Impact of Interventricular membranous septum length on pacemaker need with different Transcatheter aortic valve implantation systems

Abstract

BackgroundThe need for new permanent pacemaker implantation (PPI) after Transcatheter Aortic Valve Implantation (TAVI) remains a critical issue. Membranous Septum (MS) length is associated with PPI after TAVI. The aim of this study was to identify different MS thresholds for the contemporary THV-platforms. Methods This retrospective, case-control study enrolled all patients who underwent a successful TAVI procedure with contemporary THV-platforms in the Erasmus University Medical Center between January 2016 and March 2020. The follow-up period for new PPI was 30 days. MS-length was determined by Computed Tomography. ResultsThe study consisted 653 TAVI patients with median age 80.6 years (IQR 74.7-84.8). New PPI occurred in 120 patients (18.4%). Patients with new PPI had a shorter MS-length (2.9 mm (IQR 2.3-4.3) vs. 4.2 mm (IQR 2.9-5.7), p < 0.001). MS-length < 3 mm identified a high-risk phenotype with 30.3% PPI-rate (OR 6.5 [95%CI 2.9-14.9]), MS-length 3-6 mm an intermediate-risk phenotype with 15.4% PPI-rate (OR 2.7 [95%CI 1.2-6.2]) and MS > 6 mm a low-risk phenotype with a 6.3% PPI-rate (reference). For the Lotus valve, there was no significant difference in PPI-rates between the high-risk (45.8%, OR 3.5 [95%CI 0.8-15.1]) and low-risk group (20%). By multivariate analysis MS-length, Agatston-score, use of Lotus valve, and ECG with first-degree AV block, RBBB or bifascular block were independent predictors for new PPI. Conclusion MS-length was an independent predictor for new PPI post-TAVI. Three phenotypes were found based on MSlength. MS < 3 mm was universally associated with a high risk for new PPI (>30%). MS > 6 mm represented a low-risk phenotype with PPI-rate < 10%. PPI-rate varied per THV type in the intermediate phenotype. PPI-rate with Lotus was high regardless of MS-length.

Impact of membranous septum length on pacemaker need with different transcatheter aortic valve replacement systems: The INTERSECT registry

“…5 A single-center experience extended these insights to other THV platforms and confirmed MS phenotypes at low, intermediate and high risk for PPI based on MS length. 8 The present multi-center study confirmed the association of these different MS phenotypes with new PPI except for the ACURATE THV. The new PPI rate with ACURATE THV remained low across the bandwidth of MS lengths.…”

Baseline CT-Based Risk Factors for Atrioventricular Block after Surgical AVR

“…Implantation depth has previously been identified as an independent predictor for postprocedural conduction disturbances and AVB III in TAVI as well as in suAVR. 4,12,25 Regarding the surgical manipulation in SAVR, suturing techniques have been modified to prevent injuries to the conduction system by sutures of the prosthesis. 29 Still, the current study has its limitations: Although MIS length was cautiously measured and interrater variability was ruled out, overestimations of the MIS in some patients are highly unlikely but still possible.…”

“…In addition to measuring the mere length of the MIS, some authors combined their observations with the surveillance of the implantation depth. [12,25] As the MIS serves as a surrogate for the location of the Bundle of His like discussed earlier, any surgical manipulation during SAVR or mechanical stress due to the nitinol cage of the prosthesis in suAVR may cause an irritation of the vulnerable nerve fibres. Thus, the idea to choose the implantation depth wisely seems to be an axiomatic assumption.…”

“…Implantation depth has previously been identified as an independent predictor for postprocedural conduction disturbances and AVB III in TAVI as well as in suAVR. [4,12,25] Regarding the surgical manipulation in SAVR, suturing techniques have been modified to prevent injuries to the conduction system by sutures of the prosthesis. [29] This article is protected by copyright.…”

“…Not only calcifications situated at the basal MIS but also shorter MIS have been shown to be a predictor for increased AVB and permanent pacemaker implantation (PPI) rates after transcatheter aortic valve implantation (TAVI) and suAVR. 4,[11][12][13] To our knowledge, there are currently no investigations on the influence of calcifications in the LVOT and the valve apparatus of the AV, and the length of the MIS on postprocedural new-onset AVB III and/or PPI after SAVR or suAVR. These variables have previously been explored in TAVI, but as the construction of the sutureless prosthesis mimics the stent used in TAVI prostheses, similar etiologies of postprocedural conductions disturbances are highly plausible.…”