Impact of membranous septum length on pacemaker need with different transcatheter aortic valve replacement systems: The INTERSECT registry

Background: New permanent pacemaker implantation (new-PPI) remains a compelling issue after Transcatheter Aortic Valve Replacement (TAVR). Previous studies reported the relationship between a short MS length and the new-PPI post-TAVR with a self-expanding THV. However, this relationship has not been investigated in different currently available THV. Therefore, the aim of this study was to investigate the association between membranous septum (MS)-length and new-PPI after TAVR with different Transcatheter Heart Valve (THV)-platforms. Methods: We included patients with a successful TAVR-procedure and an analyzable pre-procedural multi-slice computed tomography. MS-length was measured using a standardized methodology. The primary endpoint was the need for new-PPI within 30 days after TAVR. Results: In total, 1811 patients were enrolled (median age 81.9 years [IQR 77.2-85.4], 54% male). PPI was required in 275 patients (15.2%) and included respectively 14.2%, 20.7% and 6.3% for Sapien3, Evolut and ACURATE-THV(p < 0.01). Median MS-length was significantly shorter in patients with a new-PPI (3.7 mm [IQR 2.2-5.1] vs. 4.1 mm [IQR 2.8-6.0], p = <0.01). Shorter MS-length was a predictor for PPI in patients receiving a Sapien3 (OR 0.87 [95% CI 0.79-0.96], p = <0.01) and an Evolut-THV (OR 0.91 [95% CI 0.84-0.98], p = 0.03), but not for an ACURATETHV (OR 0.99 [95% CI 0.79-1.21], p = 0.91). By multivariable analysis, first-degree atrioventricular-block (OR 2.01 [95% CI 1.35-3.00], p = <0.01), right bundle branch block (OR 8.33 [95% CI 5.21-13.33], p = <0.01), short MS-length (OR 0.89 [95% CI 0.83-0.97], p < 0.01), annulus area (OR 1.003 [95% CI 1.001-1.005], p = 0.04), NCC implantation depth (OR 1.13 [95% CI 1.07-1.19] and use of Evolut-THV(OR 1.54 [95% CI 1.03-2.27], p = 0.04) were associated with new-PPI. Conclusion: MS length was an independent predictor for PPI across different THV platforms, except for the ACURATE-THV. Based on our study observations within the total cohort, we identified 3 risk groups by MS length: MS length <= 3 mm defined a high-risk group for PPI (>20%), MS length 3-7 mm intermediate risk for PPI (10-20%) and MS length > 7 mm defined a low risk for PPI (<10%). Anatomy-tailored-THV-selection may mitigate the need for new-PPI in patients undergoing TAVR.

Automated summary

This study investigated the association between membranous septum (MS) length and new pacemaker implantation (PPI) after Transcatheter Aortic Valve Replacement (TAVR) using different Transcatheter Heart Valve (THV) platforms. The results showed that MS length was an independent predictor for PPI across different THV platforms, except for one. Three risk groups were identified based on MS length, and anatomically tailored THV selection may reduce the need for new PPI in patients undergoing TAVR.