Author + information
- Received April 8, 2019
- Revision received May 6, 2019
- Accepted May 21, 2019
- Published online August 28, 2019.
- Hasan Jilaihawi, MDa,∗∗ (, )
- Zhengang Zhao, MDb,∗,
- Run Du, MDa,
- Cezar Staniloae, MDa,
- Muhamed Saric, MDa,
- Peter J. Neuburger, MDa,
- Michael Querijero, MS PA-Ca,
- Alan Vainrib, MDa,
- Kazuhiro Hisamoto, MDa,
- Homam Ibrahim, MDa,
- Tara Collins, MS PA-Ca,
- Emily Clark, MS PA-Ca,
- Illya Pushkar, MPHa,
- Daniel Bamira, MDa,
- Ricardo Benenstein, MDa,
- Afnan Tariq, MDa and
- Mathew Williams, MDa
- aHeart Valve Center, NYU Langone Health, New York, New York
- bDepartment of Cardiology, West China Hospital, Sichuan University, Chengdu, China
- ↵∗Address for correspondence:
Dr. Hasan Jilaihawi, Heart Valve Center, NYU Langone Health, New York, Suite 9V, 530 1st Avenue, New York, New York 10016.
Objectives This study sought to minimize the risk of permanent pacemaker implantation (PPMI) with contemporary repositionable self-expanding transcatheter aortic valve replacement (TAVR).
Background Self-expanding TAVR traditionally carries a high risk of PPMI. Limited data exist on the use of the repositionable devices to minimize this risk.
Methods 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).
Results Right bundle branch block, MS length, largest device size (Evolut 34 XL; Medtronic, Minneapolis, Minnesota), and implant depth > MS length predicted PPMI. On multivariate analysis, only implant depth > MS 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).
Conclusions 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.
↵∗ Drs. Jilaihawi and Zhao contributed equally to this work.
Dr. Jilaihawi has been a consultant to Edwards Lifesciences and Venus Medtech; and has received grant/research support from Medtronic and Abbott Vascular. Dr. Staniloae has been a consultant to Medtronic. Dr. Saric has served on speakers bureaus for Philips and Medtronic; and on an advisory board for Siemens. Dr. Neuburger is a consultant to Medtronic and is on the Advisory Board for Livanova. Dr. Querijero has received speakers fees from Medtronic. Dr. Vainrib has been a consultant. Dr. Ibrahim has been a proctor for Medtronic. Dr. Williams has been a consultant to Medtronic; and has received research funding from Edwards Lifesciences and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 8, 2019.
- Revision received May 6, 2019.
- Accepted May 21, 2019.
- 2019 American College of Cardiology Foundation
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