Predictors of permanent pacemaker requirement in aortic stenosis patients undergoing self-expanding valve transcatheter aortic valve replacement using the cusp overlap technique.

Introduction: Since TAVR was approved for lower-risk aortic stenosis (AS) patients, managing post-implantation conduction disturbances has become crucial, especially with self-expanding heart valves (SEV). This study aims to identify risk factors for conduction disturbances in such patients using a specific fluoroscopic cusp overlap (COL) technique.

Methods: This retrospective study analyzed AS patients who underwent TAVR with SEV from 2019 to 2022, excluding those needing pacemakers or valve-in-valve procedures. Patients were grouped by conventional (CON) and COL techniques, with outcomes monitored using Valve Academic Research Consortium (VARC)-2 criteria.

Results: In this cohort study of 114 patients, 17 were excluded due to pre-existing pacemakers. Forty-seven received SEVs using COL, and 50 with CON techniques. The COL group showed a significant reduction in new LBBB (27.7% vs. 46%,  = 0.006) and PPI rates (4.3% vs. 18%,  = 0.033) compared to the CON group. Deeper implantation depth below the non-coronary cusp (NCC) and left coronary cusp (LCC) was linked to an increased risk of conduction disturbances. Multivariate analysis identified smaller left ventricular outflow tract diameter, shorter membranous septum length, and greater pre-releasing implantation depth below the LCC as predictors of future PPI risk.

Conclusion: The use of the COL technique significantly reduces the risk of newly developed conduction disturbances after SEV TAVR. Keeping SEV implantation depth within 1 mm of the membranous septum length and maintaining an implantation depth of <6 mm below the LCC before final release further minimizes the risk of PPI.