Cusp-overlap view reduces conduction disturbances and permanent pacemaker implantation after transcatheter aortic valve replacement even with balloon-expandable and mechanically-expandable heart valves

Figures

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  Figure 1. The aortic valve and the conduction system. The proximity of the aortic valve and the cardiac conduction system explains the occurrence of new conduction disturbances after transcatheter aortic valve replacement. Illustration showing the localization of the membranous septum and the left bundle branch between the right- and the non-coronary cusp. LCC/NCC/RCC, left-/non-/right-coronary cusp; LCA/RCA, left/right coronary artery.

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  Figure 2. Study design. Between 03/2019 and 12/2020 consecutive patients without permanent pacemaker or implantable cardioverter defibrillator undergoing native valve transcatheter aortic valve replacement (TAVR) were included in the study. Prior to 02/2020 TAVR was performed in a three-cusp coplanar projection, and subsequently in a cusp-overlap projection.

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  Figure 3. Implantation depth. Measurement from the non-coronary cusp (NCC) to the distal end of the intraventricular portion of the implanted valve.

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  Figure 4. Anatomical distinctions between tricuspid-coplanar (TCC) and cusp overlap (COP) projections. Angiographic images of implantation in TCC (left) versus COP (right) for Edwards SAPIEN 3 (upper panel) and Boston Lotus Edge valves (lower panel). In the COP view the left- (LCC) and right-coronary cusp (RCC) overlap while the non-coronary cusp (NCC) is isolated on the left side.

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  Figure 5. Comparison of cusp overlap projection (COP) and tricuspid coplanar projection (TCC) for TAVR with Edwards SAPIEN 3 and Boston LOTUS Edge valves. (A) implantation depth, (B) new permanent pacemaker implantation (PPI) rate, (C) implantation depth in patients with or without new PPI, (D) incidence of new-onset of left bundle branch block (LBBB).