Calcium distribution patterns of the aortic valve as a risk factor for the need of permanent pacemaker implantation after transcatheter aortic valve implantation

Buntaro Fujita; Maximilian Kütting; Moritz Seiffert; Smita Scholtz; Sandrine Egron; Emir Prashovikj; Jochen Börgermann; Timm Schäfer; Werner Scholtz; Rainer Preuss; Jan Gummert; Ulrich Steinseifer; Stephan M Ensminger

doi:10.1093/ehjci/jev343

Calcium distribution patterns of the aortic valve as a risk factor for the need of permanent pacemaker implantation after transcatheter aortic valve implantation

Eur Heart J Cardiovasc Imaging. 2016 Dec;17(12):1385-1393. doi: 10.1093/ehjci/jev343. Epub 2016 Jan 12.

Authors

Affiliations

¹ Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Georgstraße 11, Bad Oeynhausen 32545, Germany BFujita@hdz-nrw.de.
² Institute of Applied Medical Engineering, Helmholtz-Institute, RWTH Aachen University, Aachen 52074, Germany.
³ Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg 20246, Germany.
⁴ Department of Cardiology, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen 32545, Germany.
⁵ Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Georgstraße 11, Bad Oeynhausen 32545, Germany.
⁶ Institute of Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen 32545, Germany.

PMID: 26758411
DOI: 10.1093/ehjci/jev343

Abstract

Aims: 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.

Methods and 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 mm³ had 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.

Conclusion: 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.

Keywords: 3D printing; calcium distribution; pacemaker; simulation; transcatheter aortic valve implantation.

Publication types

Comparative Study

MeSH terms

Aged
Analysis of Variance
Aortic Valve Stenosis / diagnostic imaging*
Aortic Valve Stenosis / mortality
Aortic Valve Stenosis / surgery*
Calcium / metabolism
Cardiac Pacing, Artificial / methods*
Cohort Studies
Confidence Intervals
Echocardiography, Three-Dimensional / methods*
Electrocardiography / methods
Female
Humans
Image Interpretation, Computer-Assisted*
Male
Multivariate Analysis
Odds Ratio
Pacemaker, Artificial
Postoperative Complications / diagnostic imaging
Postoperative Complications / therapy
Prognosis
Prospective Studies
Risk Assessment
Survival Rate
Transcatheter Aortic Valve Replacement / adverse effects
Transcatheter Aortic Valve Replacement / methods*

Substances

Calcium