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• W3080316606 abstract "Central MessageImplanting the TAVR prosthesis higher (aortic) may reduce the need for permanent pacemaker, and preoperative imaging may guide us in certain patients more vulnerable for complete heart block.See Article page 42. Implanting the TAVR prosthesis higher (aortic) may reduce the need for permanent pacemaker, and preoperative imaging may guide us in certain patients more vulnerable for complete heart block. See Article page 42. Transcatheter aortic valve replacement (TAVR) is now commercially available for the treatment of severe aortic stenosis for all risk groups. Therefore, it is more important than ever to optimize clinical outcomes, considering the longevity of younger patients receiving TAVR. Conduction abnormalities including permanent pacemaker (PPM) and left bundle branch block are associated with increased hospitalization for heart failure, lack of improvement in left ventricular ejection fraction, longer intensive care stay, and mortality.1Chamandi C. Barbanti M. Munoz-Garcia A. Latib A. Nombela-Franco L. Gutiérrez-Ibanez E. et al.Long-term outcomes in patients with new permanent pacemaker implantation following transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2018; 11: 301-310Crossref PubMed Scopus (112) Google Scholar,2Fadahunsi O.O. Olowoyeye A. Ukaigwe A. Li Z. Vora A.N. Vemulapalli S. et al.Incidence, predictors, and outcomes of permanent pacemaker implantation following transcatheter aortic valve replacement: analysis from the U.S. Society of Thoracic Surgeons/American College of Cardiology TVT registry.JACC Cardiovasc Interv. 2016; 9: 2189-2199Crossref PubMed Scopus (230) Google Scholar The incidence of new PPM comparing the balloon-expandable SAPIEN 3 valve (Edwards Lifesciences, Irvine, Calif) was similar to surgery in the PARTNER 3 randomized trial.3Mack M.J. Leon M.B. Thourani V.H. Makkar R. Kodali S.K. Russo M. et al.Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.N Engl J Med. 2019; 380: 1695-1705Crossref PubMed Scopus (2764) Google Scholar In contrast, PPM was significantly greater than surgery in the Evolut low-risk randomized clinical trial using the self-expanding valve at 17.4%.4Popma J.J. Deeb G.M. Yakubov S.J. Mumtaz M. Gada H. O'Hair D. et al.Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients.N Engl J Med. 2019; 380: 1706-1715Crossref PubMed Scopus (2122) Google Scholar With the staggering increase in TAVR valve implantation in the United States, there remains an immense interest in finding potential techniques to lower this incidence, especially in those with an increased risk for a PPM. These patient populations include those with a baseline right bundle branch block, presence of coronary artery disease, greater Society of Thoracic Surgeons score, and self-expanding valve.1Chamandi C. Barbanti M. Munoz-Garcia A. Latib A. Nombela-Franco L. Gutiérrez-Ibanez E. et al.Long-term outcomes in patients with new permanent pacemaker implantation following transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2018; 11: 301-310Crossref PubMed Scopus (112) Google Scholar Most recently, the depth of TAVR valve implant and length of membranous septum are also emerging as a strong predictors of high-grade atrioventricular block (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.7; P < .001) and the need for new PPM (OR, 1.43; 95% CI, 1.1-1.8; P = .002).5Hamdan A. Guetta V. Klempfner R. Konen E. Raanani E. Glikson M. et al.Inverse relationship between membranous septal length and the risk of atrioventricular block in patients undergoing transcatheter aortic valve implantation.JACC Cardiovasc Interv. 2015; 8: 1218-1228Crossref PubMed Scopus (151) Google Scholar In this issue of the Journal, Chen and colleagues6Chen Y.-H. Chang H.-H. Liao T.-W. Leu H.-B. Chen I.-M. Chen P.-L. et al.Membranous septum length predicts conduction disturbances following transcatheter aortic valve replacement.J Thorac Cardiovasc Surg. 2022; 164: 42-51.e2Abstract Full Text Full Text PDF Scopus (18) Google Scholar retrospectively analyzed computed tomography (CT) scans of 195 high surgical risk patients who underwent TAVR. Length of membranous septum (MS) was measured in coronal view and infra-annular MS in the stretched view. Implant depth (ID) of transcatheter heart valve was calculated from fluoroscopy. Subtracting this ID from MS gave the “coronal ΔMSID” and from infra-annular MS gave the “infra-annular ΔMSID.” Essentially, these were the “residual septum length” after the transcatheter heart valve was implanted. As expected, deeper valve implants along with shorter MS were a predictor of conduction abnormalities. The authors were also able to demonstrate thresholds or optimal cut-off points for coronal ΔMSID ≤3.2 mm and infra-annular ΔMSID ≤–0.2 mm, beyond which conduction abnormalities increase. This raised an interesting practical usability where preprocedure CT analysis may help guide the operators on desired implant depths. A similar concept was studied by Jilaihawi and colleagues7Jilaihawi H. Zhao Z. Du R. taniloae C. Saric M. Neuburger P.J. et al.Minimizing permanent pacemaker following repositionable self-expanding transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2019; 12: 1796-1807Crossref PubMed Scopus (175) Google Scholar on 248 patients who underwent TAVR with a self-expanding valve and found implant depth > membranous septum length as a predictor of PPM (OR, 8.04; 95% CI, 2.58-25.04; P < .001). They took this a step further and studied 100 consecutive patients prospectively using MIDAS approach—MInimizing Depth According to the membranous Septum. Whenever possible, the operators positioned the device at a depth of < MS length (as measured on CT) and were able to reduce the new PPM rate from 9.7% in the standard cohort to 3.0% (P = .035), and the rate of new left bundle branch block from 25.8% to 9% (P < .001). These studies demonstrate that thoughtful preprocedure planning and meticulous valve implantation technique could result in a very low PPM rate with not only self-expanding, but also balloon-expandable, valves. In addition, it remains to be seen whether the imager's CT reading reproducibility and implanter's technique can be reproduced in low-volume or inexperienced centers. However, operators run a risk of placing the valve to aortic, leading to increased paravavular regurgitation or embolization. The concept by Chen and colleagues is definitely provocative but needs validation in a larger cohort before becoming the standard to care. If it is validated, this innovative technique could be used in patient education in regards to the specific individual “patient pacemaker risk,” allowing operators to navigate between treatment choices with equipoise. Membranous septum length predicts conduction disturbances following transcatheter aortic valve replacementThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 1PreviewInsufficient distance between membranous septum (MS) length and implant depth (ID) may aggravate mechanical compression of the conduction tissue by transcatheter aortic valve replacement (TAVR) prosthesis. We investigated the implication of MS length measured in the coronal view (coronal MS length) compared with infra-annular MS length from stretched vessel image to predict conduction disturbances following TAVR with CoreValve/Evolut R valves (Medtronic, Minneapolis, Minn). Full-Text PDF" @default.
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• W3080316606 title "Commentary: Landing high, but not too high, yields fewer pacemakers after transcatheter aortic valve replacement" @default.
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