Factors associated with a high or low implantation of self-expanding devices in TAVR

Abstract

Objectives: Optimizing valve implantation depth (ID) plays a crucial role in minimizing conduction disturbances and achieving optimal functional integrity. Until now, the impact of intraprocedural fast (FP) or rapid ventricular pacing (RP) on the implantation depth has not been investigated. Therefore, we aimed to (1) evaluate the impact of different pacing maneuvers on ID, and (2) identify the independent predictors of deep ID.

Methods: 473 TAVR patients with newer-generation self-expanding devices were retrospectively enrolled and one-to-one propensity-score-matching was performed, resulting in a matching of 189 FP and RP patients in each cohort. The final ID was analyzed, and the underlying functional, anatomical, and procedural conditions were evaluated by univariate and multivariate analysis.

Results: The highest ID was reached under RP in severe aortic valve calcification and valve size 26 mm. Multivariate analysis identified left ventricular outflow (LVOT) calcification [OR 0.50 (0.31-0.81) p = 0.005*], a "flare" aortic root [OR 0.42 (0.25-0.71), p = 0.001*], and RP (OR 0.49 [0.30-0.79], p = 0.004*) as independent highly preventable predictors of a deep ID. In a model of protective factors, ID was significantly reduced with the number of protective criteria (0-2 criteria: - 5.7 mm ± 2.6 vs. 3-4 criteria - 4.3 mm ± 2.0; p < 0.0001*).

Conclusion: Data from this retrospective analysis indicate that RP is an independent predictor to reach a higher implantation depth using self-expanding devices. Randomized studies should prove for validation compared to fast and non-pacing maneuvers during valve delivery and their impact on implantation depth.

Trail registration: Clinical Trial registration: NCT01805739.

Study design: Evaluation of the impact of different pacing maneuvers (fast ventricular pacing-FP vs. rapid ventricular pacing-RP) on implantation depth (ID). After one-to-one-propensity-score-matching, independent protective and risk factors for a very deep ID beneath 6 mm toward the LVOT (< - 6 mm) were identified. Stent frame pictures as a courtesy by Medtronic®. AVC aortic valve calcification.

Keywords: Implantation depth; TAVI; TAVR.

Conflict of interest statement

VV, TZ, AP, CJ, and RW have received consulting fees, travel expenses, or study honoraria from Medtronic and Edwards Lifesciences. All other authors have nothing to disclose with regard to this project.

© 2021. The Author(s).

Figures

Fig. 1

Independent predictors of very deep ID A Identified predictors of a very deep implantation depth (ID) toward the LVOT. B C-statistics of the independent predictors. C Converted protective model that includes all independent predictors, resulting in a significantly higher ID depending on the number of criteria (0–2 criteria: − 5.7 mm ± 2.6 vs. 3–4 criteria − 4.3 mm ± 2.0; p < 0.0001****). AUC area under the curve

Fig. 2

Thirty-day outcome and functional status. A Final ID according to different AVC severity and the applied criteria of the protective model. B Functional improvement—shown as the mean gradient (dPmean)—in the FP and RP cohorts. C Frequency distribution of paravalvular leakage-related aortic regurgitation (AR) comparing the FP and RP cohorts.