Predictive factors of high burden of ventricular pacing in patients undergoing permanent pacemaker implantation after transcatheter aortic valve implantation

A high burden of right ventricular pacing (RVP) increases the risk of heart failure hospitalization in both the general and TAVI populations. However, data on predictive factors for a high burden of RVP in post-TAVI patients with permanent pacemaker implantation (PPI) are limited.

The primary objective was to identify independent predictors of a high burden of RVP in patients with current indications for PPI post-TAVI. The secondary objective was to assess the composite endpoint of all-cause mortality or first heart failure hospitalization (HFH) according to RVP percentage.

This observational study included consecutive patients who underwent PPI following TAVI between 2013 and 2023 at our institution. Patients not followed up at our center and those with conduction system pacing were excluded. High burden of RVP was defined as a ventricular pacing percentage greater than 20% (>20%VP) at 3- to 12-month follow-up. An algorithm favoring spontaneous atrioventricular conduction was programmed at discharge, except in cases of persistent complete atrioventricular block. For the latter, AV conduction was assessed at 3-month visit; in case of AV conduction recovery, pacemaker was reprogrammed with an algorithm favoring spontaneous AV conduction and one-year ventricular pacing percentage was used for the primary analysis.

Among 193 patients included, 92 (47.7%) had >20%VP at 3- to 12- month follow up. Male gender (OR=2.48, 95%CI 1.31–4.67), permanent atrial fibrillation (OR=2.49, 95%CI 1.01–6.15), and high degree AV block as the indication for PPI (OR=5.05, 95%CI 2.32–11.0) were independent predictors of >20%VP. A risk score (H2AS score) predicting >20%VP was derived, including High Degree AV block (2 points), permanent atrial fibrillation (1 point) and male sex (1 point). A score of ≥ 3 identified a 68% prevalence of >20%VP (Figure 1). Over a median follow-up of 27.7 months, >20%VP was associated with a higher risk of all-cause mortality or heart failure hospitalization (HR=2.03, 95%CI 1.09–3.81; p=0.03) (Figure 2).

A high RVP burden (>20%VP) can be anticipated using a readily available pre-PPI risk assessment. The H2AS risk-score may assist clinicians in determining the most appropriate ventricular pacing strategy for patients post-TAVI.Figure 1  Figure 2