title: Importance of the left ventricular outflow tract in the need for pacemaker implantation after transcatheter aortic valve replacement.
abstract: BACKGROUND
  The interaction of left ventricular outflow tract (LVOT) and transcatheter heart valve (THV) is complex and may be device design specific. We sought to study LVOT characteristics and its relation with permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR).
  
  
  METHODS
  We studied 302 patients with a median age of 81years [75-84]. Computed tomography was used to assess LVOT in terms of amount of calcium, perimeter and device size relative to LVOT.
  
  
  RESULTS
  We implanted a Medtronic CoreValve (MCS) in 203 patients, Edwards-Sapien XT (ESV-XT) in 38, Edwards-Sapien S3 (ESV-S3) in 26 and Lotus in 35 patients. Sixty-eight patients (22.5%) received a new PPI within 30days after the index procedure. The incidence of PPI was 22.7% with MCS, 10.5% with ESV-XT, 26.9% with ESV-S3 and 31.4% with Lotus. By multivariate analysis RBBB at baseline (OR 2.9 [1.2-6.9, p=0.014), second generation valves (OR 2.1 [1.0-4.5], p=0.048), DOI (OR 1.20 per 1mm increment, [1.09-1.31], p<0.001) and LVOT sizing (OR per 1% increment 1.03 [1.01-1.07], p=0.022) were associated with need for PPI. Sensitivity analyses suggest that a lesser degree of LVOT oversizing triggers PPI with second generation THVs vs. first generation THVs.
  
  
  CONCLUSIONS
  More LVOT oversizing is associated with a higher need for permanent pacemaker implantation after TAVR, even more so with deeper THV implants and next generation devices (ESV-S3 and Lotus). Sizing algorithms should focus more on LVOT dimensions to reduce PPI.
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands.
authors.forename: Ramón
authors.initials: R
authors.lastname: Rodríguez-Olivares
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands.
authors.forename: Lennart
authors.initials: L
authors.lastname: van Gils
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands.
authors.forename: Nahid
authors.initials: N
authors.lastname: El Faquir
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands.
authors.forename: Zouhair
authors.initials: Z
authors.lastname: Rahhab
authors.affiliation: Department of Cardiology, Ospedali Riuniti, Università degli studi di Foggia, Foggia, Italy.
authors.forename: Luigi F M
authors.initials: LF
authors.lastname: Di Martino
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands.
authors.forename: Sander
authors.initials: S
authors.lastname: van Weenen
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands.
authors.forename: John
authors.initials: J
authors.lastname: de Vries
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands.
authors.forename: Tjebbe W
authors.initials: TW
authors.lastname: Galema
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands.
authors.forename: Marcel L
authors.initials: ML
authors.lastname: Geleijnse
authors.affiliation: Department of Radiology, Erasmus MC, Rotterdam, the Netherlands.
authors.forename: Ricardo P J
authors.initials: RP
authors.lastname: Budde
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands.
authors.forename: Eric
authors.initials: E
authors.lastname: Boersma
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands.
authors.forename: Peter P
authors.initials: PP
authors.lastname: de Jaegere
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands. Electronic address: n.vanmieghem@erasmusmc.nl.
authors.forename: Nicolas M
authors.initials: NM
authors.lastname: Van Mieghem
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging* / Q000601:surgery*; D004452:Echocardiography; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000379:methods* / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D008297:Male; D010138:Pacemaker, Artificial; D011474:Prosthesis Design; D014057:Tomography, X-Ray Computed; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods* / Q000706:statistics & numerical data; D016896:Treatment Outcome
keywords: Aortic stenosis; Left ventricular outflow tract; Multi-slice computed tomography; Pacemaker implantation; Transcatheter aortic valve implantation