Left bundle branch area pacing vs. right ventricular pacing in post-transcatheter aortic valve implantation patients: a retrospective propensity-matched analysis

Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis across a wide range of patients.1 Despite technological advances, conduction disturbances remain frequent, and many patients require permanent pacemaker (PPM) implantation.2,3 Conventional right ventricular pacing (RVP) may induce electrical and mechanical dyssynchrony, promoting left ventricular dysfunction and heart failure.4 Left bundle branch area pacing (LBBAP) offers a more physiological activation by engaging the native conduction system.5 Although beneficial in non-TAVI populations,6,7 its role after TAVI is not well defined. This study compares outcomes of LBBAP vs. RVP in post-TAVI patients requiring PPM implantation. This single-centre retrospective cohort included consecutive patients undergoing TAVI between January 2020 and December 2024 who subsequently required PPM implantation. Clinical, procedural, and follow-up data were obtained from institutional electronic records and dedicated databases. Patients with known or suspected cardiac amyloidosis were excluded a priori. To allow a balanced comparison between pacing strategies, propensity score matching (1:1 nearest neighbour, calliper 0.2 SD) was performed using age, sex, Society of Thoracic Surgeons (STS) score, baseline left ventricular ejection fraction (LVEF), QRS duration, and presence of left bundle branch block (LBBB) as covariates. All procedures conformed to the Declaration of Helsinki and to the 2021 ESC/EACTS Guidelines on valvular heart disease. The study was approved by the local ethics committee. Device selection (self-expanding or balloon-expandable) was at the operator’s discretion. Procedural success was defined by the VARC-3 criteria,8 including freedom from death, major complications, or need for repeat intervention. Continuous telemetry and serial ECGs were performed for ≥48 h post-TAVI to detect conduction disturbances. Permanent pacemaker implantation followed 2021 ESC Guidelines on pacing and CRT,9 based on persistent or symptomatic high-degree atrioventricular block or significant pauses. In patients undergoing RVP, the lead was placed at the septal position, programmed in VVI or DDD mode. Left bundle branch area pacing was performed following current expert consensus, with the lead positioned 1–2 cm distal to the His region within the interventricular septum. Left bundle branch area pacing success required evidence of conduction system capture (Qr/qR/rSR′ pattern in V1, V6 R-wave peak time < 75 ms, or selective/non-selective capture transition). When conduction capture was not demonstrated, left ventricular septal pacing was accepted if electrical criteria were met. Acceptable thresholds were 4 mV. All devices incorporated algorithms to minimize unnecessary RVP. Clinical endpoints included all-cause and cardiovascular mortality, cardiovascular hospitalizations, changes in LVEF, New York Heart Association (NYHA) class, paced QRS duration, and device-related complications. Follow-up visits occurred at 3 and 12 months, then annually, with device interrogation, ECG, and echocardiography when indicated. Remote monitoring complemented in-person evaluations. Continuous variables were expressed as mean ± SD or median (IQR) and compared with t-test or Mann–Whitney U test; categorical data were compared with χ² or Fisher’s exact test. Kaplan–Meier and Cox proportional hazards models were used to assess survival outcomes, with hazard ratios (HR) and 95% confidence intervals (CI). The proportional hazards assumption was verified for all models. Patients were stratified according to a ventricular pacing burden of ≥70%, a threshold identifying individuals at risk of pacing-induced dysfunction. To standardize comparisons, survival analyses were censored at 15 months. Analyses were performed with R (R Foundation, Vienna, Austria) and GraphPad Prism (GraphPad Software, San Diego, CA), with P < 0.05 considered statistically significant. A total of 342 post-TAVI patients who underwent PPM implantation were included. Among them, 93 (27.2%) received LBBAP, while the remaining underwent conventional RVP. After 1:1 propensity score matching, 73 patients per group were analysed. Baseline, clinical, and procedural characteristics were comparable between groups (Figure 1A). (A) Baseline, clinical, and procedural characteristics of the study population. (B) Kaplan–Meier survival curves for all-cause mortality (upper panel) and cardiovascular hospitalizations (lower panel) in patients who underwent LBBAP or RVP following TAVI. (C) Bar graphs illustrating changes in QRS duration and LVEF from baseline to follow-up in patients undergoing TAVI treated with RVP or LBBAP. (D) Bar graphs illustrating all-cause mortality (upper panel) and cardiovascular hospitalizations (lower panel) in patients undergoing RVP or LBBAP, classified by ventricular pacing percentage at follow-up (>70% vs.