Relationship between septo-valvular angle and risk of pacemaker implantation after transcatheter aortic valve implantation: a preliminary study

Abstract

Aim Pre-transcatheter aortic valve implantation (TAVI) computed tomography (CT) has proven to be crucial in identifying pre- and post-procedural predicting factors predisposing the onset of major arrhythmias that require permanent pacemaker (PPM) implantation caused by the compressive effects of the prostheses on the conduction system at the membranous septum (MS) and the muscular crest of the interventricular septum. Our analysis aims to verify if the pre-TAVI assessment of the angle between the MS and the aortic annulus (SVA) might be a predictive factor for the onset of arrhythmias that requires PPM. Methods Two cardiovascular specialist radiologists retrospectively and double-blind evaluated a randomized list of preprocedural CT of 57 patients who underwent TAVI with a self-expandable valve from April 2019 to February 2020. Two anatomical features were measured by readers: width of the SVA and MS length (MSL). Results A PPM was implanted in 18 patients (31%) after the procedure. There was no significant difference in the anatomical measurements performed between the two observers, regarding both anatomical measurements (intraclass correlation coefficient was 0.944 for the SVA and 0.774 for the MSL]. Receiver-operating characteristic curves (ROC) performed for both measurements have documented: for the SVA sensitivity 94% and Negative predictive value (NPV) 96% (area under the curve: 0.77; 95% confidence interval 0.66–0.90). The MSL ROC was not significant. The mean SVA value stratified for patients who did not undergo PPM implantation and patients who did resulted as significant (P < 0.005). Conclusion Measurement of the SVA performed in preprocedural CT scans has proven to be related to the onset of major arrhythmias after TAVI requiring permanent pacemaker implantation with high sensitivity (94%) and NPV (96%).

TAVI-CT score to evaluate the anatomic risk in patients undergoing transcatheter aortic valve implantation

“…The ratio of minimum aortic valve anulus diameter to maximum aortic valve anulus diameter, labelled as elliptical index, was used to generate a 3-tier score, with 2 points yielded in case of an elliptical index ≤ 0.7, 1 point yielded in case of an elliptical index > 0.7 and ≤ 0.8, and 0 points yielded in case of an elliptical index > 0.8 30 , 31 . One point was yielded in case of an aortic isthmus angle ≤ 95°, with 0 points yielded in case of an aortic isthmus angle > 95° 32 , 33 . One point was yielded in case of an aorta-ventricle angle > 55°, with 0 points yielded in case of an aorta-ventricle angle ≤ 55°.…”

What we have learnt in valvular heart disease from our journal

“…Compared with surgery, TAVI had a better hemodynamic profile (lower gradient and larger aortic orifice area) but higher rate of residual regurgitation and permanent pacemaker 12 . The risk of permanent pacemaker after TAVI may be predicted by assessing the angle between membranous septum and aortic annulus 13 . In-hospital mortality after TAVI seems to be associated with race since a higher survival was noted in black compared with white subjects; 8 long term mortality was independent of age 14 .…”

“…12 The risk of permanent pacemaker after TAVI may be predicted by assessing the angle between membranous septum and aortic annulus. 13 Inhospital mortality after TAVI seems to be associated with race since a higher survival was noted in black compared with white subjects; 8 long term mortality was independent of age. 14 Global and regional indices of myocardial function improved early after TAVI.…”

Acute expansion of nitinol-based self-expandable device in patients undergoing transfemoral aortic valve implantation

“…[1][2][3][4][5] In the last decade, many efforts have been made to improve patient selection for TAVR, and reduce procedural complications and adverse outcomes. [6][7][8][9][10][11][12][13] In patients undergoing TAVR, prosthesis adaptation to the aortic root is of paramount importance to avoid severe paravalvular leaks, achieve an effective orifice area and minimize patientprosthesis mismatch. 14,15 Of interest, it is widely described that TAVR with a balloon-expandable valve was systematically associated with a certain degree of valve stent recoil.…”

“…Transcatheter aortic valve replacement (TAVR) is the treatment of choice for patients with severe symptomatic aortic stenosis and has become the preferred strategy in patients at intermediate/high surgical risk 1–5 . In the last decade, many efforts have been made to improve patient selection for TAVR, and reduce procedural complications and adverse outcomes 6–13 . In patients undergoing TAVR, prosthesis adaptation to the aortic root is of paramount importance to avoid severe paravalvular leaks, achieve an effective orifice area and minimize patient–prosthesis mismatch 14,15 …”