Impact of the use of cusp-overlap projection on the incidence of permanent pacemaker implantation post-transcatheter aortic valve implantation with self-expanding valves

Abstract

Introduction: Current rates of permanent pacemaker implantation (PPMI) after transcatheter aortic valve implantation (TAVI) range between 3.4% and 25.9%. PPMI is associated with a worse prognosis. A lower valve implantation depth is associated with an increased risk of conduction disturbances. Theoretically, cusp-overlap projection (COP) has the potential to enable higher valve deployment.

Objective: To compare the 30-day PPMI incidence post-TAVI using self-expanding valves according to the fluoroscopic guidance technique.

Methods: This retrospective single-center study assessed consecutive patients undergoing TAVI with CoreValve™ valves between April 2019 and November 2021, grouped according to the fluoroscopic guidance technique (COP vs. coplanar implantation technique [CIT]).

Results: A total of 122 patients were included, predominantly women (52.5%), with a mean age of 81.6±5.5 years. COP was used in 49.2% of the sample. The CIT group had a significantly higher prevalence of previous beta-blocker use (p<0.01), lower baseline left ventricular ejection fraction (p=0.04) and a higher EuroSCORE II (p=0.02). The 30-day PPMI rate was 27.9% (n=34), with no significant difference between the COP and CIT groups (26.7% vs. 29.0%, p=0.77). Complete atrioventricular block was the main cause (38.5%). Likewise, mean fluoroscopy time (p=0.14) and contrast volume (p=0.35) used were similar between the two groups. Radiation dose was lower in the COP group (p=0.02). There was no significant difference between post-TAVI grades III and IV aortic valve regurgitation (p=0.27) and there were no cases of periprocedural acute coronary occlusion.

Conclusions: This study shows that the COP technique, although safe and not associated with increased complexity, did not significantly reduce the 30-day PPMI rate compared to the traditional CIT view.

Keywords: Conduction disturbances; Cusp-overlap projection; Distúrbios de condução; Substituição valvar aórtica percutânea; Transcatheter aortic valve replacement; Técnica de sobreposição de cúspides.