Background:  Permanent pacemaker implantation (PPI) is a common complication after transcatheter aortic valve implantation (TAVR). Optimization of the implantation depth (ID) by introducing the cusp-overlap projection (COP) technique led to a reduced rate of PPI when the self-expanding Evolut valve was used. 

Objectives: The aim of this study was to determine if using the novel cusp-overlap projection technique for TAVR results in a higher ID and reduced incidence of PPI even in balloon-expandable heart valves.

Methods: In this prospective case-control study the rate of periprocedural PPI was analyzed between two consecutive TAVR groups with the balloon-expandable Edwards SAPIEN 3 valve using either conventional three-cusp coplanar (TCC) projection technique or COP view for implantation from 03/2019 to 12/2020. Infra-annular membranous septum lengths and ID were measured using pre-TAVR computed tomography and postprocedural angiography. 

Results: A total of 280 patients without history of PPI undergoing Edwards SAPIEN 3 TAVR procedure in our hospital heart center were included in this analysis. Of those, 143 (51.1%) underwent TAVR using COP, whereas in 137 (48.9%) TCC was used.  Baseline characteristics including mean age (79.5 vs. 79.2 years; P=0.689), gender (male: 62.3% vs. 67.6%; P=0.472), STS-score (3.8 vs. 3.5; P=0.588) and atrial fibrillation (27.3% vs. 26.5%; P=0.851) were equally distributed in both groups. Rate of prior left and right bundle branch block were 16.2% and 15.4% in the COP group versus 10.9% and 17.2% in the TCC group (P<0.001 and P=0.722, respectively). Using COP, a significant higher ID at the non-coronary cusp (NCC) was achieved compared to the conventional TCC technique (mean difference -1.0 mm, 95%-CI -1.9 to -0.1 mm; P=0.029). Higher implantation was associated with a lower post-procedural PPI incidence (P=0.006). Furthermore, a short membranous septum was associated with higher risk of PPI (P=0.030).

Conclusion: The application of COP technique leads to significant higher implantation depth, thus lowering the risk of PPI even in balloon-expandable TAVR when compared to the standard TCC technique. Besides, the COP technique could be suitable to reduce the incidence of PPI by a membranous septum guided prothesis implantation.