Real-world experience with the cusp-overlap deployment technique in transcatheter aortic valve replacement: A propensity-matched analysis

Abstract

BackgroundThe implantation depth (ID) is a critical condition for optimal hemodynamic and clinical outcomes in transcatheter aortic valve replacement (TAVR). The recently recommended cusp-overlap technique (COT) offers optimized fluoroscopic projections facilitating a precise ID. This single-center observational study aimed to investigate short-term clinical performance, safety, and efficacy outcomes in patients undergoing TAVR with self-expandable prostheses and application of COT in a real-world setting.Materials and methodsFrom September 2020 to April 2021, a total of 170 patients underwent TAVR with self-expandable devices and the application of COT, while 589 patients were treated from January 2016 to August 2020 with a conventional three-cusp coplanar view approach. The final ID and 30-day outcomes were compared after 1:1 propensity score matching, resulting in 150 patients in both cohorts.ResultsThe mean ID was significantly reduced in the COT cohort (−4.2 ± 2.7 vs. −4.9 ± 2.3 mm; p = 0.007) with an improvement of ID symmetry of less than 2 mm difference below the annular plane (47.3 vs. 57.3%; p = 0.083). The rate of new permanent pacemaker implantation (PPI) following TAVR was effectively reduced (8.0 vs. 16.8%; p = 0.028). While the fluoroscopy time decreased (18.4 ± 7.6 vs. 19.8 ± 7.6 min; p = 0.023), the dose area product increased in the COT group (4951 ± 3662 vs. 3875 ± 2775 Gy × cm2; p = 0.005). Patients implanted with COT had a shorter length of in-hospital stay (8.4 ± 4.0 vs. 10.3 ± 6.7 days; p = 0.007).ConclusionTranscatheter aortic valve replacement using the cusp-overlap deployment technique is associated with an optimized implantation depth, leading to fewer permanent conduction disturbances. However, our in-depth analysis showed for the first time an increase of radiation dose due to extreme angulations of the gantry to obtain the cusp-overlap view.

Reduction of permanent pacemaker implantation by using the cusp overlap technique in transcatheter aortic valve replacement: a meta-analysis

“…A total of 1227 patients undergoing CIT-TAVR (n = 586) or COP-TAVR (n = 641) were eligible for quantitative analysis (Table 1) [18][19][20][21][22]. There were no significant differences between the groups considering median age, sex, STS score, prior AV block type 1, prior LBBB, prior RBBB, calcium score of the aortic valve, LVOT calcification, and perimeter-derived annulus diameter (Table 1).…”

“…There were no significant differences between the groups considering median age, sex, STS score, prior AV block type 1, prior LBBB, prior RBBB, calcium score of the aortic valve, LVOT calcification, and perimeter-derived annulus diameter (Table 1). A preexisting PPM was an exclusion criterion for all analyzed studies except for Maier et al The rate of preexisting PPM was 8.0% in both groups following propensity matching [22].…”

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

“…However, whether the higher ID was affected by the stiffer guidewire or is predominantly linked to some center-specific deployment characteristics is questionable. According to the current knowledge about the importance of an OID ( 6 – 8 ), recommendations for best practice implantation of the Medtronic self-expandable device have changed from a target ID between −3 and −5 mm toward −3 mm in 2020, also recommending a cusp overlap angulation technique (COT) to reach a higher ID ( 10 , 11 ). Thus, it is noteworthy that most cases were performed with the knowledge of the initially deeper ID and without the COT technique.…”

“…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.…”