Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany.
Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany.
JACC Cardiovasc Interv. 2016 Nov 14;9(21):2200-2209. doi: 10.1016/j.jcin.2016.08.034.
The aim of this study was to identify predictors of permanent pacemaker implantation (PPMI) following transcatheter aortic valve replacement (TAVR) with a balloon-expandable transcatheter valve (Edwards SAPIEN 3).
New-onset conduction disturbances requiring PPMI remain a major concern following TAVR. Predictors are not yet well defined.
The influence of angiographic implantation depth, device landing zone calcium volume, oversizing, pre- and post-dilation, and baseline conduction disturbances on PPMI rate was analyzed in 229 patients undergoing TAVR with the SAPIEN 3 device.
PPMI was performed in 14.4% of patients. Patients requiring PPMI had higher left ventricular outflow tract (LVOT) calcium volume in the area below the left coronary cusp (LVOT) and the area below right coronary cusp (LVOT) (LVOT median calcium 23.7 mm vs. 3.0 mm; p < 0.001; LVOT median calcium 6.6 mm vs. 0.3 mm; p = 0.014), a higher prevalence of pre-existing right bundle branch block (15% vs. 2%, p = 0.004), and lower implantation depth (ventricular portion of the stent frame 29 ± 12% vs. 21 ± 5%; p < 0.001). On multivariate regression analysis, LVOT calcium volume >13.7 mm, LVOT calcium volume >4.8 mm, pre-existing right bundle branch block, and implantation depth >25.5% emerged as independent predictors of PPMI. Upon modification of the implantation technique, aiming at a high final valve position, implantation depth decreased from 24% ventricular portion to 21% (p = 0.012), accompanied by a decrease in PPMI rate (19.2% vs. 9.2%; p = 0.038).
LVOT and LVOT calcium load, baseline right bundle branch block, and implantation depth were identified as independent predictors of the need for PPMI post-TAVR. Patient groups with different PPMI risk could be stratified using these 4 predictors. A slightly higher valve implantation site may prevent excessive PPMI rates.
本研究旨在确定经导管主动脉瓣置换术（TAVR）后使用球囊扩张经导管瓣膜（爱德华兹 SAPIEN 3）植入永久性起搏器（PPMI）的预测因素。
新出现的传导障碍需要植入 PPMI 仍然是 TAVR 后的主要关注点。但目前尚未明确预测因素。
本研究分析了 229 例行 TAVR 患者的血管造影植入深度、器械着陆区钙体积、过度扩张、预扩张和后扩张以及基线传导障碍对 PPMI 发生率的影响，这些患者均使用 SAPIEN 3 装置。
14.4%的患者需要植入 PPMI。需要植入 PPMI 的患者左冠状动脉瓣（LC）下和右冠状动脉瓣（RC）下的左心室流出道（LVOT）钙体积更高（LVOT 钙中位数 23.7mm 比 3.0mm；p<0.001；LVOT 钙中位数 6.6mm 比 0.3mm；p=0.014），存在更高的右束支传导阻滞（15%比 2%，p=0.004），植入深度更低（支架框架心室部分 29±12%比 21±5%；p<0.001）。多变量回归分析显示，LVOT 钙体积>13.7mm、LVOT 钙体积>4.8mm、存在右束支传导阻滞和植入深度>25.5%是 PPMI 的独立预测因素。通过修改植入技术，以实现高的最终瓣膜位置，植入深度从 24%心室部分降低到 21%（p=0.012），同时 PPMI 发生率降低（19.2%比 9.2%；p=0.038）。
LVOT 和 LVOT 钙负荷、基线右束支传导阻滞和植入深度被确定为 TAVR 后需要 PPMI 的独立预测因素。可以使用这 4 个预测因素对具有不同 PPMI 风险的患者进行分层。稍微提高瓣膜植入部位可能会降低 PPMI 发生率。
