Prophylactic Permanent Pacemaker Implantation for Baseline Right Bundle Branch Block in Patients Undergoing Transcatheter Aortic Valve Replacement: Clinical Efficacy, Safety, and Long-Term Pacing Requirement

Background: Baseline right bundle branch block (RBBB) is an established predictor of permanent pacemaker (PPM) requirement after transcatheter aortic valve replacement (TAVR). There are limited data to support prophylactic PPM implantation in advance of TAVR. We aimed to evaluate the efficacy and safety of prophylactic PPM implantation in patients with RBBB prior to TAVR, and to identify the predictors of pacing dependence after TAVR.

Methods: This was a retrospective cohort study of patients undergoing prophylactic PPM implantation for baseline RBBB prior to TAVR at two high-volume UK centers between 2014 and 2022.

Results: Baseline RBBB was identified in 170/4580 (3.7%) patients undergoing TAVR during the study period. Of these, 106/170 (62.4%) underwent prophylactic PPM implantation. This group had a significantly shorter median length of hospital stay after TAVR compared to patients with RBBB undergoing TAVR without prophylactic PPM implantation (2 vs. 4 days, p = 0.028). Urgent PPM implantation after TAVR was required in 43/64 (67.2%) of patients with RBBB who underwent TAVR without a prophylactic PPM. Analysis of ventricular pacing over 12 months post-TAVR demonstrated a significant pacing requirement (ventricular pacing > 10%) in 50/79 (63%) of patients with a prophylactic PPM. Pacing requirement was independently predicted by baseline first-degree heart block (odds ratio 2.4, p = 0.03) and QRS duration >140 ​ms (odds ratio 4.3, p = 0.01).

Conclusions: In this retrospective two-center cohort study, prophylactic PPM implantation for patients with baseline RBBB was safe, effective, and reduced the length of hospital stay. First-degree atrioventricular block and broad RBBB (QRS > 140 ​ms) were independent baseline predictors of significant pacing requirements.