Impact of permanent pacemaker implantation after transcatheter aortic valve implantation: an updated systematic review with meta-analysis of reconstructed time-to-event data

Background Permanent pacemaker implantation (PPI) remains a frequent complication after transcatheter aortic valve implantation (TAVI), yet its long-term prognostic impact remains debated. Purpose To determine the association between new PPI after TAVI and long-term mortality and heart failure (HF) rehospitalization using reconstructed individual patient time-to-event data. Methods We systematically identified studies reporting Kaplan–Meier curves with numbers at risk after TAVI. Individual patient time-to-event data were reconstructed using validated methodology. Patients who died within 30 days were excluded to reduce survivorship bias. Hazard ratios (HR) were derived using Cox regression and pooled with random-effects models. Time-dependent effects were assessed using flexible parametric mixed-effects modeling. Results Twenty-two studies including 92’296 patients were analyzed (68’037 no PPI; 15’625 new PPI; 8’634 previous PPI). After excluding early mortality, 87’107 patients remained for time-to-event analysis. New PPI after TAVI was associated with significantly higher long-term mortality compared with no PPI (pooled HR 1.25 [95% CI 1.15–1.36]; pooled Kaplan–Meier HR 1.26 [1.21–1.31]; p<0.0001). Patients with previous PPI exhibited the highest mortality risk (HR 1.38 [1.32–1.45] vs no PPI; HR 1.09 [1.03–1.16] vs new PPI). New PPI was also associated with increased HF-related rehospitalisation (HR 1.28 [1.06–1.55]). Time-dependent modelling demonstrated that excess mortality risk in PPI patients is greatest early after TAVI but remains elevated for up to 5 years. Conclusion In this large meta-analysis using reconstructed time-to-event data, PPI after TAVI is associated with a sustained increase in mortality and HF rehospitalization. These findings underscore the clinical importance of procedural strategies aimed at minimizing conduction injury and avoiding unnecessary PPI.