Transjugular intracardiac echocardiography-guided transcatheter aortic valve replacement using intra-annular self-expandable valves to reduce permanent pacemaker implantation

Abstract Introduction Transcatheter aortic valve replacement (TAVR) using Navitor, an intra-annular self-expandable valve (IA-SEV), has been shown to provide favorable postprocedural hemodynamics and reduce paravalvular leakage. However, permanent pacemaker implantation (PPMI) remains a concern, with previous studies reporting a 30-day PPMI rate of approximately 10% to 15%. We previously proposed a novel method to reduce PPMI using transjugular intracardiac echocardiography (TJ-ICE)-guided TAVR, which enables implantation at an optimal depth by directly visualizing the membranous septum (MS) during the procedure. This method demonstrated reduced PPMI rates using both Sapien and Evolut series. However, no data were available on TJ-ICE-guided TAVR using IA-SEV. Purpose The aim of this study was to evaluate the effectiveness of TJ-ICE-guided TAVR in reducing PPMI rates using IA-SEV. Methods and Results We enrolled 45 consecutive patients with severe aortic stenosis who underwent TAVR using IA-SEV between 2022 and 2025 at our university in Japan. The mean age was 86 ± 4 years, with 88.9% (n=40) being female. The patients' height, body weight, and body surface area were 148 143-152 cm, 47 40-54 kg, and 1.4 ± 0.2, respectively. The prevalence of CRBBB was 11.1% (n=5). Computed tomography revealed an annulus area of 376 ± 52 mm², a perimeter of 70 ± 5 mm, a bicuspid valve prevalence of 0%, and an MS length of 5.2 ± 1.4 mm. All procedures were performed via the transfemoral approach under conscious sedation. Using TJ-ICE guidance, we aimed to position the valve within the MS. The MS length measured via TJ-ICE was 5.6 ± 1.6 mm (Fig A: ICE shows MS. The yellow circle highlights MS; Figure B: Focus of MS). Pre-dilation was required in 44 cases (97.8%). The distribution of implanted valve sizes was as follows: 23 mm (44.4%, n=20), 25 mm (33.3%, n=15), 27 mm (20.0%, n=9), and 29 mm (2.2%, n=1). Re-capture was not required in 42.2% (n=19) of cases, while it was needed once in 33.3% (n=15), twice in 11.1% (n=5), and three or more times in 13.3% (n=6). The device was successfully placed within the MS in 88.9% (n=40) (Fig C: ICE shows the device placed within MS. The yellow arrow indicates the bottom edge of the device; Fig D: Focus of MS and the device). Post-dilation was required in 21 cases (48.8%). The final device position within MS was confirmed by computed tomography before discharge, which was consistent with intra-procedural TJ-ICE findings (Figure E: CT image. The yellow arrow highlights the bottom edge of the device). The 30-day PPMI rate was 2.2% (n=1). Additionally, patients were classified based on device placement within the MS and the presence of CRBBB at baseline (Figure F). In one case with CRBBB, complete atrioventricular block occurred during the attempt to advance the pre-dilatation balloon, and the device was subsequently implanted within the MS. Conclusions TJ-ICE-guided TAVR using IA-SEV reduced the incidence of new PPMI.