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

Abstract

Background The need for permanent pacemaker (PPM) implantation is a common complication after transcatheter aortic valve replacement (TAVR). Deep implantation position is a risk factor for PPM implantation. Thus, in the field of self-expandable (SE) transcatheter heart valves (THV) cusp overlap projection (COP) technique was implemented to reduce parallax, allowing a more precise guidance of implantation depth. Aims This meta-analysis aims to report the outcome of patients undergoing TAVR with SE THV using COP versus conventional implantation technique (CIT). Methods Systematical search in MEDLINE and EMBASE yielded five observational controlled studies comparing both implantation techniques for the SE Evolut prosthesis (Medtronic Intern. Ltd., CA, USA) and fulfilling the inclusion criteria for meta-analysis. Results Totally, 1227 patients were included, comprising 641 who underwent COP and 586 CIT TAVR. Incidence of post-procedural need for PPM implantation was significantly lower in COP group (9.8% vs 20.6%; OR = 0.43; p < 0.00001). This was accompanied by significantly higher implantation position in COP group (mean difference distance from distal end of the intraventricular portion of the THV to the non-coronary cusp (NCC): − 1.03 mm; p = 0.00001). Incidence of new-onset left bundle branch block did not differ. Regarding procedural and 30-day mortality, technical success, post-procedural aortic regurgitation, and rates of multiple device implantation, no difference between COP and CIT was found. Conclusion COP is an effective and safe implantation technique to reduce the need for a permanent pacemaker implantation during TAVR with SE Evolut prosthesis. Graphical abstract

Transcatheter aortic valve replacement: Past, present, and future

“…The results of this study inspired the use of a cusp‐overlapping technique for self‐expandable TAVR to achieve a high implantation position, and again the rates of PPM implantation were consequently lower 124 . It should be noted that high implantation may theoretically increase the risk of valve embolisation and aortic regurgitation, 125 but overall the safety profile of the cusp‐overlapping technique appears to be similar to the conventional approach 124,126 …”

“… 124 It should be noted that high implantation may theoretically increase the risk of valve embolisation and aortic regurgitation, 125 but overall the safety profile of the cusp‐overlapping technique appears to be similar to the conventional approach. 124 , 126 …”

Predictors, clinical impact, and management strategies for conduction abnormalities after transcatheter aortic valve replacement: an updated review

“…Moreover, the COP technique has the potential to become the gold standard for surgically observing projections of self-expanding THVs. Some studies have shown that compared with CIT, the COP technique significantly reduces the risk of PPI after the implantation of self-expanding valves for TAVR without increasing the incidence of adverse outcome events ( 137 , 138 ). The COP technique offers equal safety and efficacy even in balloon-expandable and mechanically expandable TAVR procedures.…”

Factors Influencing Implantation Depth During Transcatheter Aortic Valve Replacement

“…13,14 Application of the COT was shown to be associated with significantly lower PPI rates in several studies and current meta-analyses. [15][16][17][18][19][20][21] Furthermore, the symmetry of the implanted THV might be improved because of antegrade positioning, better visualisation of the non-coronary cusp nadir and accurate assessment of the actual device depth without foreshortening of the LVOT. 17 Even if the COT was established for specific self-expandable valves due to their greater extension into the LVOT, it has already been shown how this technique might influence ID, PPI need, and haemodynamic performance using balloon-expandable and other devices.…”