Long-term changes in pacemaker stimulation burden and its influence on clinical outcomes after transcatheter aortic valve implantation: a multicenter study
R Schmitt, F Rees, P Steinhoff, T Stolte, T Nestelberger, F Mahfoud, D Westermann, P Breitbart, P Ruile, J J ReichlAbstract
Background
Permanent pacemaker (PPM) implantation remains a common complication after transcatheter aortic valve implantation (TAVI). The long-term clinical implications of pacemaker dependency following TAVI remain a subject of ongoing debate and investigation. In a previous single-center study from our group, examining the relationship between TAVI implantation depth and subsequent pacing burden, we found that approximately one-third of patients with initially low PPM stimulation rates experienced a clinically relevant increase to >20% ventricular pacing within the first three months following TAVI. This temporal evolution suggests progressive conduction system injury and raises concerns about potential delayed adverse effects on cardiac function and clinical outcomes.
Purpose
This multicenter study investigated long-term changes in ventricular pacing burden and their association with mortality and major adverse cardiovascular events (MACE).
Methods
Patients receiving PPM after TAVI between 2009 and 2024 at two tertiary centers were retrospectively analyzed. Patients were categorized by ventricular pacing burden (>20% defined as high) at baseline and follow-up: high/high (n=309), high/low (n=103), low/high (n=143), and low/low (n=216). Both self-expanding and balloon-expandable valves were included. Pacemaker burden was assessed at discharge and three months, and five-year outcomes, including mortality and major adverse cardiovascular events, were recorded.
Results
A total of 771 patients who underwent TAVI followed by PPM implantation were analyzed (median age 82 years; 49.5% female). Patients were categorized by ventricular pacing burden at baseline and follow-up: high/high (n=309), high/low (n=103), low/high (n=143), and low/low (n=216). At 5 years, all-cause mortality did not differ significantly among groups (log-rank p=0.310). In contrast, the composite MACE endpoint differed significantly (p=0.038). Compared with the low/low group, hazard ratios for 5-year MACE were 0.74 (95% CI 0.52–1.06) for low/high, 0.61 (95% CI 0.40–0.93) for high/low, and 0.97 (95% CI 0.69–1.35) for high/high, with the high/low group exhibiting the lowest cumulative MACE incidence.
Conclusions
Approximately 30% of patients experienced changes in ventricular pacing burden over time. While neither initial nor temporal pacing patterns affected overall mortality, a decreasing pacing rate (high/low) was significantly associated with a lower risk of MACE. These findings indicate that patients with persistently high pacing burden should may benefit from structured cardiological follow-up, including optimization of pacing parameter.