Impact of pre-existing conduction abnormalities on permanent pacemaker implantation after transcatheter aortic valve replacement: A meta-analysis

Table 1 Population, Intervention, Comparison, Outcome, and Study design framework for the literature search

Domain	Criteria
Population (P)	Adults (≥ 18 years) undergoing TAVR for aortic stenosis
Intervention/exposure (I)	Pre-existing conduction abnormalities on baseline ECG (e.g., RBBB, LBBB, first-degree AV block, bifascicular block, other baseline conduction disease)
Comparison (C)	TAVR patients without pre-existing conduction abnormalities (normal baseline ECG)
Outcomes (O)	Primary: Requirement for PPI after TAVR. Secondary (if reported): New-onset conduction disturbances, timing of pacemaker implantation, length of hospital stay, short-term mortality
Study design/setting (S)	RCTs, prospective and retrospective observational cohorts, and case series (n > 10) and registry analyses, published in English between January 1, 2010, and February 19, 2026 (inclusive); full text available

AV: Atrioventricular; ECG: Electrocardiogram; LBBB: Left bundle branch block; PPI: Permanent pacemaker implantation; RBBB: Right bundle branch block; RCT: Randomized controlled trial; TAVR: Transcatheter aortic valve replacement.

Table 2 Results of the systematic review

Ref.	Study design	Study location	Population characteristics	Intervention	Primary outcomes	Key findings
Muntané-Carol et al[18] (2021)	Prospective multicenter	Canada, United States	TAVR recipients without prior pacemaker	Minimalist TAVR with 14-day AECG monitoring	Occurrence of delayed HAVB or CHB	4.6% (21/459) developed delayed HAVB/CHB, leading to PPM in 81%
Pavlicek et al[19] (2023)	Prospective cohort	Germany	Severe AS; 54% male; mean age 80	TAVR with SEV (n = 103) or BEV (n = 100)	HAVB requiring PPM within 30 days	7% (15/203) required PPI; new LBBB (OR = 15.7) and diabetes (OR = 3.8) were predictors
Meduri et al[28] (2019)	RCT (REPRISE III)	United States, Germany	High/extreme surgical risk; mean age 83	Lotus mechanically-expanded vs CoreValve SEV	PPM within 30 days and dependency at 1 year	PPM higher with Lotus (34%) vs CoreValve (18%); dependency was 43% at 30 days
Castro-Mejía et al[36] (2022)	Retrospective multicenter	Spain	Severe AS; 39% male; median age 83	New-generation SEVs (Evolut, Acurate, Portico, Allegra)	Peri-procedural modification of AV conduction	17.7% required PPI; valve recapture (OR = 2.8) and depth (OR = 1.9) were predictors
Auffret et al[22] (2017)	Multicenter registry	Global (Canada, France, Spain, etc.)	AS candidates; 50% male; mean age 82	TAVR grouped by baseline RBBB	Cumulative all-cause mortality	Baseline RBBB in 10.3%; 30-day PPM in RBBB (40.1%) vs others (13.5%)
Bagur et al[23] (2012)	Case-matched cohort	Canada	Elderly AS; matched by baseline ECG	TAVI (Edwards) vs isolated SAVR	Complete AVB and PPM within 30 days	PPM higher in TAVI (7.3%) vs SAVR (3.4%); RBBB predicted TAVI PPM (OR = 8.6)
Wasim et al[30] (2025)	Prospective observational cohort	Norway	Severe AS; 50% male; mean age 80.6	TAVI (various valves) over low vs high volume phases	New PPM ≤ 30 days and all-cause death	31.6% total PPI rate; dropped from 45.8% to 23.9% with experience
Chen et al[25] (2024)	Registry analysis	United States, Canada	Intermediate/high risk PARTNER 2 S3 registries	TAVR with balloon-expandable SAPIEN 3	New PPM within 30 days	12.5% required PPI; RBBB (OR = 5.8) and depth > 6 mm (OR = 1.86) were predictors
Dizon et al[31] (2015)	RCT and registry analysis	United States, Canada	Inoperable/high-risk AS (PARTNER trial)	TAVI (Edwards SAPIEN)	1-year all-cause mortality	New PPM (6.8%) and prior PPM (22.9%) independently predicted mortality
Natarajan et al[37] (2022)	Prospective cohort	Canada	Outpatient AS; mean age 81.8	Routine 2-week pre/post rACM	Compliance to rACM and unplanned post-TAVI PPMI	15.6% total PPMI rate; 12.5% rACM notifications; unplanned PPMI only 3.1%
Fraccaro et al[33] (2011)	Registry analysis	Italy	AS due to calcification; mean age 81	TAVI with CoreValve system	Incidence/predictors of PPM	39% required PPI; predictors were depth (P = 0.039) and pre-existing RBBB (P = 0.046)
Guetta et al[20] (2011)	Registry analysis	Israel	AS Israeli registry; mean age 83	CoreValve TAVI	Development of HDAVB within 30 days	36% developed HDAVB (40% total PPM); RBBB (OR = 43) and depth (OR = 22) were predictors
Husser et al[38] (2016)	Prospective cohort	Germany, Switzerland	High-risk AS; mean age 80-81.	SAPIEN 3 (n = 96) vs SAPIEN XT (n = 87)	New IVCA and PPM implantation	PPM rate 12.5% (S3) vs 12.6% (XT); S3 had more fascicular blocks (17% vs 5%)
Khawaja et al[27] (2011)	Retrospective multicenter	United Kingdom, Ireland	United Kingdom CoreValve Collaborative; mean age 81.3	CoreValve TAVI	PPM within 30 days	33.3% required PPI; predictors included peri-pro AVB (OR 6.29) and predilatation (OR 2.68)
Kooistra et al[24] (2020)	Retrospective multicenter	Netherlands, Spain	Multi-center European registry; median age 82	TAVI (SEV vs BEV vs Other)	Timing of onset and predictors of late CDs	12% PPM rate; 18% of these were late (> 48 hours); IVCD (OR = 3.3) and RBBB (OR = 2.6) predict late PPM
Kostopoulou et al[32] (2015)	Randomized prospective	Greece	NYHA II/III AS; mean age 81	CoreValve TAVI with EPS vs ECG alone	Predictors of conduction abnormalities	22% PPM within 1 month; baseline HV interval (cut-off 52 ms) was prognostic
Ledwoch et al[34] (2013)	Prospective registry (GARY)	Germany	German GARY registry; mean age 81.5	TAVI (CoreValve vs Sapien)	Predictors of PPM up to 30 days	33.7% PPM rate; independent predictors: CoreValve (OR = 2.86), porcelain aorta (OR = 1.64)
Naveh et al[21] (2017)	Prospective observational	Israel	AS at Hadassah center; mean age 80.7	TAVI (CoreValve vs Sapien)	Predictors for long-term pacing dependency	34.5% total PPI; 68.4% dependent; RBBB (OR = 18) and delta PR > 28 ms were predictors
Rampat et al[26] (2017)	Retrospective multicenter	United Kingdom	United Kingdom LOTUS experience; mean age 81.2	LOTUS mechanically-expanded valve	PPM up to hospital discharge	31.8% PPM rate; 55.2% new LBBB; pre-procedural block composite (OR = 2.54) and absence of valve calcification (OR = 0.55) were independent predictors
Van Gils et al[29] (2018)	Prospective cohort (CONDUCT)	Netherlands	Rotterdam cohort; mean age 79	TAVI (various valves) with daily ECG monitoring.	QRS dynamics vs PPM requirement	23% PPM rate; only persistent QRS prolongation led to PPM in normal baseline patients

AS: Aortic stenosis; AV: Atrioventricular; AVB: Atrioventricular block; BEV: Balloon-expandable valve; CHB: Complete heart block; CD: Conduction disturbance; ECG: Electrocardiogram; EPS: Electrophysiology study; HAVB: High-degree atrioventricular block; HDAVB: High-degree atrioventricular block; HV: His-ventricular; IVCA: Intraventricular conduction abnormality; LBBB: Left bundle branch block; LOTUS: LOTUS Edge valve system; LVEF: Left ventricular ejection fraction; NYHA: New York Heart Association; OR: Odds ratio; PPM: Permanent pacemaker; PPI: Permanent pacemaker implantation; RBBB: Right bundle branch block; RCT: Randomized controlled trial; rACM: Remote ambulatory cardiac monitoring; SAVR: Surgical aortic valve replacement; SEV: Self-expanding valve; TAVI: Transcatheter aortic valve implantation; TAVR: Transcatheter aortic valve replacement.

Table 3 Risk of bias assessment via Newcastle-Ottawa Scale for observational studies

Ref.	Rep. exposed	Sel. non-exp.	Ascert. exp.	Outcome absent	Ctrl main	Ctrl addit.	Assess. outcome	Follow-up dur.	Adequacy FU	Total
Auffret et al[22] (2017)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	9
Chen et al[25] (2024)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	9
Dizon et al[31] (2015)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	9
Kooistra et al[24] (2020)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	8
Pavlicek et al[19] (2023)	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	8
Muntané-Carol et al[18] (2021)	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	8
Bagur et al[23] (2012)	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
Wasim et al[30] (2025)	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	8
Ledwoch et al[34] (2013)	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	No	7
Naveh et al[21] (2017)	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	No	7
Van Gils et al[29] (2018)	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	No	7
Castro-Mejía et al[36] (2022)	No	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	7
Husser et al[38] (2016)	No	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	7
Natarajan et al[37] (2022)	No	Yes	Yes	Yes	Yes	No	Yes	Yes	No	6
Khawaja et al[27] (2011)	No	Yes	Yes	Yes	Yes	No	Yes	Yes	No	6
Rampat et al[26] (2017)	No	Yes	Yes	Yes	Yes	No	Yes	Yes	No	6
Guetta et al[20] (2011)	No	Yes	Yes	Yes	Yes	No	Yes	Yes	No	6
Fraccaro et al[33] (2011)	No	Yes	Yes	Yes	Yes	No	Yes	Yes	No	6

Rep. exposed: Representativeness of the exposed cohort; Sel. non-exp.: Selection of the non-exposed cohort; Ascert. exp.: Ascertainment of exposure; Outcome Absent: Outcome not present at study start; Ctrl main: Comparability on main confounders; Ctrl addit.: Comparability on additional confounders; Assess. outcome: Assessment of outcome; Follow-up dur.: Adequacy of follow-up length; Adequacy FU: Adequacy of follow-up of cohorts; Yes: Criterion met; No: Criterion not met.

Table 4 Patient demographics and general characteristics, mean ± SD/range/median (interquartile range)

Ref.	n	Age	Male	Female	Population characteristics	Diagnosis
Muntané-Carol et al[18] (2021)	459	79 ± 8	251	208	Minimalist TAVR; SAPIEN 3 (85.6%) or Evolut (12.6%); hypertension (91.9%)	Severe aortic stenosis
Pavlicek et al[19] (2023)	203	80 ± 6	106	97	Symptomatic; EvolutR or SAPIEN 3; diabetes (37%), CAD (59%)	Degenerative severe aortic stenosis
Meduri et al[28] (2019)	874 (baseline characteristics reported for 704 pacemaker-naive patients)	82-83 (approx)	345	359	High/extreme surgical risk; Lotus vs CoreValve (Classic/EvolutR)	Symptomatic severe aortic stenosis
Castro-Mejía et al[36] (2022)	344	83 (79-86)	135	209	New generation SEV (Evolut-R/Pro, Acurate-neo, Portico, Allegra)	Severe aortic stenosis
Auffret et al[22] (2017)	3527	82 ± 8	1764	1763	Baseline RBBB impact; 61% BEV; 39% SEV	Symptomatic severe aortic stenosis
Bagur et al[23] (2012)	822 (411/group)	81 ± 11 (TAVI); 80 ± 4 (SAVR)	357	465	Elderly; TAVI (Edwards) vs isolated SAVR; matched by baseline ECG	Symptomatic severe aortic stenosis
Wasim et al[30] (2025)	548	80.6 ± 6.7	271	277	Unselected cohort; various valves; AF (30%)	Severe aortic stenosis
Chen et al[25] (2024)	857	82-83 (approx)	501	356	Intermediate/high risk; SAPIEN 3; annulus calcification highlighted	Symptomatic severe aortic stenosis
Dizon et al[31] (2015)	2531	84.5 ± 7.2	1324	1207	Inoperable/high-risk; Edwards SAPIEN valve	Severe aortic stenosis
Natarajan et al[37] (2022)	192	81.8 ± 6.4	104	88	Outpatient TAVI; 95.3% Sapien S3/ultra; remote monitoring	Symptomatic severe aortic stenosis
Fraccaro et al[33] (2011)	64	80.97 ± 6.55	29	35	Dystrophic calcification; CoreValve Revalving System	Aortic stenosis
Guetta et al[20] (2011)	70	83 ± 4.6	26	44	High risk or inoperable; CoreValve system	Symptomatic severe aortic stenosis
Husser et al[38] (2016)	183	80-81 (approx)	97	86	High-risk; SAPIEN 3 vs SAPIEN XT	Symptomatic severe aortic stenosis
Khawaja et al[27] (2011)	243	81.3 ± 6.7	123	120	Very high/excessive surgical risk; CoreValve	Symptomatic severe aortic stenosis
Kooistra et al[24] (2020)	2804	82 (77-85)	1,248	1,556	Elderly; SEV (37%) vs BEV (56%) vs Lotus (7%)	Severe aortic stenosis
Kostopoulou et al[32] (2015)	45	81 ± 5	27	18	NYHA II/III; normal/slightly impaired LV function; CoreValve	Severe aortic stenosis
Ledwoch et al[34] (2013)	1147	81.5-82 (approx)	468	679	Elderly; high comorbidities; CoreValve or Sapien	Severe symptomatic aortic stenosis
Naveh et al[21] (2017)	110	80.7 ± 6.5	51	59	Symptomatic AS; Medtronic CoreValve or Edwards Sapien XT	Symptomatic aortic stenosis
Rampat et al[26] (2017)	201	81.2 ± 7.7	102	99	High surgical risk; LOTUS bioprosthesis	Degenerative aortic stenosis
Van Gils et al[29] (2018)	291	79 ± 8	156	135	Transarterial TAVI; CoreValve, Sapien XT/3, Lotus	Severe aortic stenosis

AF: Atrial fibrillation; AS: Aortic stenosis; BEV: Balloon-expandable valve; CAD: Coronary artery disease; ECG: Electrocardiogram; LV: Left ventricular; NYHA: New York Heart Association; PPI: Permanent pacemaker implantation; RBBB: Right bundle branch block; SAVR: Surgical aortic valve replacement; SEV: Self-expanding valve; TAVI: Transcatheter aortic valve implantation; TAVR: Transcatheter aortic valve replacement.

Table 5 Summary of reported associations between baseline conduction abnormalities (other than right bundle branch block) and permanent pacemaker implantation after transcatheter aortic valve replacement

Ref.	n	Conduction abnormality	PPI rate in subgroup (%)	Adjusted effect estimate	Notes
Auffret et al[22] (2017)	3527	First-degree AV block	18.5%	Not independently significant in MV model	Baseline PR > 200 ms associated with higher PPI rate; not significant on multivariate analysis
Kooistra et al[24] (2020)	2804	IVCD (non-RBBB)		OR 3.3 (95%CI: 1.7-6.3)	IVCD independently predicted late PPI (> 48 hours post-procedure)
Rampat et al[26] (2017)	201	Pre-procedural block composite (1° AVB, hemiblock, BBB)		OR 2.54 (95%CI: 1.19-5.43)	Composite pre-procedural conduction disease was an independent predictor of PPI in the LOTUS cohort, alongside absence of aortic valve calcification (OR 0.55)
Khawaja et al[27] (2011)	243	QRS duration > 120 ms (IVCD/hemiblock)		OR 2.1 (95%CI: 1.0-4.5)	Prolonged QRS independently predicted PPI in CoreValve cohort; not RBBB-specific
Naveh et al[21] (2017)	110	PR interval prolongation (> 200 ms)		OR 4.7 (95%CI: 1.2-18.3)	Baseline delta PR > 28 ms independently predicted long-term pacing dependency at 6-12 months
Van Gils et al[29] (2018)	291	Pre-existing conduction disease (non-RBBB)		Not reported	In Cohort A (normal baseline), new QRS prolongation (not pre-existing disease) drove PPI requirement
Pavlicek et al[19] (2023)	203	New-onset LBBB after TAVR		OR 15.7 (CI not reported)	New-onset LBBB was the strongest predictor of high-degree AV block requiring PPI in this cohort
Fraccaro et al[33] (2011)	64	Pre-existing RBBB + first-degree AVB combination	100%	Not modelled separately	All patients with both RBBB and implant depth > 6 mm required PPI; no patients without both factors did

Data extracted from narratively reported subgroup analyses and multivariable models within the included studies. No studies provided sufficient extractable comparative data for a formal pooled odds ratio meta-analysis of left bundle branch block, bifascicular block, or isolated first-degree atrioventricular block as primary predictors of permanent pacemaker implantation. Effect estimates are as reported in the original publications and may reflect crude or adjusted values. AVB: Atrioventricular block; BBB: Bundle branch block; IVCD: Intraventricular conduction delay; LBBB: Left bundle branch block; OR: Odds ratio; PPI: Permanent pacemaker implantation; RBBB: Right bundle branch block; TAVR: Transcatheter aortic valve replacement.

Table 6 Long-term pacing dependency data across included studies

Ref.	n (PPM)	Follow-up	Dependency rate	Definition/notes
Naveh et al[21] (2017)	38	6-12 months	68.4%	Long-term pacing dependency
Van Gils et al[29] (2018)	66	6 months	61%	> 20% ventricular pacing
Meduri et al[28] (2019)	245	1 year	50%	83% of 30-day dependent remained so at 1 year
Dizon et al[31] (2015)	173	1 year	51% paced ECGs	95% RV-paced morphology
Wasim et al[30] (2025)	173	Follow-up visits	38%	PM dependency during follow-up
Guetta et al[20] (2011)	28	3 months	40%	HDAVB persisting at 3-month check
Fraccaro et al[33] (2011)	25	6 months	23.5%	> 95% pacing; mean burden 19% in remainder
Kostopoulou et al[32] (2015)	10	24 months	40%	60% recovered endogenous rhythm by 1 month
Bagur et al[23] (2012)	30	Discharge	80% paced rhythm	Long-term dependency not formally reported

PPM: Permanent pacemaker; PM: Pacemaker; RV: Right ventricular; ECG: Electrocardiogram; HDAVB: High-degree atrioventricular block.

Table 7 Comparison of the present systematic review with selected prior meta-analyses examining predictors of permanent pacemaker implantation after transcatheter aortic valve replacement

Ref.	Study design	Included studies/patients	Search period	OR for RBBB predicting PPI	REML random-effects analysis	Subgroup analysis by valve type	Subgroup analysis by study era	Meta-regression on publication year	Leave-one-out sensitivity analysis	Egger test for publication bias	Long-term pacing dependency synthesis	Summary of non-RBBB conduction abnormalities
Present study	Systematic review and meta-analysis	20/15515	2010-2026	4.52 (95%CI 2.64-7.74)	Yes	Yes (Figure 4; Supplementary Figure 3)	Yes (Supplementary Figure 6)	Yes (Supplementary Figure 7)	Yes (Supplementary Figure 2)	Yes (P = 0.907)	Yes (Table 6, 9 studies)	Yes (Table 5)
Mohammadi et al[5] (2025)	Systematic review and network meta-analysis	108/77538	Not reported	RR approx. 3.20	No	No	No	No	No	No	No	No
Peng et al[2] (2025)	Systematic review and meta-analysis	Not reported separately	Systematic	Not computed	No	No	No	No	No	No	No	No
Sultan et al[3] (2024)	Prospective subanalysis (Navitor IDE)	Prospective cohort	Prospective	Device-specific analysis	No	Yes	No	No	No	No	No	No

OR: Odds ratio; RR: Relative risk; PPI: Permanent pacemaker implantation; RBBB: Right bundle branch block; REML: Restricted maximum likelihood.