Minimizing Permanent Pacemaker Implantation After TAVR: Current Strategies, Monitoring Pathways, and Future Directions.

Transcatheter aortic valve replacement (TAVR) has evolved over the last two decades into a cornerstone therapy for patients with severe symptomatic aortic stenosis. This therapy was initially reserved for those at high or prohibitive surgical risk but is now firmly established across all surgical risk categories. Its non-inferiority to surgical aortic valve replacement has been demonstrated even in low-risk populations, supporting the rapid worldwide expansion of its use. Nevertheless, despite procedural refinements and the advent of newer-generation prostheses, conduction disturbances leading to permanent pacemaker implantation (PPI) remain one of the most frequent and clinically relevant complications. Reported incidence ranges between 8% and 20% depending on prosthesis type, implantation technique, and baseline patient characteristics. Multiple clinical, anatomical, and procedural factors have been identified as strong predictors of post-TAVR conduction disturbances. Taken together, the integration of anatomical and clinical risk assessment, precise procedural planning, careful device selection, structured monitoring, and emerging therapeutic strategies constitutes a comprehensive, evidence-based approach to reduce the burden of conduction disturbances following TAVR. Such a multimodal framework has the potential not only to lower the incidence of permanent pacemaker implantation but also to improve safety, optimize healthcare resource utilization, and support the broader adoption of TAVR in increasingly younger and lower-risk patient populations.