514. First citation in articleCrossref Medline, Google Scholar Siddiqi TJ , Usman MS , Ahmed J , Shahid I , Ahmed W , Alkhouli M . Evaluating the effect of multivalvular disease on mortality after transcatheter aortic valve replacement for aortic stenosis: a meta-analysis and systematic review. Future Cardiol . 2022; 18 (6):487–496. First citation in articleCrossref, Google Scholar Généreux P , Pibarot P , Redfors B , et al. Staging classification of aortic stenosis based on the extent of cardiac damage. Eur Heart J . 2017; 38 (45):3351–3358. First citation in articleCrossref Medline, Google Scholar Okuno T , Heg D , Lanz J , et al. Refined staging classification of cardiac damage associated with aortic stenosis and outcomes after transcatheter aortic valve implantation. Eur Heart J Qual Care Clin Outcomes . 2021; 7 (6):532–541. First citation in articleCrossref Medline, Google Scholar Vahanian A , Beyersdorf F , Praz F , et al. 2021 ESC/EATCS Guidelines for the management of valvular heart disease. Eur Heart J . 2022; 43 (7):561–632. First citation in articleCrossref Medline, Google ScholarFiguresReferencesRelatedDetails Volume 112Issue 2Februar 2023ISSN: 1661-8157eISSN: 1661-8165 InformationPraxis (2023), 112, pp. 53-54 https://doi.org/10.1024/1661-8157/a003983.© 2023Hogrefe AGPDF download

Impact of implantation technique on conduction disturbances for TAVR with the self-expanding portico/navitor valve.

Use of a right-left (R-L) cusp overlap view for transcatheter aortic valve replacement (TAVR) with self-expanding valves has recently been proposed aiming to reduce permanent pacemaker implantation (PPMI). An objective, data-driven explanation for this observation is missing. To assess the impact of different implantation techniques on the risk of PPMI following TAVR with the Portico/NavitorTM transcatheter heart valve (THV; Abbott). A TAVR-population treated with Portico/NavitorTM had the THV implanted in a right versus left anterior oblique (RAO/LAO) fluoroscopic view with no parallax in the delivery system. The impact of these different implantation views on the spatial relationship between THV and native aortic annulus and the risk of conduction disturbances and PPMI after TAVR was studied. A total of 366 matched TAVR patients were studied: 183 in the RAO group and 183 in the LAO group. The degree of aortic annulus plane tilt was significantly smaller in the RAO versus LAO group (median: 0°vs. 23°, p < 0.001), with no plane tilt in 105 out of 183 cases (57.3%) in the RAO group. At 30 days after TAVR, the overall PPMI and guideline-directed PPMI rates were 12.6% versus 18.0% (p = 0.15) and 8.2% versus 15.3% (p = 0.04) in the RAO versus LAO group, respectively. Use of a R-L cusp overlap (RAO-caudal) view for implantation of the Portico/NavitorTM valve results in less tilt of the native aortic annulus plane and a clear trend toward a lower 30-day PPMI rate as compared to TAVR using the conventional LAO implantation view.

1046 DIAGNOSTIC PERFORMANCE OF CALCIUM SCORE ASSESSMENT IN ATRIOVENTRICULAR CONDUCTION DETERIORATION AFTER TAVI: A SINGLE CENTRE PILOT STUDY

Abstract Background The risk of cardiac conduction system defects (CCD) after transcatheter aortic valve implantation (TAVI) remains high and requiring permanent pacemaker implantation (PPI) in 20% of the patients. Numerous studies have suggested that up to half of patients who underwent PPI within 30 days after TAVI do not depend on their PM at one year. The micro-calcific deposits of the atrioventricular node cannot be detected by standard echocardiography, while CT scan can reliably identify them. While pacemaker implantation was recommended according to clinical status and current guideline, in this small retrospective analysis, pre-procedural CT scan calcium quantification was considered an anatomical predictor of AV conduction prolongation until advanced disorder and cardiac block. We assume that differential calcium localization into the AV node might contribute to progression of conduction disorders until complete heart block. Aims The objective of this pilot study is to evaluate the impact of calcium score assessment as a predictor of the development of CCD after TAVI. The goal is to evaluate the interaction between PM dependency and the value of calcium score at the CT scan pre-TAVI. the data collected in this single-center cohort analysis AIMS TO help identify patients at higher risk of permanent pacemaker implantation after TAVI pacemaker insertion and pacemaker-dependent patients at one year through CT calcium scoring. Methods From January 2020 to September 2021, we retrospectively collected data from our institute. One-hundred and thirty patients without prior PM underwent TAVI in our institution. Overall mean age was 79,7 years old with 57,1% of females, with a pre-procedural diagnosis of aortic stenosis and a mean gradient of 47,4 mmHg. At 30 days, PPI was reported in 21 patients (16,1%). Out of twenty-one patients 47,6% developed complete atrioventricular block, 19% developed atrioventricular block II grade type 2 and 33,3% other conduction defects. The dependency at the implantation was 51,1%. With a dedicated software at the CT scan, we assessed the calcium score located in three regions near the atrioventricular node: aortic valve, left ventricular outflow tract (LVOT) and anterior mitral annular (Figure 1). Two patients were excluded for the diagnosis of severe aortic stenosis low-flow low-gradient. The Primary endpoint was to identify patients who had higher risk of PPI after TAVI pacemaker insertion. Results At 12 months follow-up, 23,8% of patients died (n=5). All the remaining patients, 28,5% had a high rate of ventricular pacing (Vp) at implantation (n=6). One year later at the follow up, three of these patients restored intrinsic rhythm and had a low Vp rate. The rate of patients found pacemaker-dependent at one year of follow-up was 76,2%. Conclusions Among 21 patients who requiring PPI after TAVI, at 12 months 14,2% restored intrinsic rhythm. The methodology of calcium scoring outside the coronary arteries is still an active area of study. In the coming months, the collected data will be analyzed to assess the association between PM dependence at follow-up and calcium score on CT scan before TAVI.

Abstract 14480: Importance of the Characteristics of Aortic Valve Calcification for Identifying Patients at a High Risk for Permanent Pacemaker Implantation After Different Types of Transcatheter Aortic Valve Replacement

Background: Aortic valve calcification is a known risk factor for permanent pacemaker implantation (PPMI) following transcatheter aortic valve replacement (TAVR). However, the impact of characteristics of the calcium deposit on the aortic valve and annulus on post-TAVR PPMI has not been well defined. Hypothesis: Analysis of the characteristics of aortic valve calcification and its interactions with different types of TAVR could identify patients at a high risk for PPMI. Methods: This single-center retrospective study included 352 patients treated with TAVR for severe symptomatic aortic stenosis. One hundred ninety-three patients received self-expanding (SE) valves and 159 patients received balloon-expandable (BE) valves. Aortic valve calcification was evaluated using multi-slice computed tomography (MSCT) and 3mensio™ software prior to the TAVR. Total calcium volume (TCV) in the aortic valve was measured in the space ±10 mm of the aortic annulus. In addition, the largest calcium nodule diameter (LCND) was measured at the non-coronary cusp - right coronary cusp commissure, which is anatomically adjacent to the His bundle. TCV and LCND were compared among patients who required PPMI vs. those who did not. Results: PPMI was required post-TAVR in 69 subjects (25.9% in SE and 11.9% in BE, p&lt;0.05). TCV was not associated with an increased risk of post-TAVR PPMI. However, the risk of PPMI increased incrementally in patients who received SE valves from LCND measured 1mm, 1-5 mm, 5-10 mm &gt;10mm ( Figure ). There was no significant association between either TCV or LCND and PPMI in BE TAVR. Conclusions: PPMI was more common in SE than in BE. The size of LCND was associated an increased risk for SE. The preprocedural assessment of LCND may help the selection of appropriate types of TAVR (SE vs. BE) to reduce the risk for PPMI.

Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Low-risk Patients: A Meta-Analysis Based on a 2-Year Follow-Up.

Previous studies have shown that transcatheter aortic valve implantation is the best alternative therapy to surgical aortic valve replacement in high-risk surgical patients with aortic stenosis. However, it is not clear whether transcatheter aortic valve implantation can be utilized in low-risk surgical patients with aortic stenosis. This studyaimed to evaluate the safety and efficacy of transcatheter aortic valve implantation in low-risk patients. From the outset of our initiative until April 2022, PubMed, EMBASE, and the Cochrane database were thoroughly searched, yielding the selection of 3 randomized controlled trials including 2644 patients with aortic stenosis, to assess outcome measures at distinct follow-up time. The mean Society of Thoracic Surgeons Predicted Risk of Mortality score of patients was 2.2. At the 30-day and 1-year follow-up, transcatheter aortic valve implan- tation was associated with a lower incidence of all-cause mortality, cardiovascular mor- tality, acute kidney injury (stage 2 or 3), life-threatening or significant bleeding, and new atrial fibrillation but an increased risk of permanent pacemaker implantation. At the 2-year follow-up, transcatheter aortic valve implantation only had an advantage in new atrial fibrillation (relative risk, 0.27; 95% CI, 0.14-0.51; P &lt; .0001), with no significant differ- ence in all-cause mortality or cardiovascular mortality. For low-risk surgical patients with aortic stenosis, compared to surgical aortic valve replacement, transcatheter aortic valve implantation was associated with lower all-cause mortality at 30-day follow-up and lower cardiovascular mortality at 1-year follow-up. Except for the advantages in new atrial fibrillation, transcatheter aor- tic valve implantation had no significant impact on mortality at 2-year follow-up.

Early Versus Late Catheter Ablation of Atrial Fibrillation and Risk of Permanent Pacemaker Implantation in Patients With Underlying Sinus Node Dysfunction.

BackgroundAtrial fibrillation (AF) is associated with anatomical and electrical remodeling. Some patients with AF have concomitant sick sinus syndrome and may need permanent pacemaker (PPM) implantation. Association between catheter ablation of AF timing and need for PPM in sick sinus syndrome has not been assessed.Methods and ResultsWe used pooled electronic health data to perform retrospective cross‐sectional analysis of 66,  595 patients with AF and sick sinus syndrome to assess the need of PPM implantation temporally, with AF performed divided into earlier within 5 years (group 1), 5 to 10 years (group 2), or beyond 10 years (group 3) of diagnosis. PPM implantation was lowest among those who had catheter ablation within 5 years of sick sinus syndrome diagnosis: group 1 versus group 2 (18.15% versus 27.21%) and group 1 versus group 3 (18.15% versus 27.22%). Interestingly, there was no difference in risk of PPM between group 2 and group 3 (27.21% versus 27.22%; odds ratio [OR], 1.00 [95% CI, 0.85–1.20]).ConclusionsEven after controlling known risk factors that increase the need for pacemaker implantation, timing of AF ablation was the strongest predictor for need for PPM. Patients adjusted OR of PPM was lower if patients had catheter ablation within 5 years of diagnosis compared with later than 5 years (adjusted OR, 0.64 [95% CI, 0.59–0.70]).

Transfemoral versus transcarotid access for transcatheter aortic valve replacement.

ObjectivesTo compare the outcomes after transcatheter aortic valve replacement (TAVR) through a transfemoral (TF) and transcarotid (TC) access at our institution.MethodsFrom January 2014 to January 2020, 62 TC-TAVR and 449 TF-TAVR were performed using 2 prosthesis devices (Edwards SAPIEN 3, n = 369; Medtronic Evolut R, n = 142). Propensity score matching was used to adjust for imbalance in the baseline characteristics of the study groups.ResultsPropensity score matching provided 62 matched pairs with comparable operative risk (mean European System for Cardiac Operative Risk Evaluation II, TC-TAVR 7.6% vs TF-TAVR 6.6%, P = .17). Thirty-day mortality (4.8% vs 3.2%, P = 1.00) and 2-year mortality (11.3% vs 12.9%, P = .64) after TC-TAVR were comparable with TF-TAVR. Strokes were numerically more frequent after TC-TAVR compared with TF-TAVR (3.2% vs 0%, P = .23), but the difference did not reach statistical significance. TF-TAVR was associated with a significantly greater risk of permanent pacemaker implantation (29.0% vs 12.9%, P = .04) compared with TC-TAVR. Other complications were not frequent and were similarly distributed between the matched groups.ConclusionsTC access for TAVR was associated with satisfactory results compared to the femoral access. TC-TAVR could be considered a valid and safe alternative to TF-TAVR when femoral access is contraindicated.

Transcatheter aortic valve replacement in aortic stenosis and cardiac amyloidosis: a systematic review and meta-analysis.

Aortic stenosis (AS) and cardiac amyloidosis (CA) are typical diseases of the elderly. Up to 16% of older adults with severe AS referred to transcatheter aortic valve replacement (TAVR) have a concomitant diagnosis of CA. CA-AS population suffers from reduced functional capacity and worse prognosis than AS patients. As the prognostic impact of TAVR in patients with CA-AS has been historically questioned and in light of recently published evidence, we aim to provide a comprehensive synthesis of the efficacy and safety of TAVR in CA-AS patients. We performed a systematic review and meta-analysis of studies: (i) evaluating mortality with TAVR as compared with medical therapy in CA-AS patients and (ii) reporting complications and clinical outcomes of TAVR in CA-AS patients as compared with patients with AS alone. A total of seven observational studies were identified: four reported mortality with TAVR, and four reported complications and clinical outcomes after TAVR of patients with CA-AS compared with AS alone patients. In patients with CA-AS, the risk of mortality was lower with TAVR (n=44) as compared with medical therapy (n=36) [odds ratio (OR) 0.23, 95% confidence interval (CI) 0.07-0.73, I2 =0%, P=0.001, number needed to treat=3]. The safety profile of TAVR seems to be similar in patients with CA-AS (n=75) as compared with those with AS alone (n=536), with comparable risks of stroke, vascular complications, life-threatening bleeding, acute kidney injury, and 30day mortality, although CA-AS was associated with a trend towards an increased risk of permanent pacemaker implantation (OR 1.76, 95% CI 0.91-4.09, I2 =0%, P=0.085). CA is associated with a numerically higher rate of long-term mortality and rehospitalizations following TAVR in patients with CA-AS as compared with those with AS alone. TAVR is an effective and safe procedure in CA-AS patients, with a substantial survival benefit as compared with medical therapy, and a safety profile comparable with patients with AS alone except for a trend towards higher risk of permanent pacemaker implantation.

Risk of Permanent Pacemaker Implantation Following Bentall Operation

Conduction disorders following cardiac surgery are common complications with incidences of permanent pacemaker dependency up to 5%. However, data on pacemaker implantation rates in the long-term follow-up after Bentall operations are scarce. In a retrospective study, a mixed cohort of 260 patients including endocarditis and aortic dissection undergoing Bentall operation between March 1996 and December 2015 was analyzed. Median follow-up time was 60 (12-107) months. Early and late rates of permanent pacemaker implantation and associated risk factors were investigated. In the postoperative course 31 (11.9%) permanent pacemakers were implanted. The 30-day incidence of pacemaker implantations was 7.7% with operations performed after a median of 6 (3-12) days after the Bentall operation. After ten years, 21% of the Bentall patients were permanent pacemaker dependent. The risk factors for permanent pacemaker dependency included age above 75 years (16.1% vs 5.7%; P < 0.001), preoperative cardiac conduction disturbance (32.3% vs 22.7%, P = 0.018), aortic valve stenosis (38.7% vs 23.1, P = 0.008), infective endocarditis (19.4% vs 7.4%, P = 0.004), tricuspid valve reconstruction (6.5% vs 0.9%, P = 0.033), sepsis (12.9% vs 4.4%, P < 0.001) and non-cardiac reoperation (19.4% vs 8.7%, P = 0.004). Pacemaker implantation significantly increased the length of initial hospitalization (13 [8-26] days vs 8 [7-13] days; P = 0.003). In the long-term follow-up, mortality was not different between the groups. Permanent pacemaker dependency is a frequent complication in the short- and long-term follow-up after Bentall operations. Screening for cardiac conduction disturbances in the short- and long-term follow-up is recommended.

Transcatheter Aortic Valve Replacement with the Self-Expandable Core Valve Evolut Prosthesis Using the Cusp-Overlap vs. Tricusp-View.

Despite the rapid increase in experience and technological improvement, the incidence of conduction disturbances in patients undergoing transcatheter aortic valve replacement (TAVR) with the self-expandable CoreValve Evolut valve remains high. Recently, a cusp-overlap view (COP) implantation technique has been proposed for TAVR with self-expandable valves offering an improved visualization during valve expansion compared to the three-cusp view (TCV). This study aims to systematically analyze procedural outcomes of TAVR patients treated with the CoreValve Evolut valve using a COP compared to TCV in a high-volume center. The primary endpoint was technical success according the 2021 VARC-3 criteria. A total of 122 consecutive patients (61 pts. TCV: April 2019 to November 2020; 61 pts. COP: December 2020 to October 2021) that underwent TAVR with the CoreValve Evolut prosthesis were included in this analysis. Although there was no difference in the primary endpoint technical success between TCV and COP patients (93.4% vs. 90.2%, OR 0.65, 95% CI 0.16, 2.4, p = 0.51), we observed a significantly lower risk for permanent pacemaker implantation (PPI) among COP patients (TCV: 27.9% vs. COP: 13.1%, OR 0.39, 95% CI 0.15, 0.97, p = 0.047). Implantation of the CoreValve Evolut prosthesis using the COP might help to reduce the rate of PPI following TAVR.

241 Transcatheter aortic valve replacement in aortic stenosis and cardiac amyloidosis: a systematic review and meta-analysis

Abstract Aims Aortic stenosis (AS) and cardiac amyloidosis (CA) are typical diseases of the elderly. Up to 16% of older adults with severe AS referred to transcatheter aortic valve replacement (TAVR) have a concomitant diagnosis of CA. CA-AS population suffers from reduced functional capacity and worse prognosis than AS patients. As the prognostic impact of TAVR in patients with CA-AS has been historically questioned and in light of recently published evidence, we aim to provide a comprehensive synthesis of the efficacy and safety of TAVR in CA-AS patients. Methods We performed a systematic review and meta-analysis of studies: 1) evaluating mortality with TAVR as compared to medical therapy in CA-AS patients, and 2) reporting complications and clinical outcomes of TAVR in CA-AS patients as compared to patients with AS alone. Results A total of 8 observational studies were identified, 4 of which reporting mortality with TAVR and 4 reporting complications and clinical outcomes after TAVR of patients with CA-AS compared with AS alone patients. In patients with CA-AS, the risk of mortality was lower with TAVR as compared to medical therapy (OR 0.23, 95% CI 0.07–0.73, I²=0%, P=0.001, number needed to treat=3). The safety profile of TAVR seems to be similar in patients with CA-AS as compared to those with AS alone, with comparable risks of stroke, vascular complications, life-threatening bleeding, acute kidney injury and 30-day mortality, although CA-AS was associated with a trend towards an increased risk of permanent pacemaker implantation (OR 1.93, 95% CI 0.91–4.09, I2=0%, P=0.085). CA is associated with a numerically higher rate of long-term mortality and rehospitalizations following TAVR in patients with CA-AS as compared to those with AS alone. Conclusions TAVR is an effective and safe procedure in CA-AS patients, with a substantial survival benefit as compared to medical therapy, and a safety profile comparable to patients with AS alone except for a trend towards higher risk of permanent pacemaker implantation.