title: Calcium distribution patterns of the aortic valve as a risk factor for the need of permanent pacemaker implantation after transcatheter aortic valve implantation.
abstract: OBJECTIVE
  New-onset conduction disturbances still represent a considerable problem after transcatheter aortic valve implantation (TAVI). The aim of this study was to identify calcification patterns with an elevated risk for permanent pacemaker implantation (PPI) after TAVI and investigate underlying mechanisms in an ex vivo setting.
  
  
  RESULTS
  One hundred and sixty-two patients who underwent TAVI with the Edwards SAPIEN XT®or Medtronic CoreValve®at our institution were analysed. The calcium load of the device landing zone was quantified with 3mensio®, and calcium patterns with an elevated risk for PPI were identified. Ex vivo simulations of balloon valvuloplasty were performed in 3D-printed silicone annuli of patients matching the identified risk profile. Patients with a calcium load of the left coronary cusp (LCC) above 209 mm3had a higher rate of PPI than patients below this threshold (16.7 vs. 2.6%, P = 0.003). Multivariate regression revealed pre-existing right bundle branch block (RBBB) and increased LCC calcification as independent predictors for PPI. Simulation of the TAVI procedure in a silicone annulus revealed an off-centreline shift of the valvuloplasty balloon and transcatheter heart valve away from the LCC towards the commissure between right- and non-coronary cusp.
  
  
  CONCLUSIONS
  Pre-existing RBBB and elevated LCC calcification were identified as independent predictors for PPI. These two risk factors enabled us to distinguish between patients according to their risk for PPI after TAVI. Ex vivo simulations suggested an off-centreline shift of the balloon as a possible explanation.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Georgstraße 11, Bad Oeynhausen 32545, Germany BFujita@hdz-nrw.de.
authors.forename: Buntaro
authors.initials: B
authors.lastname: Fujita
authors.affiliation: Institute of Applied Medical Engineering, Helmholtz-Institute, RWTH Aachen University, Aachen 52074, Germany.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Kütting
authors.affiliation: Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg 20246, Germany.
authors.forename: Moritz
authors.initials: M
authors.lastname: Seiffert
authors.affiliation: Department of Cardiology, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen 32545, Germany.
authors.forename: Smita
authors.initials: S
authors.lastname: Scholtz
authors.affiliation: Institute of Applied Medical Engineering, Helmholtz-Institute, RWTH Aachen University, Aachen 52074, Germany.
authors.forename: Sandrine
authors.initials: S
authors.lastname: Egron
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Georgstraße 11, Bad Oeynhausen 32545, Germany.
authors.forename: Emir
authors.initials: E
authors.lastname: Prashovikj
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Georgstraße 11, Bad Oeynhausen 32545, Germany.
authors.forename: Jochen
authors.initials: J
authors.lastname: Börgermann
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Georgstraße 11, Bad Oeynhausen 32545, Germany.
authors.forename: Timm
authors.initials: T
authors.lastname: Schäfer
authors.affiliation: Department of Cardiology, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen 32545, Germany.
authors.forename: Werner
authors.initials: W
authors.lastname: Scholtz
authors.affiliation: Institute of Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen 32545, Germany.
authors.forename: Rainer
authors.initials: R
authors.lastname: Preuss
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Georgstraße 11, Bad Oeynhausen 32545, Germany.
authors.forename: Jan
authors.initials: J
authors.lastname: Gummert
authors.affiliation: Institute of Applied Medical Engineering, Helmholtz-Institute, RWTH Aachen University, Aachen 52074, Germany.
authors.forename: Ulrich
authors.initials: U
authors.lastname: Steinseifer
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Georgstraße 11, Bad Oeynhausen 32545, Germany.
authors.forename: Stephan M
authors.initials: SM
authors.lastname: Ensminger
mesh_terms: D000368:Aged; D000704:Analysis of Variance; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging* / Q000401:mortality / Q000601:surgery*; D002118:Calcium / Q000378:metabolism; D002304:Cardiac Pacing, Artificial / Q000379:methods*; D015331:Cohort Studies; D016001:Confidence Intervals; D019560:Echocardiography, Three-Dimensional / Q000379:methods*; D004562:Electrocardiography / Q000379:methods; D005260:Female; D006801:Humans; D007090:Image Interpretation, Computer-Assisted; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D010138:Pacemaker, Artificial; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000628:therapy; D011379:Prognosis; D011446:Prospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects / Q000379:methods*
chemical_list: D002118:Calcium
keywords: 3D printing; calcium distribution; pacemaker; simulation; transcatheter aortic valve implantation