Key result
Δcoronal MSID <1.8 mm predicts ~8-fold higher new conduction disturbance risk in bicuspid self-expanding TAVR.
Why the study?
New-onset conduction disturbances remain the most common complication after TAVR in bicuspid aortic valve patients, but predictors and modifiable technical factors are not well defined.
Cohort (n=209)
Yes
In patients with bicuspid aortic valves undergoing self-expanding TAVR, short membranous septum length and prosthesis oversizing are strong predictors of new-onset conduction disturbances.
Objective: To evaluate the predictors of new-onset conduction disturbances in bicuspid aortic valve patients using self-expanding valve and identify modifiable technical factors. Background: New-onset conduction disturbances (NOCDs), including complete left bundle branch block and high-grade atrioventricular block, remain the most common complication after transcatheter aortic valve replacement (TAVR). Methods: A total of 209 consecutive bicuspid patients who underwent self-expanding TAVR in 5 centers in China were enrolled from February 2016 to September 2020. The optimal cut-offs in this study were generated from receiver operator characteristic curve analyses. The infra-annular and coronal membranous septum (MS) length was measured in preoperative computed tomography. MSID was calculated by subtracting implantation depth measure on postoperative computed tomography from infra-annular MS or coronal MS length. Results: Forty-two (20.1%) patients developed complete left bundle branch block and 21 (10.0%) patients developed high-grade atrioventricular block after TAVR, while 61 (29.2%) patients developed NOCDs. Coronal MS <4.9 mm (OR: 3.08, 95% CI: 1.63–5.82, p = 0.001) or infra-annular MS <3.7 mm (OR: 2.18, 95% CI: 1.04–4.56, p = 0.038) and left ventricular outflow tract perimeter <66.8 mm (OR: 4.95 95% CI: 1.59–15.45, p = 0.006) were powerful predictors of NOCDs. The multivariate model including age >73 years (OR: 2.26, 95% CI: 1.17–4.36, p = 0.015), Δcoronal MSID <1.8 mm (OR: 7.87, 95% CI: 2.84–21.77, p < 0.001) and prosthesis oversizing ratio on left ventricular outflow tract >3.2% (OR: 3.42, 95% CI: 1.74–6.72, p < 0.001) showed best predictive value of NOCDs, with c-statistic = 0.768 (95% CI: 0.699–0.837, p < 0.001). The incidence of NOCDs was much lower (7.5 vs. 55.2%, p < 0.001) in patients without Δcoronal MSID <1.8 mm and prosthesis oversizing ratio on left ventricular outflow tract >3.2% compared with patients who had these two risk factors. Conclusion: The risk of NOCDs in bicuspid aortic stenosis patients could be evaluated based on MS length and prosthesis oversizing ratio. Implantation depth guided by MS length and reducing the oversizing ratio might be a feasible strategy for heavily calcified bicuspid patients with short MS.
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Guo et al. (2021) conducted a cohort in Bicuspid aortic valve stenosis (n=209). Δcoronal MSID < 1.8 mm vs. Δcoronal MSID ≥ 1.8 mm was evaluated on New-onset conduction disturbances (NOCDs) (OR 7.87, 95% CI 2.84-21.77, p=<0.001). A Δcoronal membranous septum minus implantation depth (MSID) of <1.8 mm strongly predicted new-onset conduction disturbances (OR 7.87) in patients with bicuspid aortic valve undergoing self-expanding TAVR.
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