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

Abstract

Objectives Optimizing 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. Methods 473 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. Results The 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*). Conclusion Data 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 registration Clinical Trial registration: NCT01805739. Graphic abstract Study 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.

Impact of different guidewires on the implantation depth using the largest self-expandable TAVI device

“…Thus, it is noteworthy that most cases were performed with the knowledge of the initially deeper ID and without the COT technique. Furthermore, as one other optimization tool of ID as previously described ( 9 ), rapid pacing was only performed in 35.2% of all cases and predominantly in Lu patients, probably also contributing to the higher ID in the end. However, a subanalysis of the same cohorts undergoing TAVI without rapid pacing mode and COT revealed a significantly higher ID using the Lunderquist TM guidewire even in a small sample size of 185 NLu vs. 17 Lu patients, which seems remarkable.…”

“…The Lunderquist TM is one of the stiffest guidewires and is available in a double-curved form. Even though little literature exists about tools to optimize ID during valve deployment (9)(10)(11), the impact of different guidewires is yet anecdotal, and structured data are still missing. Thus, we hypothesized that Abbreviations: ID, implantation depth; LCC, left coronary cusp; LVOT, left ventricular outflow tract; NCC, non-coronary cusp; MSCT, multislice computer tomography; N(Lu), Non-(Lunderquist); OR, odds ratio.…”

“…The Lunderquist TM is one of the stiffest guidewires and is available in a double-curved form. Even though little literature exists about tools to optimize ID during valve deployment ( 9 – 11 ), the impact of different guidewires is yet anecdotal, and structured data are still missing. Thus, we hypothesized that the stiffer Lunderquist guidewire would be superior to other guidewires and would enhance stabilization during STHV-34 deployment, assuring a higher and more controlled implant depth that might translate into higher procedural success and lower permanent pacemaker implantation (PPI) rates.…”

Factors Influencing Implantation Depth During Transcatheter Aortic Valve Replacement

“…In contrast, downward migration is known to occur in the case of a large LVOT and less calcified aortic valves. [ 10 , 11 , 24 , 25 ] The final device position may also be influenced by geometrical aspects of the configuration of the aortic root. A flared configuration, in which the LVOT is smaller than the annulus, leads mainly to an upward direction, while a tube or tapered configuration results in a deeper ID.…”

“…A flared configuration, in which the LVOT is smaller than the annulus, leads mainly to an upward direction, while a tube or tapered configuration results in a deeper ID. [ 25 ] Furthermore, an unfavourable angulation of the aortic root and thoracic or abdominal aortic tortuosities may lead to enhanced shear forces on the delivery system, resulting in delayed transmission of manipulations to achieve the correct anatomic position and, hence, dislocation primarily toward the LVOT. In this context, LVOT calcification may inhibit micro- and macro-movements of the device toward the LVOT and enable a higher ID.…”