Eliminating transvenous right ventricular leads reduces pacing-related cardiac tamponade during TAVI: a mechanistic meta-analysis

Background Rapid ventricular pacing is mandatory during transcatheter aortic valve implantation (TAVI). Conventional right ventricular (RV) temporary pacing requires transvenous lead placement and introduces a potentially preventable mechanism of myocardial perforation and cardiac tamponade. Left ventricular (LV) guidewire pacing avoids RV instrumentation, but its impact on clinically relevant outcomes has not been systematically evaluated. Purpose To assess whether LV guidewire pacing improves procedural safety compared with conventional RV temporary pacing during TAVI. Methods A systematic review and meta-analysis of MEDLINE, Embase, CENTRAL and Web of Science was performed through February 2026. The protocol was prospectively registered in PROSPERO. Comparative studies of LV versus RV pacing during TAVI were included. The primary endpoint was cardiac tamponade. A pre-specified mechanistic analysis differentiated pacing lead–related from annular rupture–related tamponade. Random-effects models were applied. Results Five studies (1 randomised trial and 4 observational cohorts) including 2,840 patients (1,910 LV; 930 RV) were analysed. Global cardiac tamponade occurred in 1.1% with LV pacing versus 2.5% with RV pacing (OR 0.45; 95% CI 0.18–1.16; p=0.08; I²=0%). LV pacing significantly reduced pacing lead–related tamponade (OR 0.09; 95% CI 0.02–0.56; p=0.03; I²=0%), while annular rupture–related events were similar between strategies. All-cause mortality was lower in pooled analyses (OR 0.45; 95% CI 0.36–0.57; p<0.001), predominantly driven by observational data. Stroke, major vascular complications, bleeding and permanent pacemaker implantation did not differ. LV pacing shortened procedural duration by 5.8 minutes (p=0.0002). Conclusion Elimination of transvenous RV lead instrumentation markedly reduces pacing lead–related cardiac tamponade without increasing major adverse events and improves procedural efficiency. LV guidewire pacing represents a mechanistically rational and immediately implementable strategy aligned with contemporary minimalist TAVI practice.