Left Ventricular Guidewire Pacing Is Associated With Lower Pacing Lead‐Related Cardiac Tamponade During Transfemoral TAVI: A Systematic Review and Meta‐Analysis

Background Rapid pacing is required during transcatheter aortic valve implantation (TAVI) to facilitate valve deployment. Conventional right ventricular (RV) temporary pacing requires transvenous lead placement and has been associated with mechanical complications, including cardiac perforation. Left ventricular (LV) guidewire pacing has emerged as an alternative strategy that may avoid lead‐related injury. We performed a systematic review and meta‐analysis to compare clinical and procedural outcomes between LV guidewire pacing and RV temporary pacing during TAVI. Methods MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and Web of Science were searched through February 15, 2026. Comparative studies evaluating LV guidewire pacing versus RV temporary pacing during TAVI were included. The primary endpoint was global cardiac tamponade. Prespecified mechanistic analyses evaluated pacing lead‐related and annular rupture‐related tamponade. Secondary endpoints included all‐cause mortality, cardiovascular mortality, major adverse cardiovascular events (MACE), stroke, major vascular complications, bleeding, permanent pacemaker implantation, and procedural metrics. Random‐effects meta‐analyses were performed using Mantel–Haenszel models. Results Five studies (one randomized controlled trial and four observational cohorts) comprising 2840 patients (1910 LV and 930 RV) were included. Global cardiac tamponade occurred in 1.1% of LV patients and 2.5% of RV patients (OR 0.45; 95% CI 0.18–1.16; p = 0.08). In mechanistic analyses, pacing lead‐related tamponade was significantly reduced with LV pacing (OR 0.09; 95% CI 0.02–0.56; p = 0.03), whereas annular rupture‐related tamponade did not differ between strategies. The pooled absolute risk reduction for pacing lead‐related cardiac tamponade was approximately 1.2%, corresponding to an estimated number needed to treat of 83. A signal toward lower all‐cause mortality was observed in pooled analyses, largely driven by observational cohorts. Major vascular complications and bleeding showed nonsignificant trends favoring LV pacing. Permanent pacemaker implantation did not differ significantly between strategies. LV pacing was associated with shorter procedural duration (mean difference −5.83 min; 95% CI −7.08 to −4.58; p < 0.001). Conclusions LV guidewire pacing during transfemoral TAVI was associated with a lower risk of pacing lead‐related cardiac tamponade and shorter procedural duration. This benefit appears to be mechanism‐specific and should not be extrapolated to annular rupture or other nonlead‐related causes of tamponade. Although LV guidewire pacing may simplify procedural workflow, its use should be individualized according to baseline conduction risk and the availability of rapid bailout pacing strategies.