Anatomical variations in permanent pacemaker requirement after TAVI in bicuspid anatomy

We sought to illustrate the varying risk of permanent pacemaker implantation (PPMI) following self-expanding TAVI among bicuspid aortic valve (BAV) subtypes, and to categorize BAV anatomical variations based on the risk of PPMI.

We retrospectively analyzed 300 BAV patients with severe aortic stenosis who underwent self-expanding TAVI. Based on leaflet morphology and calcification severity at the commissure between right coronary cusp (RCC) and non-coronary cusp (NCC), BAVs were classified into two subtypes: BAV with MS below commissure (BAV-MSBC) and BAV with MS below leaflet (BAV-MSBL). Univariate and multivariate logistic regressions were performed to identify potential risk factors of PPMI. PPMI rate differed significantly between BAV-MSBC and BAV-MSBL [32.8% (42 of 128) vs. 5.8% (10 of 172), P < 0.001]. Multivariate analysis identified BAV-MSBC [odds ratio (OR) = 10.15, 95% confidence interval (CI): 4.07–25.34, P < 0.001], previous AVB I (OR = 4.15, 95% CI: 1.32–13.04, P = 0.015) and right bundle branch block (OR = 26.39, 95% CI: 4.81–144.82, P < 0.001) as risk factors of PPMI, while △MSID-RCC (OR = 0.78, 95% CI: 0.70–0.86, P < 0.001) was protective. The multivariate model had an AUC of 0.887 (95% CI: 0.843–0.930).

PPMI risk differs significantly between BAV subtypes, possibly due to variations in MS proximity to the stent. The new BAV classification method may improve PPMI risk prediction and patient management.