Entry Site Is Associated With Aortic Enlargement After Pre-emptive Endovascular Repair for Uncomplicated Type B Aortic Dissection.

OBJECTIVES: We aimed to examine the mid-term results corresponding to the entry site in patients who underwent pre-emptive thoracic endovascular aortic aneurysm repair (TEVAR) for uncomplicated type B aortic dissection (TBAD). METHODS: We included 27 patients who underwent pre-emptive TEVAR for uncomplicated TBAD between September 2014 and December 2019. We divided the patients into 2 groups depending on the proximal landing zone (zone 2 group, zone ≥3 group) and retrospectively analyzed the risk of all-cause and aorta-related mortality, aortic events (rupture, open conversion, and secondary intervention), and aortic enlargement (≥5 mm). RESULTS: The median age of the patients was 53 (47-65) years. The median duration from the onset of uncomplicated TBAD to TEVAR was 43 (30-99) days, and the median follow-up duration was 48 (36-57) months. The maximum preoperative diameter of the dissected aorta was 40 mm in the zone 2 group and 35 mm in the zone ≥3 group (p=0.134). There was no case of hospital death or spinal cord ischemia; however, there was 1 (3.7%) case of perioperative stroke in the zone 2 group. Multivariate analysis of the risk factors for aortic enlargement following pre-emptive TEVAR for uncomplicated TBAD revealed that only zone 2 landing was an independent risk factor. The estimated Kaplan-Meier curve showed a higher rate of aortic enlargement in the zone 2 group at 4 years after pre-emptive TEVAR (46.4% vs 0%, log-rank test; p=0.011). CONCLUSIONS: In this study on TBAD, we found that zone 2 landing was associated with aortic enlargement after pre-emptive TEVAR. In cases where the distance from the left subclavian artery to a major entry point was short, there were more cases of aortic dilatation. CLINICAL IMPACT: The effectiveness of entry closure for type B aortic dissection was demonstrated in the INSTEAD XL trial. The cause of aortic enlargement after pre-emptive endovascular treatment for type B aortic dissection remains controversial. In the present study, zone 2 landing was a risk factor for aortic enlargement after pre-emptive thoracic endovascular aortic aneurysm repair (TEVAR) for uncomplicated type B dissection. Patients with zone 2 landing should be closely followed up after pre-emptive TEVAR.

Excessive EP4 Signaling in Smooth Muscle Cells Induces Abdominal Aortic Aneurysm by Amplifying Inflammation.

OBJECTIVE: Excessive prostaglandin E2 production is a hallmark of abdominal aortic aneurysm (AAA). Enhanced expression of prostaglandin E2 receptor EP4 (prostaglandin E receptor 4) in vascular smooth muscle cells (VSMCs) has been demonstrated in human AAAs. Although moderate expression of EP4 contributes to vascular homeostasis, the roles of excessive EP4 in vascular pathology remain uncertain. We aimed to investigate whether EP4 overexpression in VSMCs exacerbates AAAs. Approach and Results: We constructed mice with EP4 overexpressed selectively in VSMCs under an SM22α promoter (EP4-Tg). Most EP4-Tg mice died within 2 weeks of Ang II (angiotensin II) infusion due to AAA, while nontransgenic mice given Ang II displayed no overt phenotype. EP4-Tg developed much larger AAAs than nontransgenic mice after periaortic CaCl2 application. In contrast, EP4fl/+;SM22-Cre;ApoE-/- and EP4fl/+;SM22-Cre mice, which are EP4 heterozygous knockout in VSMCs, rarely exhibited AAA after Ang II or CaCl2 treatment, respectively. In Ang II-infused EP4-Tg aorta, Ly6Chi inflammatory monocyte/macrophage infiltration and MMP-9 (matrix metalloprotease-9) activation were enhanced. An unbiased analysis revealed that EP4 stimulation positively regulated the genes binding cytokine receptors in VSMCs, in which IL (interleukin)-6 was the most strongly upregulated. In VSMCs of EP4-Tg and human AAAs, EP4 stimulation caused marked IL-6 production via TAK1 (transforming growth factor-ß-activated kinase 1), NF-κB (nuclear factor-kappa B), JNK (c-Jun N-terminal kinase), and p38. Inhibition of IL-6 prevented Ang II-induced AAA formation in EP4-Tg. In addition, EP4 stimulation decreased elastin/collagen cross-linking protein LOX (lysyl oxidase) in both human and mouse VSMCs. CONCLUSIONS: Dysregulated EP4 overexpression in VSMCs promotes inflammatory monocyte/macrophage infiltration and attenuates elastin/collagen fiber formation, leading to AAA exacerbation.

Brachiocephalic artery dissection is a marker of stroke after acute type A aortic dissection repair.

OBJECTIVE: Postoperative stroke is a serious unsolved complication after acute type A aortic dissection (ATAAD) repair. We investigated the incidence and risk factors of stroke, and hypothesized that dissection of supra-aortic vessels is an important risk factor of this morbidity. METHODS: Between 2012 and 2019, 202 (56% men, median age 68 years) patients with ATAAD underwent surgical repair. Clinical data, image findings, method of circulatory support, and repair technique were retrospectively investigated to explore the risk factor of postoperative stroke. RESULTS: Of the 202 patients, operative mortality was 6% and the incidence of postoperative stroke was 12% (n = 25). Brachiocephalic artery (BCA) dissection was associated with a higher risk of stroke (odds ratio, 3.89; 95% confidence interval, 1.104-13.780; p = .035) having no relation to the presence or absence of left common carotid artery dissection. Preoperative malperfusion syndrome, circulatory arrest time, isolated cerebral perfusion time, repair technique (total arch replacement), and femoral artery perfusion alone were not related to the incident rate of postoperative stroke. Stroke occurred in both hemispheres, regardless of the laterality of carotid artery dissection. CONCLUSION: BCA dissection was an independent risk factor of stroke after ATAAD repair.

Coil embolization of intercostal arteries accessed by surgical exposure for type II endoleak after thoracic endovascular aortic repair.

Many patients with type II endoleak after thoracic endovascular aortic repair (TEVAR) are closely observed without secondary intervention. Herein, we report a new technique of coil embolization for type II endoleak from intercostal arteries after TEVAR for ruptured acute type B aortic dissection. A hybrid procedure of exposing intercostal arteries via subcostal incision in the prone position and transcatheter technique enables embolization of intercostal arteries at their origin from the aorta. This technique could avoid lung injury and be applicable in multiple intercostal arteries. This technique may be a useful secondary intervention for type II endoleak after TEVAR caused by intercostal arteries.

An appropriately sized soft polyester external stent prevents enlargement and neointimal hyperplasia of a saphenous vein graft in a canine model.

Although the efficacy of external stents for vein grafts in coronary artery bypass grafting has been recognized, the ideal diameter and material of the stent remain controversial. We created a new external stent made of soft polyester mesh and performed an animal experiment using canines. Bilateral saphenous vein grafts were interposed in the bilateral common carotid artery of 10 beagles. The grafts in the left carotid artery were designated as the control group, and those in the right rolled by a soft polyester mesh external stent were designated as mesh group. Two of the 10 animals were sacrificed due to severe wound infection. The other eight were observed by echography for 6 months, and then grafts were extracted and thickness of the neointima of the grafts was measured. The control group showed 146% ± 26% postoperative enlargement of the internal diameter of the vein grafts after 6 months, whereas the mesh group showed only 115% ± 15% after the same duration (P = 0.0003). The median thickness of the neointima in the mesh group (170 µm [range: 150-190]) was significantly thinner than that in the control group (260 µm [range: 220-310], P < 0.0001). Some degree of correlation between the thickness of neointima and proportion of enlargement was noted (r = 0.518, P = 0.0024). A soft polyester mesh external stent for vein grafts successfully suppressed the enlargement of the vein grafts and thickness of the neointima after 6 months.

Proteomic analysis of aortic smooth muscle cell secretions reveals an association of myosin heavy chain 11 with abdominal aortic aneurysm.

Abdominal aortic aneurysm (AAA) is a life-threatening disease, and no disease-specific circulating biomarkers for AAA screening are currently available. We have identified a smooth muscle cell (SMC)-specific biomarker for AAA. We cultured aneurysmal tunica media that were collected from eight patients undergoing elective open-repair surgeries. Secreted proteins in culture medium were subjected to liquid chromatography/tandem mass spectrometry. Myosin heavy chain 11 (myosin-11) was identified as a SMC-specific protein in the tunica media-derived secretions of all patients. We then examined myosin-11 protein concentrations by ELISA in plasma samples from patients with AAA ( n = 35) and age-matched healthy control subjects ( n = 34). Circulating myosin-11 levels were significantly higher in patients with AAA than control subjects. The area under the receiver-operating characteristic curve (AUC) of myosin-11 was 0.77, with a specificity of 65% at a sensitivity of 91%. Multivariate logistic regression analysis showed a significant association between the myosin-11 level and presence of AAA. When the myosin-11 level was combined with hypertension, it improved the prediction of AAA (AUC 0.88) more than hypertension per se. We then investigated the correlation between aortic diameter and circulating myosin-11 levels using AAA serum samples from patients undergoing endovascular aneurysm repair ( n = 20). Circulating myosin-11 levels were significantly correlated with maximum aortic diameter. Furthermore, changes in myosin-11 concentrations from the baseline 12 mo after endovascular aneurysm repair were associated with those in aortic diameter. These data suggest that circulating levels of myosin-11, which is a SMC-specific myosin isoform, may be useful as a biomarker for AAA. NEW & NOTEWORTHY Extensive studies have revealed that inflammation- or proteolysis-related proteins are proposed as biomarkers for abdominal aortic aneurysm (AAA). Changes in these protein concentrations are not specific for smooth muscle, which is a major part of AAA pathologies. Hence, no disease-specific circulating markers for AAA are currently available. We found, using secretome-based proteomic analysis on human AAA tunica media, that myosin heavy chain 11 was associated with AAA. Circulating myosin heavy chain 11 may be a new tissue-specific AAA marker.

Clinical Implications of Electrocardiograms for Patients With Type A Acute Aortic Dissection.

Type A acute aortic dissection (AAD) is a serious cardiovascular emergency requiring urgent surgery. Timely accurate diagnosis is essential, but often challenging, because of the wide spectrum of clinical presentations. In patients with type A AAD, chest pain is the most common symptom; furthermore, ischemic ST-T changes such as ST-segment elevation or depression or negative T waves are frequently observed on presentation ECG. These clinical presentations of type A AAD are difficult to differentiate from those of acute coronary syndrome (ACS), which could lead to delayed diagnosis and treatment of type A AAD or misdiagnosis of ACS followed by inappropriate treatment. Of note, ischemic ST-T changes have been shown to be associated with poor outcomes in patients with type A AAD. Because ECG is simple, inexpensive, noninvasive, readily available, and rapidly interpretable at the time of presentation, risk stratification based on ECG findings is considered very useful clinically. ECG findings of type A AAD thus have clinically important diagnostic, therapeutic, and prognostic implications; however, the relationships among these factors remain poorly understood. We review the prevalence of ECG abnormalities, clinical features associated with such changes, and the prognostic importance in patients with type A AAD.

[Treatment Strategy for Complicated Acute Type B Aortic Dissection in the Thoracic Endovascular Aortic Repair Era].

Our treatment strategy for acute type B aortic dissection (ABAD) included complicated type is as follows. Indications of thoracic endovascular aortic repair (TEVAR) for ABAD are rupture and organ ischemia, and TEVAR has been the 1st line central repair therapy since January 2009 in our institution. At the time of TEVAR for ruptured communicating type ABAD, we usually seal the proximal entry tear and cover the existing range of hematoma at descending aorta. Procedures for ABAD with malperfusion should be changed according to the patient's condition such as branch vessel obstructions either dynamic type or static type. We select TEVAR for ABAD with malperfusion in order to prevent late aortic events as well as treat the dynamic malperfusion. For complicated ABAD patients with poor condition and hemodynamic instability, TEVAR achieving central repair rapidly and less-invasively is considered an advantageous procedure. We usually pay attention how to use TEVAR and how to combine with other therapies for complicated ABAD treatment.

Evaluation and Influence of Brachiocephalic Branch Re-entry in Patients With Type A Acute Aortic Dissection.

BACKGROUND: Stanford type A acute aortic dissection (A-AAD) extends to the brachiocephalic branches in some patients. After ascending aortic replacement, a remaining re-entry tear in the distal brachiocephalic branches may act as an entry and result in a patent false lumen in the aortic arch. However, the effect of brachiocephalic branch re-entry concomitant with A-AAD remains unknown.Methods and Results:Eighty-five patients with A-AAD who underwent ascending aortic replacement in which both preoperative and postoperative multiple-detector computed tomography (MDCT) scans could be evaluated were retrospectively studied. The presence of a patent false lumen in at least one of the brachiocephalic branches on preoperative MDCT was defined as brachiocephalic branch re-entry, and 41 patients (48%) had this. Postoperatively, 47 of 85 (55%) patients had a patent false lumen in the aortic arch. False lumen remained patent after operation in 34 out of the 41 (83%) patients with brachiocephalic branch re-entry, as compared to that in 13 of the 44 (30%) patients without such re-entry (P<0.001). Brachiocephalic branch re-entry was a significant risk factor for a late increase in the aortic arch diameter greater than 10 mm (P=0.047). CONCLUSIONS: Brachiocephalic branch re-entry in patients with A-AAD is related to a patent false lumen in the aortic arch early after ascending aortic replacement and is a risk factor for late aortic arch enlargement.

Renal perfusional cortex volume for arterial input function measured by semiautomatic segmentation technique using MDCT angiographic data with 0.5-mm collimation.

OBJECTIVE: The purpose of this study was to evaluate the usefulness of renal perfusional cortex volume for arterial input function. MATERIALS AND METHODS: This retrospective study included 45 potential kidney donors--33 patients with aortic dissection and 12 patients with renovascular hypertension--who underwent both MDCT angiography with 0.5-mm collimation and renal (99m)Tc-diethylenetriamine pentaacetic acid (DTPA) scanning using the modified Gates method. Each perfusional cortex volume for the arterial input function and parenchymal volume was measured by semiautomatic segmentation using the region-growing technique. Linear regression analysis and correlation coefficients were used to assess the impact of the cortical volume, parenchymal volume, and renal scanning glomerular filtration rate (GFR) on estimated GFR (eGFR) using a modified Modification of Diet in Renal Disease (MDRD) equation. RESULTS: The correlation coefficient was higher for the total renal DTPA GFR adjusted for body surface area, weight-adjusted perfusion cortex volume, and adjusted total parenchyma volume in rank (r = 0.712, 0.642, 0.510, respectively, p< 0.0001 for each). The coefficient of the right renal perfusional cortex volume percent with a mean value of 52.1% ± 10.1% was 0.826 (p < 0.0001) for the right renal DTPA GFR percent with a mean value of 51.0% ± 12.1% (range, 22.0-89.5%), although the value for the right renal parenchymal volume percent with a mean value of 49.5% ± 5.5% was 0.764 (p < 0.0001). CONCLUSION: Weight-adjusted perfusional cortex volume for arterial input function can be measured clinically and may replace renal DTPA scanning using the modified Gates method.

Coronary subclavian steal syndrome detected during coronary bypass surgery in a hemodialysis patient.

Coronary subclavian steal syndrome associated with upper extremity arteriovenous fistula is an uncommon but potentially life-threatening condition. We present a case of a 65-year-old male on hemodialysis with a left upper extremity arteriovenous fistula who underwent coronary revascularization involving bypass with the left internal thoracic artery to the left anterior descending artery. Intraoperative transit-time graft flow measurements and fluorescence imaging showed a reversed flow in the left internal thoracic artery, and the left internal thoracic artery was successfully converted as a free graft from the ascending aorta to the left anterior descending artery.

"Sandwich Technique" via a Right Ventricle Incision to Repair Postinfarction Ventricular Septal Defects.

BACKGROUND: Residual shunting and mortality are problems associated with the current surgical repair techniques for postinfarction ventricular septal defects (VSD). We developed the "sandwich technique" via a right ventricle incision and assessed the surgical outcome of 13 years of experience with this technique. METHODS: Between June 2001 and March 2013, 25 consecutive patients with postinfarction VSD underwent surgical repair using this technique. This technique includes the following: Application of direct ultrasonography to the right ventricular (RV) wall enables the surgeon to visualize the lesion, perform an appropriate incision into the RV, and perform a trabecular resection. One patch is placed on the left ventricular (LV) side and the other on the RV side of the VSD. The VSD is sealed with gelatin-resorcin-formalin (GRF) glue between the two patches. RESULTS: Thirty-day mortality was 0% (0/25 case). A postoperative major shunt occurred in three patients (12%, 3/25) and two of them required reoperation (8%, 2/25). Hospital mortality was 28% (seven patients). Mean follow-up period was 4.2 ± 3.7 years. The overall survival at one, five, and 10 years was 71 ± 9%, 65 ± 10%, and 56 ± 12%, respectively. There was no cardiac death during follow-up in the patients who survived for six months after the surgery. No tissue degeneration related to GRF glue was noted. CONCLUSION: The "sandwich technique" via a right ventricle incision results in a low incidence of postoperative leak and good short- and mid-term survival.

Thoracic endovascular aortic repair for ruptured descending thoracic aortic aneurysm.

BACKGROUND: We evaluated clinical outcomes of thoracic endovascular aortic repair (TEVAR) for ruptured descending thoracic aortic aneurysm (rDTAA). METHODS: Twenty-three patients with rDTAA (mean age, 76.8 ± 8.8 years) underwent TEVAR at our center between January 2008 and April 2013. RESULTS: In twenty-three patients, five patients (21.7%) were in shock before surgery. Technical success was achieved in 21 patients. After TEVAR, retrograde Type A aortic dissection occurred in one patient, Type I endoleak in one patient, and Type II endoleak in three patients. The 30-day mortality rate was 4.3% (n = 1), and there were five in-hospital deaths (21.7%). Six patients (26.1%) developed cerebral complications and two patients suffered from paraplegia. In the late phase, four patients died because of the following aortic events: re-rupture in one patient, rupture of another untreated aneurysm in two patients, and esophageal perforation in one patient. CONCLUSIONS: TEVAR is associated with relatively low early morbidity and mortality and can be performed in older and high-risk patients. However, because aortic events during follow-up after TEVAR are not rare, we recommend close follow-up and application of early and aggressive reintervention.

[Tension hemothorax accompanying rupture of the descending aortic aneurysm].

Although, tension hemothorax appears along with thoracic injuries in many cases, the incidence is rare and the concept itself has not yet been established. Moreover, reports on tension hemothorax caused by the rupture of thoracic aortic aneurysms are very rare. Herein, we report a case in which thoracic endovascular aortic repair( TEVAR) was carried out following chest drainage in order to treat tension hemothorax accompanying rupture of the descending aortic aneurysm, thus leading to the survival of the patient.

What is the Optimal Proximal Landing Zone of the Stent Graft in Treatment of Aortic Type B Dissection?

PURPOSE: Retrograde type A aortic dissection (RTAD) represents a serious complication of endovascular treatment for type B aortic dissection (TBAD). To avoid RTAD, it is recommended to land the proximal end of the stent graft in a non-dissected aortic segment. In this study, we investigated whether landing in the dissection area increased the number of events at the proximal site. METHODS: We conducted a retrospective review of endovascular treatments for TBAD at a single institution between 2009 and 2022. Patients were divided into two groups: group A, with a proximal landing zone entirely within the dissected area, and group B, with the proximal extent of the seal zone in the non-dissected area. We evaluated the occurrence of proximal events, including RTAD, and examined long-term outcomes to assess the validity of landing in the dissection area. RESULTS: The study included eighty-nine patients who underwent endovascular treatment for TBAD. New intimal tears in the proximal landing site occurred in 3 cases (3.4%), with 1 case (2%) in group A and 2 cases (5.1%) in group B, showing no significant difference. Among the three cases, one (1.1%) in group B with zone 2 landing resulted in RTAD. At 60 months, the overall survival was 85%, and freedom from aorta-related mortality was 88%, with no significant difference between the groups. CONCLUSION: Even if the proximal landing is in a dissected area, a treatment strategy performed in zone 3 without proximal landing in zone 2, seeking a non-dissected area, can still provide sufficient therapeutic effects. Level of Evidence 3 Retrospective single-center cohort analysis.

Coronary protection using a pressure wire during transcatheter aortic valve implantation.

Coronary obstruction is a rare but life-threatening complication of transcatheter aortic valve implantation (TAVI). This article describes the case of a patient with severe aortic valve stenosis treated with TAVI, during which preventive coronary wiring using a pressure wire was performed for coronary protection. After the deployment of the transcatheter heart valve (THV), the values of the fractional flow reserve (FFR) and resting full-cycle ratio (RFR) remarkably decreased, although the findings of transesophageal echocardiography and coronary angiography did not suggest coronary obstruction. Intravascular ultrasound revealed severe stenosis in the left main trunk due to the displacement of the calcified native leaflets. The decrease in the FFR and RFR values after THV deployment led to a diagnosis of partial coronary obstruction, and percutaneous coronary intervention was successfully performed. In patients at a high risk for coronary obstruction, coronary protection with a pressure wire is useful for the diagnosis and prevention of coronary flow deterioration during TAVI. Functional assessment using a pressure wire before and after TAVI may contribute to the accurate diagnosis of coronary obstruction. Learning objective: Accurate diagnosis of coronary obstruction during transcatheter aortic valve implantation (TAVI) is important for successful management. In patients at a high risk for coronary obstruction, coronary protection with a pressure wire is useful for the diagnosis and prevention of coronary flow deterioration during TAVI. The remarkable decrease in the fractional flow reserve and resting full-cycle ratio values after the deployment of the transcatheter heart valve may suggest coronary obstruction.

Ratio of left ventricular outflow tract area to aortic annulus area and complete atrioventricular block after transcatheter aortic valve replacement for aortic stenosis.

BACKGROUND: Mechanical compression of cardiac conduction system by transcatheter heart valves leads to complete atrioventricular block (CAVB) after transcatheter aortic valve replacement (TAVR). Bulging of ventricular septum in the left ventricular outflow tract (LVOT) may be associated with greater compression of conduction system, leading to irreversible CAVB. OBJECTIVE: This study aimed to investigate the association of ventricular septal bulging with TAVR-related CAVB and permanent pacemaker implantation (PPI). METHODS: Among 294 consecutive patients with severe aortic stenosis who underwent TAVR between July 2017 and February 2023, 271 were included in the analysis. As a quantitative evaluation of bulging of the ventricular septum, the ratio of LVOT area to aortic annulus area (L/A ratio) was measured at the systolic phase of computed tomography images. RESULTS: TAVR-related CAVB occurred in 64 patients (23.6%). Twenty-eight patients (10.3%) required PPI. The optimal thresholds of L/A ratio for predicting TAVR-related CAVB and PPI were 1.0181 and 0.985, respectively. Patients with less than the cut-off values had higher rate of TAVR-related CAVB and PPI than those above (28.3% vs 13.1%, p = 0.0063; 14.7% vs 4.4%, p = 0.0077, respectively). A multivariate analysis showed that L/A ratio < 1.0181 was an independent predictor of TAVR-related CAVB (odds ratio [OR] 2.65, p = 0.011), in addition to prior right bundle branch block (OR 3.76, p = 0.0005), use of a self-expanding valve (OR 1.99, p = 0.030), and short membranous septum length (OR 0.96, p = 0.037). Only L/A ratio < 0.985 was independently associated with PPI (OR 3.70, p = 0.011). CONCLUSION: Low L/A ratio is a predictor of TAVR-related CAVB and PPI.

Impact of New-Onset Right Bundle-Branch Block After Transcatheter Aortic Valve Replacement on Permanent Pacemaker Implantation.

BACKGROUND: A delayed and recurrent complete atrioventricular block (CAVB) is a life-threatening complication of transcatheter aortic valve replacement (TAVR). Post-TAVR evaluation may be important in predicting delayed and recurrent CAVB requiring permanent pacemaker implantation (PPI). The impact of new-onset right bundle-branch block (RBBB) after TAVR on PPI remains unknown. METHODS AND RESULTS: In total, 407 patients with aortic stenosis who underwent TAVR were included in this analysis. Intraprocedural CAVB was defined as CAVB that occurred during TAVR. A 12-lead ECG was evaluated at baseline, immediately after TAVR, on postoperative days 1 and 5, and according to the need to identify new-onset bundle-branch block (BBB) and CAVB after TAVR. Forty patients (9.8%) required PPI, 17 patients (4.2%) had persistent intraprocedural CAVB, and 23 (5.7%) had delayed or recurrent CAVB after TAVR. The rates of no new-onset BBB, new-onset left BBB, and new-onset RBBB were 65.1%, 26.8%, and 4.7%, respectively. Compared with patients without new-onset BBB and those with new-onset left BBB, the rate of PPI was higher in patients with new-onset RBBB (3.4% versus 5.6% versus 44.4%, P<0.0001). On post-TAVR evaluation in patients without persistent intraprocedural CAVB, the multivariate logistic regression analysis showed that new-onset RBBB was a statistically significant predictor of PPI compared with no new-onset BBB (odds ratio [OR], 18.0 [95% CI, 5.94-54.4]) in addition to the use of a self-expanding valve (OR, 2.97 [95% CI, 1.09-8.10]). CONCLUSIONS: Patients with new-onset RBBB after TAVR are at high risk for PPI.