Effectiveness of the electrophysiological study for risk stratification of conduction disturbances after transcatheter aortic valve implantation

Introduction

Conduction disturbances (CDs) are common after transcatheter aortic valve implantation (TAVI) and remain a leading cause of permanent pacemaker implantation (PPI), contributing to prolonged hospitalisation and adverse long-term outcomes. Identifying patients who genuinely require PPI is challenging. Electrophysiological study (EPS) has been proposed to refine post-procedural risk stratification, but its diagnostic value in this setting remains uncertain.

Purpose

To evaluate the performance of EPS in predicting the need for PPI in patients who develop conduction disturbances after TAVI.

Methods

We performed a single-centre retrospective study of consecutive TAVI recipients who developed new or progressive conduction disturbances and underwent EPS. The His–ventricular (HV) interval was measured using standard protocols, and PPI was recommended for patients with a prolonged HV interval according to local practice. Follow-up included inpatient telemetry, ECG surveillance, and device interrogation where applicable. A PPI was considered clinically indicated if high-grade atrioventricular block, clinically relevant bradyarrhythmia, or substantial ventricular pacing (≥5% pacing burden) was documented during follow-up. PPIs not meeting these criteria were classified as non-indicated. In patients without initial PPI, late high-grade conduction disturbances or delayed PPI were recorded. The diagnostic performance of the HV interval for identifying clinically indicated PPI was assessed using standard accuracy metrics and receiver-operating characteristic (ROC) analysis.

Results

Between 2000 and 2025, 78 patients underwent EPS for post-TAVI conduction disturbances. The mean age was 81 ± 6 years, 68% were male, and 78% had received balloon-expandable valves. Atrial fibrillation was present in 12%. Baseline ECG abnormalities were frequent, including LBBB in 51%, RBBB in 41%, and first-degree atrioventricular block in 32%; 87% required a temporary pacemaker after TAVI. The median follow-up was 34 months.

PPI was performed in all 54 patients with an HV interval >70 ms. During follow-up, 63% of these met criteria for a clinically indicated pacing indication. Among patients with a normal HV interval, 32% developed clinically relevant late conduction disturbances requiring delayed PPI. Overall, the HV interval demonstrated moderate diagnostic performance, with a sensitivity of approximately 70%, specificity of approximately 60%, and an ROC area of 0.65 for identifying clinically indicated pacing requirements.

Conclusion

The HV interval showed moderate ability to identify patients who required permanent pacing after TAVI. EPS may contribute to post-procedural risk assessment, but should complement, rather than replace, other clinical and electrocardiographic markers.