Background: A high permanent pacemaker implantation (PPI) risk remain a concern of self-expandable transcatheter aortic valve implantation (TAVI), despite continued improvements in implantation methodology. We aimed to assess the impact of real-time direct visualization of the membranous septum using transjugular intracardiac echocardiography (ICE) during TAVI on reducing the rates of conduction disturbances including the need for PPI. Methods: Consecutive patients treated with Evolut R and Evolut PRO/PRO+ from February 2017 to September 2022 were included in this study. We compared outcomes between the conventional implantation method using the 3-cusps view ("3-cusps without ICE" group), the recent method using cusp-overlap view ("cusp-overlap without ICE" group), and our novel method using ICE ("cusp-overlap with ICE" group). Results: Of the 446 patients eligible for analysis, 211 (47.3%) were categorized as the "3-cusps without ICE" group, 129 (28.9%) were in the "cusp-overlap without ICE" group, and 106 (23.8%) comprised the "cusp-overlap with ICE" group. Compared with the "3-cusps without ICE" group, the "cusp-overlap without ICE" group had a smaller implantation depth (2.2 [IQR 1.0-3.5] mm vs 4.3 [IQR: 3.3-5.4], P <0.001) and lower 30-day PPI rates (7.0% vs 14.2%, P = 0.035). Compared with the "cusp-overlap without ICE" group, the "cusp-overlap with ICE" group had lower 30-day PPI rates (1.0%, P = 0.014), albeit with comparable implantation depths (1.9 [IQR 0.9-2.9] mm, P = 0.150). Multivariable analysis showed that our novel method using ICE with the cusp-overlap view was independently associated with a 30-day PPI rate reduction. There were no group differences in 30-day all-cause mortality (1.4% vs 1.6% vs 0%; P = 0.254). Conclusions: Our novel implantation method using transjugular ICE, which enabled a real-time direct visualization of the membranous septum, achieved a predictably high position of prostheses, resulting in a substantial reduction of conduction disturbances requiring PPI after TAVI.

The authors have declared no competing interest.

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Institutional Review Board of the Kokura Memorial Hospital

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The data that support the findings of this study are available from the corresponding author, KI, upon reasonable request.