Perioperative Risk Factors for Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis.

Background: Transcatheter aortic valve replacement (TAVR) has become the preferred treatment for severe aortic stenosis, particularly in patients at high surgical risk. Conduction block requiring permanent pacemaker (PPM) implantation remains a common complication post-TAVR. This systematic review and meta-analysis aimed to clarify perioperative (≤30-day) predictors of PPM implantation. Methods: A systematic search was performed using the PubMed, Web of Science, and Embase databases to gather all relevant studies examining the relationship between TAVR and pacemaker implantation outcomes within 30 days of the procedure. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Results: A total of 82 studies comprising 124,808 patients were included. The overall incidence of PPM implantation within 30 days post-TAVR was 17.5%. Key baseline risk factors included right bundle branch block (RBBB) (OR, 5.48; 95% CI, 4.52-6.64) and first-degree atrioventricular block (AVB) (OR, 2.30; 95% CI, 1.82-2.90). Baseline left bundle branch block (LBBB), mitral annular calcification, and male sex were not significantly associated with PPM implantation. A longer membranous septum (MS) length was associated with a reduced risk (OR, 0.78; 95% CI, 0.66-0.93). Additionally, procedural risk factors included greater implant depth (OR, 1.20; 95% CI, 1.13-1.28), the use of self-expanding valves (OR, 2.59; 95% CI, 2.06-3.27), and balloon predilation (OR, 1.37; 95% CI, 1.10-1.71). The cusp overlap technique (COT) significantly reduced PPM risk (OR, 0.45; 95% CI, 0.35-0.58). Furthermore, a greater difference between MS length and implantation depth (ΔMSID) was inversely correlated with PPM implantation risk (OR, 1.36; 95% CI, 1.22-1.50), and post-TAVR new-onset LBBB was a strong predictor of PPM implantation (OR, 2.26; 95% CI, 1.66-3.07). Conclusions: This meta-analysis identified key perioperative predictors of PPM implantation following TAVR. RBBB, first-degree AVB, increased implant depth, self-expanding valves, and predilation all have been shown to increase PPM risk, whereas COT and lower ΔMSID are protective factors. The PROSPERO Registration: CRD42023438228, URL: https://www.crd.york.ac.uk/PROSPERO/view/CRD42023438228.