Key result
TAVR implantation above CTA-estimated conduction pathways is linked to zero pacemaker implantations.
Why the study?
Conduction disturbances requiring permanent pacemaker implantation remain a major limitation to transcatheter aortic valve implantation, and optimized patient-specific implantation depth to reduce PPI risk is not well understood.
Does CTA-based conduction system simulation-guided implantation above the conduction pathway reduce postprocedural permanent pacemaker implantation in patients undergoing TAVI?
Cohort (n=228)
Does CTA-based conduction system simulation-guided implantation above the conduction pathway reduce postprocedural permanent pacemaker implantation in patients undergoing TAVI?
Patient-specific CTA-based conduction system simulation may guide TAVI implantation depth to potentially eliminate the need for postprocedural permanent pacemaker implantation.
Should not yet change TAVI practice; hypothesis-generating for CTA-guided conduction pathway targeting to reduce PPI.
BACKGROUND: Conduction disturbances requiring permanent pacemaker implantation (PPI) remain a major limitation to transcatheter aortic valve implantation (TAVI). OBJECTIVE: We applied post hoc classification using a novel preprocedural computed tomography angiography (CTA)-based conduction system simulation technology to understand optimized patient-specific TAVI implantation depth to reduce PPI risk. METHODS: CARA Metis conduction system simulation based on identifying key landmarks of the conduction axis was retrospectively applied to patients who received TAVI. Device depth was measured from postprocedural CTA. The primary outcome was postprocedural PPI. Post hoc classification of patients into 4 implantation strategies was applied: (1) patient-specific conduction system protocol vs (2) implantation 1-2 mm, (3) 2-3 mm, and (4) 3-4 mm below the aortic annulus, respectively. RESULTS: Among 228 patients (median age 82.0; 57% female), 51 (22.4%) required PPI. Mean (standard deviation) distances of the estimated course of His bundle (point B and midpoint BC) and left bundle branch origin (point C) to the aortic annulus were 5.3 mm (2.3), 3.9 mm (2.1), and 2.5 mm (2.2), respectively. Implantation below the conduction pathway (n = 203) resulted in significantly higher odds of PPI (for each 1 mm below points B, midpoint BC, and C, odds ratio [OR] 1.25 [95% confidence interval {CI} 1.14-1.39], OR 1.27 [95% CI 1.14-1.42], and OR 1.24 [95% CI 1.12-1.38], respectively). Implantation above (n = 25) resulted in significantly fewer PPI (0.0% vs 17.4%, 10.0%, and 25.0% implanting above the patient's conduction system vs 1-2 mm, 2-3 mm, and 3-4 mm below the aortic annulus, respectively; P < .0001). CONCLUSION: CTA-based conduction system simulation may offer a patient-specific, conduction-axis-guided TAVI deployment strategy, minimizing the need for PPI. The results of this study are hypothesis generating and require prospective trial validation.
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Ruile et al. (2025) conducted a cohort in Transcatheter aortic valve implantation (TAVI) (n=228). Implantation above the CTA-estimated conduction pathway vs. Implantation below the conduction pathway was evaluated on Postprocedural permanent pacemaker implantation (PPI) (OR 1.25, 95% CI 1.14-1.39, p=<.0001). Implantation above the CTA-estimated conduction pathway resulted in 0.0% permanent pacemaker implantation, significantly lower than implantation below the aortic annulus (P < .0001).
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