Conduction system pacing in TAVR patients requiring permanent pacemaker implantation

BACKGROUND: Permanent pacemaker (PPM) implantation remains a common complication after transcatheter aortic valve replacement (TAVR) and is associated with poorer long-term outcomes. Conduction system pacing (CSP) has emerged as a promising alternative to reduce the negative effects of chronic pacing. OBJECTIVES: To determine whether CSP is associated with improved outcomes in patients requiring a PPM after TAVR. METHODS: Observational multicenter study including consecutive patients requiring PPM implantation within 30 days after TAVR. This population was propensity matched using a logistic regression model. The primary outcome was a composite endpoint including death and heart failure hospitalization at 1-year follow-up. Echocardiographic and ECG changes over time were secondary endpoints. RESULTS: After propensity score matching, 706 patients were included: 185(26.2%) in the CSP group and 521 (73.8%) in the RVP group. CSP was associated with a significantly lower risk of all-cause death or heart-failure hospitalization at 1 year compared to RVP (10.8% vs 20.9%; adjusted HR 0.48 0.30-0.78; p = 0.003). This was driven by significant reductions in both all-cause mortality (HR 0.52 0.28-0.96; p = 0.036) and heart-failure hospitalization (HR 0.50 0.25-0.99; p = 0.049). In addition, CSP was associated with a significantly shorter QRS duration at 30 days compared with RVP (121± 22 ms vs. 141± 18 ms; p < 0.001), as well as a significant improvement in LVEF at 1-year follow-up (+2.8 percentage points; p<0.001). CONCLUSIONS: In TAVR patients requiring PPM, CSP showed better 1-year clinical outcomes than RVP. Prospective randomized studies are needed to confirm longer-term benefits and refine patient selection.