Leadless Pacemaker Use Following Transcatheter Aortic Valve Replacement: National Trends and Predictors, 2019–2023

Background New‐onset conduction abnormalities requiring permanent pacemaker implantation are common following transcatheter aortic valve replacement (TAVR). Leadless pacemakers may reduce procedure‐related complications in this high‐risk population, however, national adoption and predictors of use remain poorly characterized. The objective of this study was to identify predictors and patterns of leadless versus conventional transvenous pacemaker implantation following TAVR in a nationally representative cohort. Methods Using the 2019–2023 National Inpatient Sample, we identified TAVR hospitalizations with same‐admission pacemaker implantation. Survey‐weighted logistic regression evaluated predictors of leadless versus transvenous device selection, adjusting for demographics, payer, income, comorbidity burden, hospital characteristics, and procedure year. Results Among 427,080 weighted TAVR hospitalizations, 28,580 (6.7%) included pacemaker implantation, with 3255 (11.4%) receiving a leadless device. Leadless use rose from 6.1% of pacemaker implants in 2019 to 14.3% in 2021, followed by stabilization through 2023. Temporal trends were the strongest independent predictor of leadless implantation (2021 vs. 2019: aOR 2.66 [95% CI 1.87–3.77]; p < 0.001). Higher comorbidity burden independently increased likelihood of leadless use (aOR 1.10 per 5‐point Elixhauser increase; p < 0.001). Large hospitals (by bed size) were associated with higher odds of leadless implantation versus small hospitals (aOR 1.58 [1.13–2.21]; p = 0.007). Age, sex, payer, and income were not associated with device type. Conclusion Leadless pacemaker adoption after TAVR increased substantially through 2021 and subsequently stabilized, with real‐world usage associated with temporal trends, comorbidity burden, and institutional volume rather than patient demographics or socioeconomic factors. This suggests relatively equitable patient‐level but institutionally uneven uptake of this emerging technology.