Minimizing Permanent Pacemaker Following Repositionable Self-Expanding Transcatheter Aortic Valve Replacement.

Area of Science:

• Cardiology
• Interventional Cardiology
• Medical Devices

Background:

• Self-expanding transcatheter aortic valve replacement (TAVR) is associated with a high risk of permanent pacemaker implantation (PPMI).
• Limited data exist on utilizing repositionable TAVR devices to mitigate this risk.

Purpose of the Study:

• To minimize the risk of permanent pacemaker implantation (PPMI) during contemporary repositionable self-expanding transcatheter aortic valve replacement (TAVR).

Main Methods:

• A cohort of 248 patients underwent TAVR with a standard approach.
• Anatomically guided MInimizing Depth According to the membranous Septum (MIDAS) approach was developed based on factors predicting PPMI.
• The MIDAS approach was prospectively applied to 100 patients, targeting implantation depth relative to the membranous septum.

Main Results:

• Implant depth greater than membranous septum length and the largest device size (Evolut 34 XL) were independent predictors of PPMI.
• The MIDAS approach reduced the PPMI rate from 9.7% to 3.0% (p=0.035).
• New left bundle branch block rates decreased from 25.8% to 9% (p<0.001) with the MIDAS approach.

Conclusions:

• The patient-specific MIDAS approach significantly reduces PPMI rates in repositionable self-expanding TAVR.
• This strategy achieves very low and predictable PPMI rates, lower than previously reported for self-expanding TAVR.