Fixing the rhythm in transcatheter aortic valve implantation patients: can we reduce the need for permanent pacemaker implantation?

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of severe aortic stenosis, yet conduction disturbances remain the most common complication. Permanent pacemaker implantation (PPI), while often necessary, may negatively impact long-term outcomes and increase healthcare burden. Identifying patients at risk of PPI and optimizing post-TAVI rhythm management is therefore of critical importance.

AREAS COVERED: This Special Report reviews key predictors of conduction disturbances after TAVI, including baseline electrocardiographic features (e.g. right bundle branch block), anatomical parameters (e.g. short membranous septum), and procedural factors (e.g. valve type and implantation depth) identified by literature review. Dynamic post-procedural changes in PR interval and QRS duration are discussed as triggers for further monitoring or electrophysiological testing. The report synthesizes findings from recent multicenter studies, guideline recommendations, and emerging tools such as ECG ambulatory monitoring using artificial intelligence and the MIDAS implantation technique.

EXPERT OPINION: Reducing unnecessary PPI requires an individualized, risk-adapted approach that integrates imaging, ECG, and procedural planning. Dynamic post-TAVI monitoring and selective use of electrophysiological studies may help avoid overtreatment. As TAVI expands to younger and lower-risk populations, refining conduction management will be essential to optimize patient outcomes and healthcare resource utilization.