Permanent Pacemaker Implantation Following Transcatheter Aortic Valve Replacement: Incidence, Predictors, and Association With Reduced Ischemic Stroke Risk

BACKGROUND: Development of conduction abnormalities requiring pacing after transcatheter aortic valve replacement (TAVR) is relatively common. The effects of post-TAVR permanent pacemaker (PPM) implantation on mortality, ischemic stroke, and cardiovascular outcomes remain incompletely characterized. AIMS: To evaluate the incidence, predictors, and cardiovascular outcomes of post-TAVR permanent pacemaker implantation, including its association with 1-year ischemic stroke risk. METHODS: Adults undergoing TAVR (2008-2019; n = 1101) were evaluated. Patients with prior PPM (n = 104) and/or valve-in-valve or redo TAVR (n = 11) were excluded. PPM placement was identified post-indexed TAVR admission based on procedure codes, including both in-hospital and post-discharge implantations. Primary outcomes included 1-year mortality, major adverse cardiovascular events (MACE), myocardial infarction (MI), and ischemic stroke. Multivariate logistic regression was performed to identify independent predictors of 1-year ischemic stroke. RESULTS: Within the TAVR cohort (N = 1101), 158 patients (14.4%) received PPM within 1-year, including 135 (12.3%) in-hospital and 23 post-discharge. PPM was not associated with a significant difference in 1-year mortality (15.8% vs. 14.7%, p = 0.816) or 1-year MACE (20.9% vs. 21.0%, p = 1.000). However, PPM was associated with significantly lower ischemic stroke rate at 1 year (1.3% vs. 4.8%, p = 0.044). In multivariate analysis adjusting for age, sex, and comorbidities, PPM was associated with 77% lower risk of 1-year ischemic stroke (adjusted OR 0.234, 95% CI 0.056-0.977, p = 0.046). Late PPM implantation (> 3 days) was associated with numerically higher 1-year mortality (30.0% vs. 14.3%, p = 0.647) and MACE (36.7% vs. 17.1%, p = 0.119) compared to early implantation, though these outcomes did not reach statistical significance. CONCLUSION: PPM after TAVR was not associated with increased mortality or MACE but was independently associated with significantly lower ischemic stroke risk. Late PPM implantation showed a trend toward worse outcomes. These findings suggest that appropriately indicated PPM may confer cerebrovascular protection, and early implantation when indicated may be preferable. These findings warrant further validation in prospective studies.