E-46 | Rates of Permanent Pacemaker Implantation Post-TAVR Using a Strategy of TEE and Non-Contrast CT in CKD Patients versus CT Angiography for Annular Sizing

Preprocedural imaging of the aortic valve complex is a critical component of transcatheter aortic valve replacement (TAVR). The anatomical position of the valve can lead to vulnerability of the nearby conduction system, increasing the risk of permanent pacemaker implantation (PPM) post-TAVR. Various factors, such as shorter membranous septum length, low valve implantation depth, and significant noncoronary cusp device landing zone calcium volume, have been associated with higher rates of PPM implantation. Traditionally, these variables have been assessed using computerized tomography angiography (CTA) chest/abdomen/pelvis. However, in patients with renal function limitations or low glomerular filtration rate (GFR), alternative imaging methods, such as transesophageal echocardiogram (TEE) and CT without contrast, are utilized for preprocedural planning. We evaluated the differences in rates of PPM implantation post-TAVR in 528 patients who underwent preprocedural CTA (n = 445) versus TEE (n = 83), using a GFR<40 as the cutoff for CTA. Our study population included patients from a tertiary care center in Los Angeles who received TAVR with the Edwards SAPIEN 3 valve between 2016-2021. Retrospective data was obtained from the electronic medical record and an internal database. There was no significant difference in the presence of pre-procedural right bundle branch block, first-degree atrioventricular block, or bifascicular block between the groups. A Fisher's exact test was used to analyze the rates of PPM placement at the day of discharge, 30 days post-procedure, and 1-year post-procedure between the CTA and TEE groups. Patients lost to follow-up or deceased were included in the analysis until the time they were lost to follow-up or the time of death. A p-value of <0.05 was considered significant. There was no significant difference in the rates of PPM implantation post-TAVR in the CTA or TEE groups by day of discharge (5.2% vs. 8.4%, p = 0.3), 30 days postoperatively (5.7% vs. 8.4%, p = 0.33), or 1 year postoperatively (7% vs. 8%; p = 0.81). Preoperative planning with TEE and non-contrast CT is non-inferior to CTA in regard to rates of PPM implantation post-TAVR.