The Predictors of Conduction Disturbances Following Transcatheter Aortic Valve Replacement in Patients With Bicuspid Aortic Valve: A Multicenter Study

Bicuspid Aortic Valve Disease: Classifications, Treatments, and Emerging Transcatheter Paradigms

Bicuspid aortic valve (BAV) is a common congenital valvular malformation, which may lead to early aortic valve disease and bicuspid-associated aortopathy. A novel BAV classification system was recently proposed to coincide with transcatheter aortic valve replacement being increasingly considered in younger patients with symptomatic BAV, with good clinical results, yet without randomized trial evidence. Procedural technique, along with clinical outcomes, have considerably improved in BAV patients compared with tricuspid aortic stenosis patients undergoing transcatheter aortic valve replacement. The present review summarizes the novel BAV classification systems and examines contemporary surgical and transcatheter approaches.

Cusp-overlap view reduces conduction disturbances and permanent pacemaker implantation after transcatheter aortic valve replacement even with balloon-expandable and mechanically-expandable heart valves

Background

Conduction disturbances demanding permanent pacemaker implantation (PPI) remain a common complication after transcatheter aortic valve replacement (TAVR). Optimization of the implantation depth (ID) by introducing the cusp-overlap projection (COP) technique led to a reduced rate of PPI when self-expanding valves were used.

Objectives

The aim of the present study was to determine if using the novel COP view is applicable for all types of TAVR prosthesis and results in a higher ID and reduced incidence of new conduction disturbances and PPI.

Methods

In this prospective case-control study 586 consecutive patients undergoing TAVR with either balloon-expandable Edwards SAPIEN S3 (n = 280; 47.8%), or mechanically expandable Boston LOTUS Edge heart valve prostheses (n = 306; 52.2%) were included. ID as well as rates of periprocedural PPI and left bundle branch block (LBBB) were compared between the conventional three-cusp coplanar (TCC) projection and the COP view for implantation.

Results

Of 586 patients, 282 (48.1%) underwent TAVR using COP, whereas in 304 patients (51.9%) the TCC view was applied. Using COP a significantly higher ID was achieved in Edwards SAPIEN S3 TAVR procedures (ID mean difference -1.0 mm, 95%-CI -1.9 to -0.1 mm; P = 0.029), whereas the final platform position did not differ significantly between both techniques when a Boston LOTUS Edge valve was used (ID mean difference -0.1 mm, 95%-CI -1.1 to +0.9 mm; P = 0.890). In Edwards SAPIEN S3 valves, higher ID was associated with a numerically lower post-procedural PPI incidence (4.9% vs. 7.3%; P = 0.464). Moreover, ID was significantly deeper in patients requiring PPI post TAVR compared to those without PPI [8.7 mm (6.8-10.6 mm) vs. 6.5 mm (6.1-7.0 mm); P = 0.005]. In Boston LOTUS Edge devices, COP view significantly decreased the incidence of LBBB post procedure (28.1% vs. 47.9%; P < 0.001), while PPI rates were similar in both groups (21.6% vs. 25.7%; P = 0.396).

Conclusion

The present study demonstrates the safety, efficacy and reproducibility of the cusp-overlap view even in balloon-expandable and mechanically-expandable TAVR procedures. Application of COP leads to significantly less LBBB in repositionable Boston LOTUS Edge valves and a numerically lower PPI rate in Edwards SAPIEN S3 valves post TAVR compared to the standard TCC projection. The results should encourage to apply the COP view more widely in clinical practice.

Computed tomography-derived membranous septum length as predictor of conduction abnormalities and permanent pacemaker implantation after TAVI: A meta-analysis of observational studies

BACKGROUND

Permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) is associated with higher risk of mortality and rehospitalization for heart failure. Efforts to prevent conduction abnormalities (CA) requiring PPI after TAVI should be made. The membranous septum (MS) length and its interaction with implantation depth (ID-ΔMSID) could provide useful information about the risk of CA/PPI following TAVI.

OBJECTIVES

To identify MS length and ΔMSID as predictors of CA/PPI following TAVI.

METHODS

Study-level meta-analysis of studies published by September 30, 2022.

RESULTS

Eighteen studies met our eligibility including 5740 patients. Shorter MS length was associated with a significantly higher risk of CA/PPI (per 1 mm decrease: odds ratio [OR] 1.60, 95% confidence interval [CI] 1.28-1.99, p < 0.001). Similarly, lower ΔMSID was associated with a significantly higher risk of CA/PPI (per 1 mm decrease: OR 1.75, 95% CI 1.32-2.31, p < 0.001). Meta-regression analyses revealed a statistically significant modulation of the effect of shorter MS length and lower ΔMSID on the outcome (CA/PPI) by balloon postdilatation (positive regression coefficients with p < 0.001); with increasing use of balloon postdilatation, the effect of shorter MS length and lower ΔMSID on the outcome increased. MS length and ΔMSID demonstrated excellent discriminative abilities, with diagnostic ORs equaling 9.49 (95% CI 4.73-19.06), and 7.19 (95% CI 3.31-15.60), respectively.

CONCLUSION

Considering that short MS length and low ΔMSID are associated with higher risk of CA and PPI, we should include measurement of MS length in the pre-TAVI planning with MDCT and try to establish optimal ID values before the procedure to avoid CA/PPI.

Cerebral Ischemic Lesions after Transcatheter Aortic Valve Implantation in Patients with Non-Calcific Aortic Stenosis

Evidence for transcatheter aortic valve implantation (TAVI) is scarce among patients with non-calcific aortic stenosis, and it is not known whether aortic valve calcification is associated with new cerebral ischemic lesions (CILs) that are detected by diffusion-weighted magnetic resonance imaging. So, our study enrolled 328 patients who underwent transfemoral TAVI using a self-expanding valve between December 2016 and June 2021 from the TORCH registry (NCT02803294). A total of 34 patients were finally confirmed as non-calcific AS and the remaining 294 patients were included in the calcific AS group. Incidence of new CILs (70.6% vs. 85.7%, p = 0.022), number of lesions (2.0 vs. 3.0, p = 0.010), and lesions volume (105.0 mm3 vs. 200.0 mm3, p = 0.047) was significantly lower in the non-calcific AS group. However, the maximum and average lesion volumes were comparable between two groups. Non-calcific AS was associated with lower risk for developing new CILs by univariate logistic regression analysis [Odds ratio (OR): 0.040, 95% confident interval (CI): 0.18-0.90, p = 0.026] and multivariate analysis (OR: 0.031, 95% CI: 0.13-0.76, p = 0.010). In summary, non-calcific AS patients had a lower risk of developing new cerebral ischemic infarction after TAVI compared to calcific AS patients. However, new ischemic lesions were still found in over 70% of patients.

Comparison of cusp-overlap projection and standard three-cusp coplanar view during self-expanding transcatheter aortic valve replacement: A systematic review and meta-analysis

Objective

Permanent pacemaker implantation (PPI) is a common complication after transcatheter aortic valve replacement (TAVR). Recently, the cusp-overlap projection (COP) technique was thought to be a feasible method to reduce PPI risk. However, the evidence is still relatively scarce. Therefore, this meta-analysis was performed to compare COP and standard three-cusp coplanar (TCC) projection technique.

Methods

PubMed and EMBASE databases were systematically searched for relevant literature published from the inception (EMBASE from 1974 and PubMed from 1966) to 16 April 2022, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The primary outcome of interest was post-operative (including in-hospital and 30-day) PPI.

Results

Total of 3,647 subjects from 11 studies were included in this meta-analysis. Of those, 1,453 underwent self-expanding TAVR using COP and 2,194 using TCC technique. In a pooled analysis, the cumulative PPI incidence was 9.3% [95% confidence interval (CI): 6.9–11.7%] and 18.9% (95% CI: 15.5–22.3%) in the COP group and TCC group, respectively. The application of the COP technique was associated with a significant PPI risk reduction (I² = 40.3% and heterogeneity Chi-square p = 0.070, random-effects OR: 0.49, 95% CI: 0.36–0.66, p < 0.001). A higher implantation depth was achieved in the COP group compared with the TCC group [standardized mean difference (SMD) = −0.324, 95% CI: (−0.469, −0.180)]. There was no significant difference between the two groups in second valve implantation, prosthesis pop-out, fluoroscopic time, post-operative left bundle branch block, mortality, stroke, moderate/severe paravalvular leakage, mean gradient, and length of hospital stay. However, radiation doses were higher in the COP group [SMD = 0.394, 95% CI: (0.216, 0.572), p < 0.001].

Conclusion

In self-expanding TAVR, the application of the cusp overlap projection technique was associated with a lower risk of PPI compared with the standard TCC technique.

Systematic review registration

[https://inplasy.com/inplasy-2022-4-0092/], identifier [INPLASY202240092].

Predictors of post-TAVI conduction abnormalities in patients with bicuspid aortic valves

OBJECTIVES

This study evaluates predictors of conduction abnormalities (CA) following transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valves (BAV).

BACKGROUND

TAVI is associated with CA that commonly necessitate a permanent pacemaker. Predictors of CA are well established among patients with tricuspid aortic valves but not in those with BAV.

METHODS

This is a single-centre, retrospective, observational study of patients with BAV treated with TAVI. Pre-TAVI ECG and CT scans and procedural characteristics were evaluated in 58 patients with BAV. CA were defined as a composite of high-degree atrioventricular block, new left bundle branch block with a QRS >150 ms or PR >240 ms and right bundle branch block with new PR prolongation or change in axis. Predictors of CA were identified using regression analysis and optimum cut-off values determined using area under the receiver operating characteristic curve analysis.

RESULTS

CA occurred in 35% of patients. Bioprosthesis implantation depth, the difference between membranous septum (MS) length and implantation depth (δMSID) and device landing zone (DLZ) calcification adjacent to the MS were identified as univariate predictors of CA. The optimum cut-off for δMSID was 1.25 mm. Using this cut-off, low δMSID and DLZ calcification adjacent to MS predicted CA, adjusted OR 8.79, 95% CI 1.88 to 41.00; p=0.01. Eccentricity of the aortic valve annulus, type of BAV and valve calcium quantity and distribution did not predict CA.

CONCLUSIONS

In BAV patients undergoing TAVI, short δMSID and DLZ calcification adjacent to MS are associated with an increased risk of CA.

Pooled-Analysis of Association of Sievers Bicuspid Aortic Valve Morphology With New Permanent Pacemaker and Conduction Abnormalities After Transcatheter Aortic Valve Replacement

Background

Studies on the association of Sievers bicuspid aortic valve (BAV) morphology with conduction disorders after transcatheter aortic valve replacement (TAVR) have not reached consensus.

Methods

We here performed a pooled-analysis to explore whether Sievers type 1 BAV morphology increased the risk of post-TAVR conduction abnormalities and permanent pacemaker implantation (PPI) compared to type 0. Systematic literature searches through EMBASE, Medline, and Cochrane databases were concluded on 1 December 2021. The primary endpoint was post-TAVR new PPI and pooled as risk ratios (RRs) and 95% confidence intervals (CIs). Conduction abnormalities as the secondary endpoint were the composites of post-TAVR PPI and/or new-onset high-degree of atrial-ventricle node block and left-bundle branch block. Studies that reported incidence of outcomes of interest in both type 1 and type 0 BAV morphology who underwent TAVR for aortic stenosis were included.

Results

Finally, nine studies were included. Baseline characteristics were generally comparable, but type 1 population was older with a higher surgical risk score compared to type 0 BAV morphology. In the pooled-analysis type 1 BAV had significantly higher risk of post-TAVR new-onset conduction abnormalities (RR = 1.68, 95%CI 1.09–2.60, p = 0.0195) and new PPI (RR = 1.97, 95%CI 1.29–2.99, p = 0.0016) compared to type 0. Random-effects univariate meta-regression indicated that no significant association between baseline characteristics and PPI.

Conclusion

Sievers type 1 BAV morphology was associated with increased risk of post-TAVR PPI and conduction abnormalities compared to type 0. Dedicated cohort is warranted to further validate our hypothesis.