Conduction disturbance recovery and permanent pacing requirement in bicuspid aortic valves post-TAVR.

BACKGROUND AND PURPOSE: Conduction disturbances (CD) are a common complication of transcatheter aortic valve replacement (TAVR), and patients with bicuspid aortic valves (BAV) seem particularly vulnerable. Whether temporary CD recover or progress to permanent pacemaker (PPM) implantation is poorly characterized in patients with BAV. We characterized recovery from intra-procedural conduction injury and predictors of recovery versus progression to permanent pacing.

METHODS

We retrospectively analyzed 307 BAV patients without prior PPM who underwent TAVR at a single center (February 2014-June 2025). Multivariable models were adjusted for age, sex, prior atrial fibrillation, coronary artery disease, aortic-valve calcium volume, and device type; peripheral vascular disease was added in the within-TempPM Firth-penalized model owing to complete separation.

RESULTS

Temporary pacemaker (TempPM) placement was required in 60 patients; 28 (46.7%) recovered without PPM. Peripheral vascular disease (PVD) was the strongest predictor of non-recovery (p = 0.027), with prior atrial fibrillation showing a similar trend (p = 0.053). Sievers Type 1, specifically the left-right coronary-fusion subtype (L-R), showed higher TempPM use (OR 7.18, p = 0.003). Self-expanding valves also increased TempPM risk (OR 4.41, p = 0.012). Among patients without peri-procedural CD, delayed PPM (11, 4.5%) was predicted only by advanced age (OR 1.08, p = 0.035).

CONCLUSIONS

Nearly half of BAV patients with peri-procedural conduction injury recover without permanent pacing, supporting extended monitoring before committing to PPM implantation. Peripheral vascular disease and prior atrial fibrillation identify patients unlikely to recover and may guide earlier PPM placement. Sievers Type 1 L-R morphology and advanced age are associated with conduction risk and should inform pre-procedural planning.