Long-term outcome of patients undergoing pacemaker implantation after transcatheter aortic valve implantation: a systematic review and meta-analysis

The long-term prognostic relevance of permanent pacemaker (PM) implantation after transcatheter aortic valve implantation (TAVI) remains uncertain. We performed a meta-analysis to evaluate its association with all-cause mortality beyond five years. Following MOOSE recommendations, PubMed and Embase were searched through September 2025 for studies reporting long-term outcomes after TAVI, including hazard ratios (HRs) comparing patients with and without new PM implantation. Pooled HRs were calculated using random-effects models with restricted maximum likelihood estimation and Hartung–Knapp adjustment. Heterogeneity was quantified using I², and robustness was tested by leave-one-out procedures and alternative model estimators. Random-effects meta-regression examined whether study-level covariates modified the association. Seven observational studies comprising 59 635 patients were included, of whom 11 325 (19%) received a new PM within 30 days after TAVI. Follow-up ranged from 60 to 120 months. PM implantation was associated with higher long-term all-cause mortality {pooled HR 1.13 (95% CI 1.07–1.19); I² = 0%}. Leave-one-out analyses confirmed stability (HR 1.11–1.13), and funnel-plot inspection revealed no asymmetry. None of the examined covariates—female sex, diabetes, atrial fibrillation, conduction disturbances, coronary artery disease, or left-ventricular ejection fraction—significantly affected the association (β range − 0.018 to + 0.024; exp(β) 0.98–1.02; all p > 0.10). Across seven contemporary registries, PM implantation after TAVI was consistently linked to a modest increase in long-term mortality, independent of baseline comorbidities, emphasizing the need for conduction-preserving implantation and physiologic pacing strategies.