Probability of requiring permanent cardiac pacing after transcatheter aortic valve implantation

Percutaneous aortic valve replacement (TAVI) has become widely used in the treatment of severe symptomatic aortic stenosis. Over the years, the incidence of peri-procedural complications has drastically decreased; however, the development of conduction disturbances requiring permanent pacemaker implantation (PPM) remains the Achilles' heel of this intervention. Our objective was to identify baseline variables associated with this complication.

We retrospectively analyzed 569 consecutive patients who underwent a successful TAVI implantation at our center between 2013 and 2024, excluding those with a prior PPM and those who died due to peri-procedural complications.

The mean age was 80.53±5.40 years, with 54.8% being women. A self-expanding prosthesis was implanted in 207 patients (36.4%). The main conduction disturbances prior to the procedure were atrial fibrillation (39%), first-degree atrioventricular block (7.7%), complete left bundle branch block (LBBB) (9.7%), and complete right bundle branch block (RBBB) (8.3%).

After TAVI implantation, 187 patients (32.9%) developed new-onset LBBB, which was transient (resolved within the first 30 days post-implantation) in 109 patients (19.2%). A PPM was required in 96 patients due to advanced peri-procedural conduction disturbances (<30 days), in 8 patients (1.4%) as an early requirement (between 30 days and one year), and in 17 patients (3%) as a late requirement (beyond one year). The incidence of peri-procedural PPM implantation was higher in the case of self-expanding prostheses (25.1% vs. 12.2%; p<0.001).

In multivariate analysis, the variables independently associated with a higher incidence of post-TAVI PPM implantation were: age (OR: 1.07; 95% CI: 1.02 to 1.12; p=0.005), prior RBBB (OR: 5.20; 95% CI: 2.70 to 10.03; p<0.001), self-expanding prosthesis (OR: 2.28; 95% CI: 1.42 to 3.66; p=0.001), large prosthesis size (OR: 3.31; 95% CI: 1.63 to 6.72; p=0.001), and medium prosthesis size (OR: 2.33; 95% CI: 1.25 to 4.33; p=0.007), compared to small prostheses. The probability of requiring PPM implantation according to the predictive model built with these variables is shown in the table.

The occurrence of new conduction disturbances and the need for PPM after TAVI implantation are frequent. Age, pre-existing RBBB, the use of a self-expanding valve, and a larger prosthesis size are independent predictors of the need for PPM after TAVI implantation.