Silent conduction disturbances after TAVI: insights from 12-lead holter monitoring

Background

Conduction disturbances are common after transcatheter aortic valve implantation(TAVI) and may evolve dynamically in the post-procedural period. Brief or single ECG recordings may fail to capture transient or unstable conduction abnormalities.

Purpose

To prospectively evaluate conduction changes within 48 hours after TAVI using continuous 12-lead Holter monitoring and to identify patients requiring permanent pacemaker (PPM) implantation within 30 days.

Methods

In this prospective observational study, 52 consecutive TAVI patients were enrolled between Feb 2025—Jan 2026. Two patients who died in-hospital from non-arrhythmic causes were excluded, leaving 50 patients for analysis. All patients underwent 24-hour pre-procedural and continuous 48-hour post-procedural 12-lead rhythm Holter monitoring. Conduction patterns within 48 hours were classified as high-grade AV block, new-onset LBBB (± intermittent), isolated PR prolongation (≥50 ms), alternating bundle branch block (BBB), or no major conduction change. Patients with persistent LBBB underwent electrophysiological study (EPS) to measure AH and HV intervals. The study aim was descriptive assessment of rhythm changes and documentation of PPM implantation within 30 days.

Results

High-grade AV block occurred in 4 patients, all of whom underwent in-hospital PPM implantation. New-onset LBBB was observed in 12 patients, of whom 4 required in-hospital PPM due to prolonged HV interval > 70 ms. Isolated PR prolongation was identified in 2 patients, with 1 requiring PPM. Alternating BBB was detected in 2 patients; one remained stable, whereas the other developed ventricular tachycardia followed by complete AV block during the first week, requiring PPM implantation.

Patients without major conduction change (n=30) demonstrated a predominantly stable course; however, even in this group, 2 required PPM in hospital and 2 additional patients underwent PPM within 30 days, presenting with complete AV block on day 5 and day 13, respectively.

Overall, 11 patients underwent in-hospital PPM implantation and 3 additional patients required PPM within 30 days(14/50, 28%).

Among the 14 patients who underwent PPM implantation, one patient was lost to follow-up and three had not yet completed one-month device evaluation. Device interrogation data were therefore available in 10 patients.During follow-up, seven patients were pacing-dependent, two demonstrated lower pacing burden(2%), and one had 0% ventricular pacing. Based on Holter-defined phenotypes, the pacing-dependent group comprised four patients with high-grade AV block, two with new-onset LBBB, and one with alternating BBB.

Conclusion

Continuous 12-lead Holter monitoring allows detailed characterization of conduction changes after TAVI. Standard ECG recordings may miss transient conduction abnormalities such as alternating or intermittent BBB, whereas 12-lead Holter monitoring provides a more comprehensive assessment of post-procedural rhythm.Study Design and Pacemaker OutcomesHolter-Defined Conduction Phenotypes