Permanent pacemaker implantation (PPI) is commonly required following transcatheter aortic valve implantation (TAVI). High burden of right ventricular pacing (RVP) has been associated with increased risk of heart failure hospitalization in both general and TAVI population. There is very limited data on the predictive factors of high burden of RVP in post-TAVI patients with PPI.

To identify predictive factors of high burden of RVP in patients undergoing post-TAVI PPI.

High burden of RVP was defined as a pacing percentage>40% (40%VP) at 3 to 12 months follow-up. All dual chamber pacemakers were programmed with algorithm favoring spontaneous AV conduction, except in case of persistent complete AV block (DDD mode). 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. Risk score for 40%VP was determined from multivariable logistic regression analysis.

From January 2013 to July 2023, 2458 consecutive patients underwent a TAVI procedure in our institution. PPI was required in 289 patients (11.8%), 200 of whom had pacemaker follow-up performed at our center and were included in the analysis. 40%VP was found in 87 patients (43.5%) at 3 to 12 months follow up. The multivariable model showed that male gender (OR=2.33, 95% CI 1.24–4.39), permanent atrial fibrillation (OR=2.65, 95% CI 1.14–6.14), and high degree AV block as reason for PM implantation (OR=5.36, 95% CI 2.37–12.15) were independent predictors of 40%VP (Table 1). A risk score (H2AS score) predicting 40%VP was determined from the multivariable model and included High Degree AV block indication for PPI (2 points), permanent AF (1 point) and male sex (1 points), with a score of 0 identifying 6.1% prevalence of 40%VP, a score of 1–2 identifying 31.9% prevalence of 40%VP and a score of>3 identifying 64.6% prevalence of 40%VP (Fig. 1).

40%VP can be anticipated using a readily available pre-PPI risk assessment. The H2AS risk-score may help to better pre-define the most appropriate ventricular pacing strategy. Conduction system pacing could be favored in patients with a high H2AS score in order to avoid the deleterious effects of RVP-induced ventricular desynchronization.