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Predicting pacemaker implantation after TAVR with procedural CT
Session:
Prémio Jovem Investigador
Speaker:
Francisco Gama
Congress:
CPC 2020
Topic:
H. Interventional Cardiology and Cardiovascular Surgery
Theme:
25. Interventional Cardiology
Subtheme:
25.3 Non-coronary Cardiac Intervention
Session Type:
Prémios
FP Number:
---
Authors:
Francisco Fernandes Gama; Pedro de Araújo Gonçalves; António Miguel Ferreira; Rui Campante Teles; João Abecasis; João Brito; Gustavo Sá Mendes; Mariana Gonçalves; Afonso Félix De Oliveira; Pedro Freitas; Manuel Almeida; Miguel Mendes
Abstract
<p><strong>Background and aim: </strong>The need for permanent pacemaker implantation (PPMI) is a burdensome complication of transcatheter aortic valve replacement (TAVR). Calcium distribution in the aortic-valvular complex (AVC) and, more recently, membranous septum (MS) length seem to be surrogate markers for conduction abnormalities after specific last generation balloon and self-expandable expandable valves. We sough to evaluate whether such pre-procedural association remains across the entire device spectrum.</p> <p><strong>Methods: </strong>Single-centre prospective study of 239 consecutive patients (140 women, median age of 84) with severe symptomatic aortic stenosis patients who underwent ECG-gated contrast-enhanced multi-detector computed tomography (MSCT) before TAVR since Jun/2017. Exclusion criteria were those with previous PPMI, previous bioprothesis, congenital bicuspid valve, and poor imaging quality. The J-score with an 850-Hounsfield unit threshold was used to detect areas of calcium in the region of interest. AVC was characterized by leaflet sector and region, using 3mensio Valves software 7.0 <sup>TM</sup>. An independent team retrospectively measured MS length blindly by determining the thinnest part of the interventricular septum in the coronal view in the better-defined systolic phase (usually at 40% of the R-R interval, Figure). Device selection (75.8% self-expandable devices, 20.1% balloon expandable, 3.1% other) and positioning were performed according to the operator criteria. Final implant depth was assessed based on the pre-release angiogram or final aortography.</p> <p><strong>Results: </strong>Mortality at 30-days was 1.3% and PPMI occurred in 43 patients (18%). Median MS length was 9.59mm (IQR: 3.11mm). After multivariable logistic regression analysis, MS length emerged as the single significant protective predictor for PPMI (OR: 0.14; 95% 95% CI: 0.05-0.42; p<0.001), independently of the device used (p<0.001). MS length showed strong discriminatory ability for PPMI (c-statistic 0.93; 95% CI 0.88-0.99). Sensitivity/specificity decision plots yielded an MS length of 6.9 mm as the optimal cut-off point for predicting the need for PPMI with a positive and negative predictive value of 91% and 93%, respectively (Figure). There wasn't any calcium accumulation within a specific region of AVC that independently predicted the outcome.</p> <p><strong>Conclusion:</strong> In our experience, a short membranous septum was strongly and independently associated with new permanent pacemaker implantation, regardless of the device type.</p> <p> Our findings suggest that this simple measure should be routinely made to help device selection and implantation technique.</p>
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