Permanent pacemaker dependency after transcatheter aortic valve implantation: prevalence, patients characteristics and main determinants

Abstract Introduction Permanent pacemaker implantation (PPI) remains a relevant complication following transcatheter aortic valve implantation (TAVI). The evolution of conduction disturbances, and long-term pacemaker dependency (PD) still represent a matter of investigation. Purpose To study the prevalence, patients’ characteristics and predictors of PD after TAVI. Methods We analyzed consecutive patients who underwent TAVI (January 2022-November 2024) included in a prospectively maintained single-center database. Clinical, electrocardiographic (baseline, 24, 48 hours after TAVI, discharge), and procedural variables were systematically collected. Pacemaker interrogations were repeated at 1 and 12 months. PD was defined as the absence of intrinsic ventricular rhythm ≥30 bpm upon reducing the pacing rate to 30 bpm for at least 10" or following transient inhibition of pacing. Results We included 376 patients (median age 8278-84 years; 51% men). Sixty-nine (18.4%) underwent PPI after TAVI. There were no significant differences related to the use of self-expandable vs balloon-expandable valves. Pre-dilatation (OR95%CI:3.491.53-7.99, p=0.003), new-onset left bundle branch block (OR95%CI:5.542.43-12.63, p0.001), and pre-existing right bundle branch block - RBBB (OR95%CI:20.687.10-60.23, p0.001) were independent predictors of PPI at univariate and multivariate logistic regression analyses. Among patients undergoing PPI and surviving at 12 months follow-up (n=61), 23 (38%) were PD. They did not show significant differences in terms of clinical (except for a higher prevalence of chronic kidney disease - 39%vs16%, p=0.040), echocardiographic or procedural features compared to those not PD at follow-up. However, they showed significant ECG differences at baseline (i.e., longer QRS duration - 110 90-140 msec vs 90 80-100 msec, p=0.025; and RBBB - 1252% vs 821%, p=0.012), and after the procedure (early-onset i.e., 24h after TAVI complete AV-block - 1774% vs 1642%, p=0.016). Median time interval between TAVI and PPI was significantly reduced in PD patients. (8754-151 hours vs. 2731-74 hours, p=0.0005). Chronic kidney disease (OR95%CI:3.421.02-11.48, p=0.046), baseline QRS duration (OR95%CI:1.031.00-1.06, p=0.015), pre-existing RBBB (OR95%CI:4.091.32-12.67, p=0.015), and new-onset complete AV block after TAVI (OR95%CI:4.091.32-12.67, p=0.015) were independent predictors of PD at univariate logistic regression analysis. At 12 months follow-up, spontaneous heart rate was lower (00-30 bpm vs. 6550-70 bpm, p0.0001), and median % of ventricular pacing was higher in PD patients (9998-100% vs 353-65%, p0.0001). Conclusions PPI is frequent after TAVI, with ~40% of these patients being PD at 12 months. Pre-existing AV and intraventricular conduction disturbances together with the early onset of a complete AV block after TAVI seem to be powerful predictors of the need for permanent pacemaker ventricular stimulation.