Increased Pacemaker Implantation Rate After New-Generation Balloon-Expandable SAPIEN 3 Valve: Who Was to Blame, the Valve or the Doctor?

SEE PAGE 805 T he occurrence of conduction disturbances and the need for permanent pacemaker implantation remain a significant issue associated with transcatheter aortic valve replacement (TAVR) (1). Indeed, the contiguity of the conduction system to the aortic annulus (landing zone of transcatheter valve prostheses) makes this procedure likely to develop this complication (2). To date, several predictors of pacemaker implantation after TAVR have been identified, including pre-existent right bundle branch block, prolonged baseline QRS duration, and age (3). These factors are strictly patient related, irrespective of the type of transcatheter prosthesis used. Historically, the self-expanding CoreValve (Medtronic, Galway, Ireland) has been associated with a higher rate of conduction disturbances compared with the balloon-expandable Edwards SAPIEN devices caused by the longer stent frame and a deeper implantation of the prosthesis in the left ventricular outflow tract (1). Having said that, some early reports of the new-generation balloon-expandable SAPIEN 3 valve (Edwards Lifesciences, Irvine, California) have demonstrated a rate of pacemaker implantation higher than generally reported with balloon-expandable devices, although still remaining lower than that seen with selfexpanding valves (4,5). However, this was not confirmed in a more recent study by Nijhoff et al.