Background:

The need for permanent pacemaker implantation (PPMI) is a common complication of transcatheter aortic valve replacement (TAVR). Implantation depth constitutes a crucial risk factor in this regard. Cusp overlap projection technique (COT) has been devolved to lower the incidence of PPMI following TAVR by reducing disturbance of the conduction system due to a more precise assessment of transcatheter heart valve’s (THV) implantation depth. Hence, this meta-analysis aims to elucidate the clinical outcome of patients undergoing TAVR using COT versus classical implantation technique (CIT).

Methods and Results: MEDLINE and EMBASE were searched through June 2022. The review yielded five observational studies comparing both techniques for the self-expandable Evolut prosthesis (Medtronic Intern. Ltd., CA, US) and fulfilling the inclusion criteria for meta-analysis. The total number of patients included was 1227 comprising 641 who underwent COT and 586 CIT TAVR. There was no significant difference in age and STS score between both groups. The presence of post-procedural need for PPMI was lower in COT group (9,8% vs 20.6%; OR = 0.43; 95% CI [0.31, 0.59]; p = 0.00001; χ2 = 0.79; I² = 0%). This was accompanied by higher implantation depth in COT group compared to CIT (mean difference of distance from non coronary cusp hinge point to ventricular end of THV frame [mm] = 0.88; 95% CI [-1.18, -0.57]; p = 0.00001; χ2 = 1.32; I² = 0%). However, with respect to the incidence of new-onset left bundle branch block no difference was found (OR = 1.04; 95% CI [0.64, 1.70]; p = 0.87; χ2 = 5.64; I² = 47%). Regarding 30-day mortality (OR = 0.70; 95% CI [0.33, 1.48]; p = 0.35; χ2 = 0.48; I² = 0%) and implantation success according to VARC-2 criteria (OR = 1.52; 95% CI [0.80, 2.90]; p = 0.20; χ2 = 0.50; I² = 0%) pooled meta-analysis displayed no statistically significant differences between COT and CIT.

Conclusions:

This is the first meta-analysis of five observational studies comparing COT and CIT showing COT is an effective and safe implantation technique to reduce the need for a permanent pacemaker implantation during TAVR with the self-expandable Evolut prosthesis.