Predictors of Permanent Pacemaker Implantation Following Valve-In-Valve Transcatheter Aortic Valve Replacement

Background: Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is increasingly used to treat structural valve degeneration. Permanent pacemaker implantation (PPI) following TAVR is associated with increased morbidity and mortality, yet predictors specific to ViV-TAVR remain poorly defined. Objective: To identify clinical and procedural predictors of PPI in patients undergoing ViV-TAVR. Methods: We conducted a retrospective observational study of consecutive ViV-TAVR cases at the Mayo Clinic from 2012 to 2022. Clinical, ECG, procedural data and fluoroscopic measurements were analyzed, and propensity score matching was used to adjust for confounding. Predictors of PPI were identified using multivariable logistic regression. Results: Among 261 patients, 24 (9.2%) required PPI. Balloon-expandable valves were used in 66.7% and self-expanding valves in 33.3%. Predictors of PPI included pre-procedural bifascicular block (OR 12.15, 95% CI: 2.52–68.89, p=0.003), greater septal implantation depth (OR 1.29, 95% CI: 1.04–1.65, p=0.019), and post-procedural new left (OR 23.56, 95% CI: 4.91–48.52, p=0.0004) and right bundle branch blocks (OR 24.4, 95% CI: 3.82–30.51, p=0.001). Aortic regurgitation as the mechanism of prosthetic valve failure was associated with reduced PPI odds (OR 0.28, 95% CI: 0.10–0.76, p=0.014). Pacing requirement—defined as >90% ventricular pacing—increased from 25% at 3 months to 56.25% at 12 months. At a median follow-up of 962.5 days (IQR 481.5–1555.3), adjusted mortality was significantly higher in the PPI group (aOR 9.4, 95% CI: 1.9–60.4, p=0.028). Conclusion: Bifascicular block, greater septal depth, and new bundle branch blocks predict PPI post-ViV-TAVR, while aortic regurgitation appears protective. Risk stratification and procedural planning are critical.