Minimizing Permanent Pacemaker Following Repositionable Self-Expanding Transcatheter Aortic Valve Replacement

Hasan Jilaihawi; Zhengang Zhao; Run Du; Cezar Staniloae; Muhamed Saric; Peter J Neuburger; Michael Querijero; Alan Vainrib; Kazuhiro Hisamoto; Homam Ibrahim; Tara Collins; Emily Clark; Illya Pushkar; Daniel Bamira; Ricardo Benenstein; Afnan Tariq; Mathew Williams

doi:10.1016/j.jcin.2019.05.056

Minimizing Permanent Pacemaker Following Repositionable Self-Expanding Transcatheter Aortic Valve Replacement

JACC Cardiovasc Interv. 2019 Sep 23;12(18):1796-1807. doi: 10.1016/j.jcin.2019.05.056. Epub 2019 Aug 28.

Authors

Hasan Jilaihawi¹, Zhengang Zhao², Run Du³, Cezar Staniloae³, Muhamed Saric³, Peter J Neuburger³, Michael Querijero³, Alan Vainrib³, Kazuhiro Hisamoto³, Homam Ibrahim³, Tara Collins³, Emily Clark³, Illya Pushkar³, Daniel Bamira³, Ricardo Benenstein³, Afnan Tariq³, Mathew Williams³

Affiliations

¹ Heart Valve Center, NYU Langone Health, New York, New York. Electronic address: [email protected].
² Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China.
³ Heart Valve Center, NYU Langone Health, New York, New York.

PMID: 31473236
DOI: 10.1016/j.jcin.2019.05.056

Abstract

Objectives: This study sought to minimize the risk of permanent pacemaker implantation (PPMI) with contemporary repositionable self-expanding transcatheter aortic valve replacement (TAVR).

Background: Self-expanding TAVR traditionally carries a high risk of PPMI. Limited data exist on the use of the repositionable devices to minimize this risk.

Methods: At NYU Langone Health, 248 consecutive patients with severe aortic stenosis underwent TAVR under conscious sedation with repositionable self-expanding TAVR with a standard approach to device implantation. A detailed analysis of multiple factors contributing to PPMI was performed; this was used to generate an anatomically guided MInimizing Depth According to the membranous Septum (MIDAS) approach to device implantation, aiming for pre-release depth in relation to the noncoronary cusp of less than the length of the membranous septum (MS).

Results: Right bundle branch block, MS length, largest device size (Evolut 34 XL; Medtronic, Minneapolis, Minnesota), and implant depth > MS length predicted PPMI. On multivariate analysis, only implant depth > MS length (odds ratio: 8.04; 95% confidence interval: 2.58 to 25.04; p < 0.001) and Evolut 34 XL (odds ratio: 4.96; 95% confidence interval: 1.68 to 14.63; 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 < MS length whenever possible; this reduced the new PPMI rate from 9.7% (24 of 248) in the standard cohort to 3.0% (p = 0.035), and the rate of new left bundle branch block from 25.8% 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 which are significantly lower than previously reported with self-expanding TAVR.

Keywords: PPM; TAVR; pacemaker; transcatheter aortic valve replacement.

MeSH terms

Aged
Aged, 80 and over
Aortic Valve / diagnostic imaging
Aortic Valve / physiopathology
Aortic Valve / surgery*
Aortic Valve Stenosis / diagnostic imaging
Aortic Valve Stenosis / physiopathology
Aortic Valve Stenosis / surgery*
Cardiac Pacing, Artificial*
Female
Heart Block / diagnosis
Heart Block / etiology
Heart Block / physiopathology
Heart Block / therapy*
Heart Valve Prosthesis*
Humans
Male
New York City
Pacemaker, Artificial*
Prospective Studies
Prosthesis Design
Retrospective Studies
Risk Assessment
Risk Factors
Severity of Illness Index
Time Factors
Transcatheter Aortic Valve Replacement / adverse effects
Transcatheter Aortic Valve Replacement / instrumentation*
Treatment Outcome