Depth, Cusp Stretching Linked to Need for Pacemaker after TAVR

WASHINGTON, DC—Variables related to implantation depth and stretching of the non-coronary cusp are indendent predictors of the need for placement of a permanent pacemaker after transcatheter aortic valve replacement (TAVR) with CoreValve, according to a study presented March 29, 2014, at the American College of Cardiology (ACC)/i2 Scientific Session.

Won-Jang Kim, MD, PhD, of Asan Medical Center (Seoul, South Korea), and colleagues looked at outcomes for 117 patients with severe aortic stenosis who underwent TAVR with the CoreValve Revalving System (Medtronic, Minneapolis, MN) at 6 Asian medical centers between March 2010 and May 2013.

Overall, 23 patients (19.7%) required permanent pacemaker after TAVR. Median time to insertion was 7 days (interquartile range, 5-13 days).

Two Predictors Isolated

There was an increased rate of permanent pacemaker insertion in patients in whom the device depth from the non-coronary cusp was large as determined by aortic root angiography, as well as in those whose native valve had been overstretched. Both of these variables were identified in multivariate logistic regression as independent predictors of need for permanent pacemaker (table 1).

Table 1. Predictors of Permanent Pacemaker after TAVR



OR (95% CI)

P Value

Device Depth from Non-Coronary Cusp

1.263 (1.034-1.543


Perimeter Stretching Index

1.584 (1.239-1.935)

< 0.0001

Predictive cutoff values were device depth >7.8 mm (P < 0.0003) from the non-coronary cusp and > 1.13 (P < 0.0001) for perimeter stretching index. The diagnostic accuracy of these variables was 93.2% and 71%, respectively.

Electrophysiology testing was performed in 18 patients. Compared with patients with no pacemaker (n = 11), those who required a permanent pacemaker (n = 7) had higher A-H interval (128.5 msec vs 110 msec; P = 0.086) but similar H-V intervals (52 msec vs 49 msec; P = 0.751).

“To reduce the need for post-TAVI [permanent pacemaker], care must be taken when selecting the device size to prevent overstretching of the native [valve] and the device should not be implanted too deep,” Dr. Kim concluded.

Study Details

Mean age was 81.2 ± 5.1 years. Device success was 91.4% and device sizes used were 26 mm (46.2%), 29 mm (43.6%) and 31 mm (10.3%). The majority of procedures (92%) were transfemoral. Balloon pre-dilatation was used in 58.9% and post-dilatation in 35.9%.




Kim W-J. Predictors of permanent pacemaker insertion following transcatheter aortic valve implantation with the CoreValve revalving system based on computed tomography analysis: an Asian multicenter registry study. Presented at: American College of Cardiology (ACC)/i2 Scientific Session; March 29, 2014; Washington, DC.




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  • Conflicts of interest for Dr. Kim were not available.