The Cusp Overlap Technique Reduces Pacemaker Implantation in TAVR: A Systematic Review and Meta-analysis

Transcatheter aortic valve replacement (TAVR) has become the preferred treatment for symptomatic aortic stenosis, yet conduction disturbances leading to permanent pacemaker implantation (PPI) remain a significant complication, particularly with self-expanding valves (SEVs). The cusp overlap view (COV) technique has been introduced to achieve a higher, more controlled valve implantation compared to the conventional coplanar view (CPV). We performed a systematic review and meta-analysis (14 studies; 5,266 TAVR patients) comparing the COV to the CPV. Data were pooled using the DerSimonian-Laird random-effects model with I² for heterogeneity. The analysis demonstrated that the COV technique was associated with significantly lower PPI rates (11.2% vs 17.7%; OR = 0.63; p <0.0001). Additionally, patients in the COV group experienced a significantly shorter hospital stay (SMD = -0.56; p = 0.016) and a modestly lower mean transvalvular gradient (SMD = -0.10; p = 0.049). Although the depth measured from the non-coronary cusp did not differ significantly between groups, the arithmetic mean distance from the non-coronary and left coronary cusps was significantly lower in the COV group (SMD = -0.21; p <0.001), indicating a higher valve position. Our meta-analysis suggests that the cusp overlap technique significantly reduces PPI rates and improves procedural outcomes in TAVR with SEVs. In conclusion, these findings suggest that COV not only enhances patient outcomes by reducing conduction disturbances and shortening hospital stays but also optimizes healthcare resource utilization. Future randomized controlled trials are needed to confirm these benefits and further standardize TAVR protocols in clinical practice.