May 14, 2021International journal of cardiac imaging20 citationsOpen Access

Implantation depth and its influence on complications after TAVI with self-expanding valves

PBPhilipp Breitbart JMJan Minners MHManuel Hein

Structured PICO

Does a lower implantation depth (≥ 4 mm) increase the risk of new conduction disturbances or paravalvular leakage in patients undergoing TAVI with self-expanding valves?

Population

104 patients undergoing transcatheter aortic valve implantation (TAVI) with a self-expanding valve (Evolut R) who had evaluable pre- and post-TAVI computed tomography angiography (CTA). Mean age 82.2 years, 66.3% female. Excluded patients with valve-in-valve procedures.

Intervention

Lower transcatheter heart valve (THV) positioning, defined as an implantation depth of ≥ 4 mm below the native annulus.

Comparator

Higher transcatheter heart valve (THV) positioning, defined as an implantation depth of < 4 mm below the native annulus.

Outcome

Occurrence of new conduction disturbances (CD) and grade of paravalvular leakage (PVL) assessed pre-discharge.safety

In TAVI using self-expanding valves, an implantation depth of ≥4 mm below the annulus significantly increases the risk of new conduction disturbances without affecting the severity of paravalvular leakage.

Limitations

Limited sample size
Low prevalence of right bundle branch block
Limited to patients with one specific self-expanding valve type (Evolut R)

Abstract

Prior studies in patients with transcatheter aortic valve implantation (TAVI) demonstrated an influence of transcatheter heart valve (THV) position on the occurrence of new conductions disturbances (CD) and paravalvular leakage (PVL) post TAVI in balloon-expandable valves (BEV). Purpose of this study was to investigate the THV implantation depth and its influence on the occurrence of CD and PVL in self-expanding valves (SEV). We performed fusion imaging of pre- and post-procedural computed tomography angiography in 104 TAVI-patients (all with Evolut R) to receive a 3-D reconstruction of the THV within the native annulus region. The THV length below the native annulus was measured for assessment of implantation depth. Electrocardiograms pre-discharge were assessed for conduction disturbances (CD), PVL was determined in transthoracic echocardiography. The mean implantation depth of the THV in the whole cohort was 4.3 ± 3.0 mm. Using the best cut-off of ≥ 4 mm in receiver operating characteristic curve analysis (sensitivity 83.3%, specificity 60.0%) patients with lower THV position developed more new CD after TAVI (68.2 vs. 23.7%, P < 0.001). A deep THV position was identified as the only predictor for new CD after TAVI (odds ratio CI 1.3121.119-1.539, P = 0.001). The implantation depth showed no influence on the grade of PVL (r = 0.052, P = 0.598). In patients with TAVI using the Evolut R SEV, a lower THV positioning (≥ 4 mm length below annulus) was a predictor for new conduction disturbances. In contrast, implantation depth was not associated with the extent of PVL. Prostheses positions of self-expanding valves and their influence on the occurrence of new conduction disturbances and the grade of paravalvular leakage after TAVI.

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