Valve Implantation Depth Research Articles

Factors associated with a high or low implantation of self-expanding devices in TAVR

ObjectivesOptimizing valve implantation depth (ID) plays a crucial role in minimizing conduction disturbances and achieving optimal functional integrity. Until now, the impact of intraprocedural fast (FP) or rapid ventricular pacing (RP) on the implantation depth has not been investigated. Therefore, we aimed to (1) evaluate the impact of different pacing maneuvers on ID, and (2) identify the independent predictors of deep ID.Methods473 TAVR patients with newer-generation self-expanding devices were retrospectively enrolled and one-to-one propensity-score-matching was performed, resulting in a matching of 189 FP and RP patients in each cohort. The final ID was analyzed, and the underlying functional, anatomical, and procedural conditions were evaluated by univariate and multivariate analysis.ResultsThe highest ID was reached under RP in severe aortic valve calcification and valve size 26 mm. Multivariate analysis identified left ventricular outflow (LVOT) calcification [OR 0.50 (0.31–0.81) p = 0.005*], a “flare” aortic root [OR 0.42 (0.25–0.71), p = 0.001*], and RP (OR 0.49 [0.30–0.79], p = 0.004*) as independent highly preventable predictors of a deep ID. In a model of protective factors, ID was significantly reduced with the number of protective criteria (0–2 criteria: − 5.7 mm ± 2.6 vs. 3–4 criteria − 4.3 mm ± 2.0; p < 0.0001*).ConclusionData from this retrospective analysis indicate that RP is an independent predictor to reach a higher implantation depth using self-expanding devices. Randomized studies should prove for validation compared to fast and non-pacing maneuvers during valve delivery and their impact on implantation depth.Trail registrationClinical Trial registration: NCT01805739.Graphic abstractStudy design: Evaluation of the impact of different pacing maneuvers (fast ventricular pacing—FP vs. rapid ventricular pacing—RP) on implantation depth (ID). After one-to-one-propensity-score-matching, independent protective and risk factors for a very deep ID beneath 6 mm toward the LVOT (< − 6 mm) were identified. Stent frame pictures as a courtesy by Medtronic®. AVC aortic valve calcification.

Anatomical predictors of high grade atrioventricular conduction disorders in patients with specific pacemaker implanted after TAVI

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf STIM TAVI-MS study Background The evolution of atrioventricular conduction disorders after transcatheter aortic valve implantation (TAVI) remains poorly understood. Recent studies have identified short membranous septum (MS) length, deep implantation depth (ID) or their relation as anatomic risk of high-grade AV block and permanent pacemaker implantation. Purpose : We sought to examine whether the atrioventricular (AV) membranous septum (MS) measured by computed tomography (CT) and the depth of valve implantation measured from the final aortic angiogram could predict high-grade atrioventricular block (HG AVB) after TAVI, based on specific pacemaker memory data. Methods STIM-TAVI-MS was a prospective, multicentre observational study that enrolled patients implanted with a specific dual chamber pacemaker after TAVI, with the SafeR algorithm activated, allowing continuous monitoring of atrioventricular conduction. The primary endpoint was the occurrence of late (after Day 7) high-grade atrioventricular block(s) during the year after TAVI. We measured on CT scans the coronal MS lenght, infra-annular MS lenght and the quantification of calcifications, on the final angiogram after TAVI we measured the implant depth (ID) to identifie ΔID-MS corresponding to the difference between implant depth and MS length. The variables were compared with the occurrence of late HG-AVB on PM memory data. Results : Among 82 patients, (mean age 84,5 years ± 4,8, self-expending valve n = 24, 29,3%), n = 47 (57.3%) had ≥1 late high-grade atrioventricular block. Mean coronal MS length was 8,1 ± 2,5 mm, mean infra annular MS was 3,4 ± 3.1 mm, mean calcification volume was 93.0 ± 88, 85,5± 104 and 141,5 ± 137,5 mm3 for the noncoronary, right coronary and left coronary cusp respectively. Mean implant depth was 7,3 ± 3,3mm, and mean ΔID-MS = -0,7 ± 4,1mm. There were no association between MS length (OR = 1,06; CI 0,91 to 1,24), ID (OR = 1,6; CI 0,85 to 2,9), nor ΔID-MS (OR = 0,67; CI 0,37 to 1,23) and late HG AVB. Calcification volume were not associated with late HG AVB. Conclusion In an high risk high grade AV block population after TAVI, anatomical analysis of MS length, degree of calcification, implant depth and ΔID-MS did not predict occurrence of late (&amp;gt; day 7 after TAVI ) high grade AV Blocks. Abstract Figure. CT scan A : aortic plane, B : MS lenght

Anatomical Predictors of Pacemaker Dependency After Transcatheter Aortic Valve Replacement.

Conduction disturbances after transcatheter aortic valve replacement (TAVR) are often transient. Limited data exist on anatomic factors predisposing to pacemaker dependency after TAVR. We sought to assess the rate and the possible predictors of pacemaker dependency after TAVR. Consecutive patients undergoing pacemaker implantation up to 30 days after TAVR between May 2014 and September 2019 were included. Baseline electrocardiographic, computed tomography, and procedural characteristics were collected, including valve implantation depth and membranous septum length, an anatomic surrogate of the distance between the aortic annulus and the His bundle. Pacemaker dependency at 30 days and 1 year and all-cause mortality during follow-up were evaluated. Of 728 TAVR patients, 112 (53.5% men; median age, 81 years) underwent pacemaker implantation after TAVR. Of these, 44.6% (50 of 112) were pacemaker dependent at 30 days and 46.7% (36 of 77) at 1 year. By multivariate analysis, independent predictors of 30-day pacemaker dependency included left ventricular outflow tract calcifications under the left coronary cusp (odds ratio, 5.69 [95% CI, 1.45-22.31]; P=0.013) and a difference between membranous septum length and implantation depth (ΔMSID) ≥3 mm (odds ratio, 7.58 [95% CI, 2.07-27.78]; P=0.002). Conversely, membranous septum length and implantation depth alone were not associated with pacemaker dependency (odds ratio, 0.79 [95% CI, 0.60-1.05]; P=0.11 and odds ratio, 1.11 [95% CI, 0.99-1.24]; P=0.08). At a median follow-up of 28.1 (11.7-48.6) months, pacemaker-dependent patients did not show a worse survival (P=0.26). Less than half of the patients undergoing pacemaker implantation after TAVR are pacemaker-dependent at midterm follow-up. ΔMSID ≥3 mm and the presence of left ventricular outflow tract calcifications under the left coronary cusp, but not membranous septum length nor implantation depth alone, are predictive of long-term pacemaker dependency after TAVR, thus influencing device selection and programming.

Predictors of pacemaker implantation after transcatheter aortic valve implantation according to kind of prosthesis and risk profile: a systematic review and contemporary meta-analysis.

Permanent pacemaker implantation (PPI) may be required after transcatheter aortic valve implantation (TAVI). Evidence on PPI prediction has largely been gathered from high-risk patients receiving first-generation valve implants. We undertook a meta-analysis of the existing literature to examine the incidence and predictors of PPI after TAVI according to generation of valve, valve type, and surgical risk. We made a systematic literature search for studies with ≥100 patients reporting the incidence and adjusted predictors of PPI after TAVI. Subgroup analyses examined these features according to generation of valve, specific valve type, and surgical risk. We obtained data from 43 studies, encompassing 29 113 patients. Permanent pacemaker implantation rates ranged from 6.7% to 39.2% in individual studies with a pooled incidence of 19% (95% CI 16-21). Independent predictors for PPI were age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01-1.09], left bundle branch block (LBBB) (OR 1.45, 95% CI 1.12-1.77), right bundle branch block (RBBB) (OR 4.15, 95% CI 3.23-4.88), implantation depth (OR 1.18, 95% CI 1.11-1.26), and self-expanding valve prosthesis (OR 2.99, 95% CI 1.39-4.59). Among subgroups analysed according to valve type, valve generation and surgical risk, independent predictors were RBBB, self-expanding valve type, first-degree atrioventricular block, and implantation depth. The principle independent predictors for PPI following TAVI are age, RBBB, LBBB, self-expanding valve type, and valve implantation depth. These characteristics should be taken into account in pre-procedural assessment to reduce PPI rates. PROSPERO ID CRD42020164043.

Predictors for permanent pacemaker implantation following transcatheter aortic valve implantation: trends over the past decade.

This study sought to identify risk factors for permanent pacemaker implantation (PPMI) after Transcatheter aortic valve implantation (TAVI) and explain their trends over the last decade. TAVI is performed nowadays for severe aortic stenosis in more patients with lower surgical risk. While most TAVI complications have been reduced, PPMI remains common. In this observational, retrospective cohort analysis, 338 TAVI patients treated between 2008 and 2017 were reviewed. Risk factors were compared between the early (2008-2013) and late years (2014-2017), and a multivariable logistic regression model was used. A decreasing trend in PPMI over time was observed (p for trend = 0.008), as was a lower rate of PPMI in the late period (19.3% vs. 31.7%, p = 0.009). Three variables were identified as independent risk factors for PPMI that also decreased significantly in the late period: valve implantation depth ≥ 8mm (OR = 4.3, 95% CI 2.3-8.2, p < 0.001), use of self-expandable valves (OR = 2.8, 95% CI 1.4-5.5, p = 0.004), and patient risk assessed by EuroSCORE II (OR = 1.07, 95% CI 1.0-1.1, p = 0.034). Indications for PPMI were also shown to change over time, with an increase in the prevalence of complete AVB as the main indication for PPMI (p = 0.048), and a trend towards a decrease in LBBB alone (p = 0.061). The decrease in post-TAVI PPMI over the past decade is multifactorial and can be explained by (1) lower baseline patient surgical risk, (2) modified procedural variables including decreased implantation depth and increased use of balloon-expandable valves, and (3) refined indications for PPMI.

Intraprocedural dynamics of cardiac conduction during transcatheter aortic valve implantation: Assessment by simultaneous electrophysiological testing

Transcatheter aortic valve implantation (TAVI) is an established treatment for patients with severe aortic stenosis and high to intermediate surgical risk. However, the proximity of the conduction system to the prosthesis landing zone bears the risk of atrioventricular conduction disorders. The underlying pathophysiology is not fully understood. The purpose of this study was to characterize the impact of TAVI on the conduction system as assessed by simultaneous electrophysiological testing. AH and HV intervals and QRS duration were measured using a quadripolar His catheter and surface electrocardiogram in 108 patients at baseline (BL), after balloon predilation (timepoint 1 [T1]), after implantation of the valve prosthesis (T2), and after postdilation, if deemed necessary (T3). Between BL and T2, significant increases of HV interval and QRS duration were observed, with a mean delta of +12.4 ms and +32.7 ms, respectively. Both balloon predilation and valve implantation had an impact on infranodal conduction. No significant increase of AH intervals was documented. The increase of QRS duration led to left bundle branch block (LBBB) in 57 patients (52.8%). Implantation depth positively correlated with QRS prolongation (ρ= 0.21, P = .042) but not with changes of AH or HV interval (ρ = -0.03, P = .762; and ρ = 0.15, P = .130, respectively). Electrophysiological testing during TAVI shows impairment of infranodal atrioventricular conduction by balloon predilation and valve implantation. This impairment is positively correlated with valve implantation depth and results in an increase of QRS duration with mainly LBBB pattern on surface electrocardiogram.

Transesophageal echocardiographic predictors of intraventricular conduction delay in patients undergoing transcatheter aortic valve replacement

Introduction Patient anatomical features, such as shorter membranous septum (MS) length, on computed tomography have been shown to predict conduction abnormalities after transcatheter aortic valve replacement (TAVR). This relationship has not yet been evaluated using transesophageal echocardiography (TEE). Our hypothesis is that the distance from the aortic annulus to the septal bulge, a surrogate of MS distance and length, will be associated with a new interventricular conduction delay and heart block post-TAVR. Likewise, we hypothesize an implantation depth of the valve closer to the septal bulge will also predict post-TAVR interventricular conduction delay. Methods Comprehensive intraprocedural echocardiographic data were analyzed retrospectively on 88 patients who underwent TAVR under general anesthesia with TEE. Pre-procedural MS distance and post-procedural implantation depth (quantified as the inferior border of valve to septal bulge) were measured in the mid-esophageal long axis view of the aortic valve in mid-systole. EKGs were evaluated pre-TAVR and immediately post-valve deployment. Univariate logistic regression was used to identify predictors of a need for post-operative pacemaker (PM) implantation and new bundle branch block (BBB). Results The population consisted of 88 patients undergoing TAVR with TEE from 2017-2018 at our institution. The median age was 84, 45/88 (51.1%) were female. After TAVR, 7/88 (7.9%) had PPM placed and 21/88 (23.8%) had a new bundle branch block, transient or permanent. MS length was inversely associated with the risk of developing an interventricular conduction delay after TAVR (OR=0.19, CI 0.05-0.75, p=0.018). As shown in Table 1, the implantation distance was inversely associated with the need for a pacemaker or developing a new interventricular conduction delay after TAVR (OR=0.19, Cl 0.06-0.6, p=0.006). Discussion MS length and valve implantation depth on intraprocedural TEE are inversely associated with the risk of developing conduction abnormalities post-TAVR. TEE assessment may be comparable to CT in predicting post-TAVI high-grade atrioventricular block, and has the additional benefit of being performed intraprocedurally in selected patients.

CUSP OVERLAP METHOD FOR SELF-EXPANDING TRANSCATHETER AORTIC VALVE REPLACEMENT

Conduction disturbances and the need for permanent pacemaker (PPM) implantation remain the most frequent drawback of transcatheter aortic valve replacement (TAVR). Valve type and implantation depth have been the most common procedural factors (both modifiable) associated with conduction disturbances post-TAVR. This risk has historically been higher with self-expanding rather than balloon-expandable TAVR. However, device positioning has emerged as an important determinant of PPM implantation, with higher device implantation resulting in lower rates of PPM implantation. Unlike balloon-expandable valves, standard coplanar 3-cusp view may not be ideal for deployment of self-expanding valve, as it requires elimination of parallax of valve frame during deployment. The cusp overlap view by overlapping the right coronary cusp (RCC) and left coronary cusp (LCC) isolates the non-coronary cusp (NCC) and offers several advantages in SE valve deployment. This view provides a good anatomical reference for deployment depth at the point of contact (NCC) as it maintains basal plane alignment of coronary cusps, elongates the outflow tract in a long axis view, reduces or eliminates parallax in the catheter marker band, and assists with depth visualization near the non-right commissure and membranous septum during deployment.

Novel Method for Implantation of Balloon Expandable Transcatheter Aortic Valve Replacement to Reduce Pacemaker Rate—Line of Lucency Method

ABSTRACT Background The risk of permanent pacemaker implantation (PPM) following transcatheter aortic valve replacement (TAVR) remains high. Valve implantation depth is an independent predictor of PPM. This study describes the rate of PPM following a novel method for valve positioning during TAVR. Methods A retrospective cohort study involved patients undergoing TAVR at our institute between January 2019 and January 2020. Baseline characteristics, procedural data, and clinical outcomes were collected and analyzed. All patients were implanted with the Edwards SAPIEN 3 or SAPIEN 3 Ultra using the radiolucent line on the stented valve, rather than the central marker, to guide positioning. We describe this as the line of lucency method. Results In total, 50 patients (96% SAPIEN 3, and 4% SAPIEN 3 Ultra) were included. The median age was 81.5 years, and 30 (60%) patients had existing conduction abnormalities: first degree atrio-ventricular block (18%), right bundle branch block (12%), left bundle branch block (10.2%), and left anterior fascicular block (16%). The modified technique was successful in all cases. No patient required PPM within 30 days. Two patients (4%) had moderate aortic regurgitation on echocardiogram at 30 days; 3 (6%) developed new left bundle branch block. There was no instance of valve embolization, coronary obstruction, or postprocedural death. Conclusion A novel technique utilizing the radiolucent line on the bottom of the stented valve during TAVR provided reproducibly high positioning with excellent clinical results. Optimal position of the valve may prevent need for subsequent PPM.

The effects of transcatheter aortic valve implantation on cardiac electrical properties

IntroductionTranscatheter aortic valve implantation (TAVI) is associated with cardiac electrical disturbances. However, beyond the risks of pacemaker implantation, few studies have performed a detailed assessment of the effects of TAVI on several cardiac electrical properties. ObjectivesTo assess the frequency and type of electrocardiographic disturbances following TAVI, according to the type of prostheses and to assess predictors of these disturbances. MethodsWe performed a detailed retrospective analysis of all electrocardiograms in patients who underwent TAVI, before and after the procedure, at a tertiary center from August 2007 to October 2016. Patients with permanent pacemakers were excluded. ResultsWe included 182 patients (78±8 years; 56% female) and self-expanding prostheses (SEP) were implanted in 54%. Most patients (80%) were in sinus rhythm at baseline. After TAVI, 21% of patients developed new-onset atrial fibrillation and there was a significant increase in PR interval at discharge (186±41 ms vs. 176±32; p=0.003), which was not maintained after at six-month follow-up (181±35 ms, p=0.06). There was also a significant increase in QRS duration at discharge (129±28 ms vs. 114±25 at baseline p<0.0001), which persisted at six-months (122±28 ms, p<0.0001). New-onset left-bundle branch block (LBBB) was observed in 25% of patients. The depth of valve implantation was a predictor of new LBBB at discharge after multivariate analysis (OR 37.6, 95% CI 14.6–65.2, p=0.001). ConclusionsThe main electrocardiographic disturbances post TAVI were PR prolongation, increased QRS and new-onset LBBB. These disturbances were more pronounced in patients undergoing SEP implantation and tended to improve at six-month follow-up. The depth of valve implantation was a predictor of conduction disturbances.

Conduction disturbances in low-surgical-risk patients undergoing transcatheter aortic valve replacement with self-expandable or balloon-expandable valves.

Despite a considerable improvement in TAVR devices and procedures, together with a reduction in procedural complications, the rate of conduction disturbances (CD) remained stable over the years. Indeed, the CD rate is still significantly higher than in surgical aortic valve replacement, and represents one of the main limitations to the expansion of TAVR to younger low-risk patients. The aim of the present study was to assess the incidence and predictors of CD in low-risk patients undergoing TAVR. Among 637 patients without preexisting CD who underwent TAVR, 116 (18.2%) were considered at low surgical risk. Up to 25% of low-risk patients presented with persistent CD at discharge. The pacemaker implantation rate was similar in the low-risk group compared to the intermediate-/high-risk group (8.7% vs 10.6%, p = 0.55). Moreover, the rate of new persistent left bundle branch block (LBBB) following TAVR was also similar between both groups (18.1% vs 22.1%, p = 0.34). At 1-year follow-up, LBBB was persistent in 62.5% of patients and 3 of them required a pacemaker implantation. Depth of valve implantation, baseline QRS duration and mean aortic transvalvular gradient were identified as independent predictors of CD in low-risk patients. Patients at low surgical risk showed an equivalent CD rate than intermediate-/high-risk patients. The depth of valve implantation was the main predictor of CD in low-risk patients undergoing TAVR. Baseline QRS duration and mean aortic transvalvular gradient were also associated with increased CD.

Risk factors for permanent pacemaker implantation in patients receiving a balloon-expandable transcatheter aortic valve prosthesis.

Permanent pacemaker implantation (PPI) is a widely recognized complication associated with TAVI (incidence up to 20%). Smaller registries have identified several variables associated with PPI. The objective was to validate patient- and transcatheter aortic valve implantation (TAVI)-related procedural variables associated with PPI. We performed a retrospective analysis of patients from six European centers undergoing TAVI with the Edwards SAPIEN 3 prosthesis. Baseline variables and pre-procedural ECG characteristics and CT-scans were taken into account. Data for 1745 patients were collected; 191 (10.9%) required PPI after TAVI. The baseline variables pulmonary hypertension (OR 1.64; 95% CI 1.01-2.59), QRS duration > 117ms (OR 2.58; 95% CI 1.73-3.84), right bundle branch block (RBBB; OR 5.14; 95% CI 3.39-7.72), left anterior hemi block (OR 1.92; 95% CI 1.19-3.02) and first-degree atrioventricular block (AVB, OR 1.63; 95%CI 1.05-2.46) were significantly associated with PPI. RBBB (OR 8.11; 95% CI 3.19-21.86) and first-degree AVB (OR 2.39; 95% CI 1.18-4.66) remained significantly associated in a multivariate analysis. Procedure-related variables included access site (TF; OR 1.97; 95% CI 1.07-4.05), implanted valve size (29mm; OR 1.88; 95% CI 1.35-2.59), mean TAVI valve implantation depth below the annulus > 30% (OR 3.75; 95% CI 2.01-6.98). Patients receiving PPI had longer ICU stays and later discharges. Acute kidney injury stage 2/3 was more common in patients with PPI until discharge (15.2 vs. 3.1%; p = 0.007), but was not statistically significant thereafter. Further differences in outcomes at 30days did not reach significance. The data will aid pre- and post-procedural patient management and prevent adverse long-term outcomes.Clinical Trial: NCT03497611.

Numerical evaluation of transcatheter aortic valve performance during heart beating and its post-deployment fluid-structure interaction analysis.

Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure that provides an effective alternative to open-heart surgical valve replacement for treating advanced calcific aortic valve disease patients. However, complications, such as valve durability, device migration, paravalvular leakage (PVL), and thrombogenicity may lead to increased overall post-TAVR morbidity and mortality. A series of numerical studies involving a self-expandable TAVR valve were performed to evaluate these complications. Structural studies were performed with finite element (FE) analysis, followed by computational fluid dynamics (CFD) simulations, and fluid-structure interaction (FSI) analysis. The FE analysis was utilized to study the effect of TAVR valve implantation depth on valve anchorage in the Living Heart Human Model, which is capable of simulating beating heart during repeated cardiac cycles. The TAVR deployment cases where no valve migration was observed were then used to calculate the post-deployment thrombogenic potential via CFD simulations. FSI analysis followed to further assess the post-deployment TAVR hemodynamic performance for different implantation depths. The deployed valves PVL, geometric and effective orifice areas, and the leaflets structural and flow stress magnitudes were compared to determine the device optimal landing zone. The combined structural and hemodynamic analysis indicated that with the TAVR valve deployed at an aft ventricle position an optimal performance was achieved in the specific anatomy studied. Given the TAVR's rapid expansion to younger lower-risk patients, the comprehensive numerical methodology proposed here can potentially be used as a predictive tool for both procedural planning and valve design optimization to minimize the reported complications.

Implantation percutanée de valve aortique et troubles conductifs

Transcatheter aortic valve implantation (TAVI) is currently becoming the treatment of choice for patients with calcific aortic stenosis. Despite several technical improvements, the incidence of conduction disturbances has not diminished and remains TAVI's major complication. These disturbances include the occurrence of left bundle branch block and/or high-grade atrioventricular block often requiring pacemaker implantation. The proximity of the aortic valve to the conduction system (conduction pathways) accounts for the occurrence of these complications. Several factors have been identified as carrying a high risk of conduction disturbances like the presence of pre-existing right bundle branch block, the type of valve implanted, the volume of aortic and mitral calcifications, the size of the annulus and the depth of valve implantation. Left bundle branch block is the most frequent post TAVI conduction disturbance. Whereas the therapeutic strategy for persistent complete atrioventricular block is simple, it becomes complex in the presence of fluctuating changes in PR interval and left bundle branch block duration. The QRS width threshold value (150-160 ms) indicative of the need for pacemaker implantation is still being debated. Although there are currently no recommendations regarding the management of these conduction disturbances, the extension of TAVI indications to patient at low surgical risk calls for a standardization of our practice. However, a decision algorithm was recently proposed by a group of experts composed of interventional cardiologists, electrophysiologists and cardiac surgeons. There are still uncertainties about the appropriate timing of pacemaker implantation and the management of new onset left bundle branch block.

Membranous septal length and valve implantation depth of TAVR: Predictors of new permanent pacemaker implantation after TAVR

Conduction disorders are frequent after transcatheter aortic valve replacement (TAVR) and there is a lack of consensus on the way to manage them, so they can prolong the hospital length of stay. However, membranous septum length assessed by computed tomography (CT) and valve implantation depth at the final angio, have been identified as strong predictors of new permanent pacemaker implantation after TAVR. We aimed to investigate how these data could help to identify the only patients who are at high risk of high degree AV block after TAVR. In this aim, we conducted a retrospective observational monocentric study which included 216 consecutive patients scheduled to undergo a TAVR procedure. Among them, we excluded valve-in-valve procedures or patients with pre-existing pacemaker. On the 162 remaining patients, 124 only had sufficient good-quality CT for MS length assessment. In our cohort, 34 patients (27,4%) received a PPM. After adjustment of pre- and post-procedural parameters, multivariable logistic regression revealed that the difference between MS length and implantation depth is the most powerful independent predictor of PPM implantation (OR: 1.5, 95% CI: 1.3 to 1.7, P < 0.001). Predictive probabilities were generated using logistic regression model. Using the difference between MS length and implantation depth as the only parameter, the c-statistic of the model of PPM showed an area under the curve of 0.89. The lone difference between MS length and implantation depth, seems to be able to select high-risk patients for PPM implantation. These results could reduce length of stay after TAVI, selecting low risk patients for whom an early discharge is allowed. This has to be now validated by a prospective study.

Long-term clinical outcome of persistent left bundle branch block after transfemoral aortic valve implantation.

The impact of persistent left bundle-branch block (pLBBB) on long-term clinical outcome remains to be determined. New-onset of pLBBB occurs frequently after transfemoral aortic valve implantation (TAVI). Seven hundred and seven consecutive patients who underwent TAVI were analyzed for baseline and procedural characteristics and clinical outcome in an up to 2-year follow-up. Patients were divided into either a group with pLBBB until hospital discharge or a group without LBBB. We performed propensity-score matching and analyzed baseline characteristics, procedural data and clinical outcome of both groups. Patients received balloon-expandable valves in 56.4%, mechanically expandable valves in 37.5%, and self-expandable valves in 6.3%. A new-onset, pLBBB was observed in 47.5% of patients after TAVI. The implantation of a mechanically expandable valve was associated with higher rate of pLBBB (54.2% vs. 20.8%, P < 0.001), whereas implantation of a balloon-expandable valve was associated with lower incidence of pLBBB (39.8% vs. 73.1%, P < 0.001). Deeper ventricular implantation at left-coronary side led to higher rates of pLBBB (7.5 ± 2.5 vs. 6.7 ± 2.6 mm, P < 0.001). The occurrence of pLBBB was associated with higher rates of permanent pacemaker implantation (40.9% vs. 15.9%, P < 0.001). By multivariate analysis, implantation of a mechanically expandable valve (Boston Scientific Lotus valve) was identified as independent predictor of occurrence of pLBBB (odds ratio 4.7, confidence interval 3.2-7.0, P < 0.001). In the 2-year follow-up, there were no significant differences between "pLBBB" and "no LBBB"-groups regarding mortality and rehospitalization due to heart failure. The occurrence of pLBBB is associated with the choice of valve type and implantation depth and requires significantly higher rates of permanent pacemaker implantations. Importantly, there are no differences in the 2-year follow-up regarding mortality and rehospitalization due to heart failure.

TCT-473 Left bundle branch block after TAVI with Edwards Sapien 3 System: influence of the valve depth

Left bundle branch block (LBBB) is the most common conduction disturbance after TAVI.The Sapien 3 system has been related to a higher incidence of LBBB.The aim of the study is to determine the possible relation between the depth of valve implantation and the new-onset LBBB. 76 patients treated with

Relation of Left Ventricular Fractional Shortening to Needfor Permanent Pacemaker After Transcatheter AorticValve Implantation

Transcatheter aortic valve implantation (TAVI) can potentially alter conduction system function due to the mechanical force applied to the conduction system by the proximal edge of the valve, particularly the CoreValve. Some reasons for post-TAVI advanced atrioventricular block have been identified. We investigated whether the degree of the motion of the basal left ventricular (LV) walls impacted the development of advanced atrioventricular block post-TAVI. A total of 407 patients (82.1 ± 6.2 years) without prior permanent pacemakers (PPMs) underwent TAVI using CoreValve (70%) or Edwards-SAPIEN (30%) prosthetic devices. The LV fractional shortening (FS) of the basal segments was measured in each patient, and the association between FS and PPM requirement, or new-onset left bundle branch block (LBBB) was evaluated. During hospitalization, 64 patients (15.7%) required PPM implantation, and 128 patients (31.4%) required PPM implantation or developed new LBBB. Independent predictors of PPM implantation included preprocedural right bundle branch block, CoreValve prosthetic device, valve implantation depth, and FS. Patients with high FS (≥40%, upper tertile) had a 2.5-fold increased risk of PPM implantation (p = 0.004) and a 1.8-fold increased risk of PPM or new LBBB (p = 0.020). Every 10% increment in FS was consistently associated with an adjusted 42% increased risk of PPM implantation (p = 0.015) and with an adjusted 43% increased risk of PPM implantation or new LBBB (p = 0.005). Thus, in our cohort, LV FS was independently associated with the need for PPM implantation during hospitalization. Hence, this simple echocardiographic measure can be used to identify patients who are at risk after TAVI.

Implantation Depth and Rotational Orientation Effect on Valve-in-Valve Hemodynamics and Sinus Flow

This study evaluated the effect of transcatheter aortic valve implantation depth and rotation on pressure gradient (PG), leakage fractions (LF), leaflet shear stress, and sinus washout in an effort to understand factors that may dictate optimal positioning for valve-in-valve (ViV) procedures. Sinus flow stasis is often associated with prosthetic leaflet thrombosis. Although recent ViV invitro studies highlighted potential benefits of transcatheter aortic valve supraannular implantation to minimize PGs, the relationship between transcatheter aortic valve depth and other determinates of valve function remains unknown. Among these, LFs, shear stress, and poor sinus washout have been associated with poorer valve outcomes. ViV hemodynamic performance was evaluated invitro vs axial positions -9.8, -6.2, 0, and+6 mm and angular orientations 0, 30, 60, and 90 degrees in a degenerated surgical aortic valve. PGs, LFs, and sinus shear stress and washout were compared. Leaflet high-speed imaging and particle-image velocimetry were performed to elucidate hemodynamic mechanisms. (1) The PG varies as a function of axial position, with supraannular deployments yielding a maximum benefit of 7.85 mm Hg less than PGs for subannular deployments irrespective of commissural alignment (p < 0.01); (2) in contrast, LF decreased in relationship to subannular deployment; and (3) at peak systole, sinus flow shear stress increased with deployment depth as did sinus washout with and without coronary flow. First, supraannular axial deployment isassociated with lower PGs irrespective of commissuralalignment. Second, subannular deployment is associated with more favorable sinus hemodynamics and less LF. Further invivo studies are needed to substantiatethese observations and facilitateoptimalprosthesis positioning during ViV procedures.

Conduction Disturbances After Transcatheter Aortic Valve Replacement: Current Status and Future Perspectives.

Transcatheter aortic valve replacement (TAVR) has become a well-accepted option for treating patients with aortic stenosis at intermediate to high or prohibitive surgical risk. TAVR-related conduction disturbances, mainly new-onset left bundle-branch block and advanced atrioventricular block requiring permanent pacemaker implantation, remain the most common complication of this procedure. Furthermore, improvements in TAVR technology, akin to the increasing experience of operators/centers, have translated to a major reduction in periprocedural complications, yet the incidence of conduction disturbances has remained relatively high, with perhaps an increasing trend over time. Several factors have been associated with a heightened risk of conduction disturbances and permanent pacemaker implantation after TAVR, with prior right bundle-branch block and transcatheter valve type and implantation depth being the most commonly reported. New-onset left bundle-branch block and the need for permanent pacemaker implantation may have a significant detrimental association with patients' prognosis. Consequently, strategies intended to reduce the risk and to improve the management of such complications are of paramount importance, particularly in an era when TAVR expansion toward treating lower-risk patients is considered inevitable. In this article, we review the available evidence on the incidence, predictive factors, and clinical association of conduction disturbances after TAVR and propose a strategy for the management of these complications.