1. Minimizing Permanent Pacemaker Following Repositionable Self-Expanding Transcatheter Aortic Valve Replacement
- Author
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Illya Pushkar, Daniel Bamira, Ricardo Benenstein, Peter J. Neuburger, Hasan Jilaihawi, Kazuhiro Hisamoto, Alan F. Vainrib, Zhen-Gang Zhao, Muhamed Saric, Michael Querijero, Emily Clark, Afnan Tariq, Homam Ibrahim, Tara Collins, Mathew R. Williams, Cezar Staniloae, and Run Du
- Subjects
Male ,Pacemaker, Artificial ,medicine.medical_specialty ,Time Factors ,Transcatheter aortic ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Prosthesis Design ,Risk Assessment ,Severity of Illness Index ,Transcatheter Aortic Valve Replacement ,03 medical and health sciences ,0302 clinical medicine ,Valve replacement ,Risk Factors ,Internal medicine ,Humans ,Medicine ,Prospective Studies ,030212 general & internal medicine ,Aged ,Retrospective Studies ,Aged, 80 and over ,business.industry ,Cardiac Pacing, Artificial ,Aortic Valve Stenosis ,Right bundle branch block ,medicine.disease ,Confidence interval ,Stenosis ,Heart Block ,Treatment Outcome ,Multiple factors ,Aortic Valve ,Heart Valve Prosthesis ,Cardiology ,Female ,New York City ,Implant ,Permanent pacemaker ,Cardiology and Cardiovascular Medicine ,business - Abstract
This study sought to minimize the risk of permanent pacemaker implantation (PPMI) with contemporary repositionable self-expanding transcatheter aortic valve replacement (TAVR).Self-expanding TAVR traditionally carries a high risk of PPMI. Limited data exist on the use of the repositionable devices to minimize this risk.At NYU Langone Health, 248 consecutive patients with severe aortic stenosis underwent TAVR under conscious sedation with repositionable self-expanding TAVR with a standard approach to device implantation. A detailed analysis of multiple factors contributing to PPMI was performed; this was used to generate an anatomically guided MInimizing Depth According to the membranous Septum (MIDAS) approach to device implantation, aiming for pre-release depth in relation to the noncoronary cusp of less than the length of the membranous septum (MS).Right bundle branch block, MS length, largest device size (Evolut 34 XL; Medtronic, Minneapolis, Minnesota), and implant depthMS length predicted PPMI. On multivariate analysis, only implant depthMS length (odds ratio: 8.04; 95% confidence interval: 2.58 to 25.04; p 0.001) and Evolut 34 XL (odds ratio: 4.96; 95% confidence interval: 1.68 to 14.63; p = 0.004) were independent predictors of PPMI. The MIDAS approach was applied prospectively to a consecutive series of 100 patients, with operators aiming to position the device at a depth of MS length whenever possible; this reduced the new PPMI rate from 9.7% (24 of 248) in the standard cohort to 3.0% (p = 0.035), and the rate of new left bundle branch block from 25.8% to 9% (p 0.001).Using a patient-specific MIDAS approach to device implantation, repositionable self-expanding TAVR achieved very low and predictable rates of PPMI which are significantly lower than previously reported with self-expanding TAVR.
- Published
- 2019