Abstract Body (Do not enter title and authors here): Background: Permanent pacemaker implantation (PPI) is a common outcome following transcatheter aortic valve replacement (TAVR), but its impact on long-term clinical outcomes remains unclear. While earlier meta-analyses reported no significant associations, they were limited by small sample sizes, lack of follow-up stratification, and absence of data from recent high-powered studies. As such, we aim to conduct a meta-analysis to evaluate the association between PPI and major clinical outcomes following TAVR, stratified by short-, mid-, and long-term follow-up durations.
Methods: A systematic search of PubMed, EMBASE, and Cochrane CENTRAL was conducted through June 2025 for studies comparing clinical outcomes including all-cause mortality (ACM), cardiovascular mortality (CVM), myocardial infarction (MI), and stroke between patients receiving vs. not receiving PPI after TAVR. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model, with subgroups of follow-up duration pooled at 30-days, 1-year and >1-year intervals. A p-value < 0.05 was considered significant in all cases.
Results: 56 studies, encompassing 107,652 patients (20,211 with PPI and 87,441 without) were included. PPI was associated with significantly increased all-cause mortality at all follow-up intervals: 30-day ACM (RR: 1.08, 95% CI: 1.00–1.16, P = 0.04), 1-year ACM (RR: 1.18, 95% CI: 1.10–1.28, P < 0.0001), and >1-year ACM (RR: 1.11, 95% CI: 1.02–1.21, P = 0.02). The risk of cardiovascular mortality demonstrated a trend towards significant increase at 30 days (RR: 1.07, 95% CI: 1.00–1.15, P = 0.05), but not at 1 year (RR: 0.96, 95% CI: 0.73–1.27, P = 0.78) or beyond (RR: 1.16, 95% CI: 0.76–1.79, P = 0.49). There were no significant differences in myocardial infarction at 30 days (RR: 0.75, 95% CI: 0.42–1.36, P = 0.35) or at 1 year (RR: 1.12, 95% CI: 0.25–5.07, P = 0.88). Stroke risk was similar at 30 days (RR: 1.04, 95% CI: 0.71–1.51, P = 0.85), with a non-significant trend toward reduced risk at 1 year (RR: 0.71, 95% CI: 0.48–1.04, P = 0.08).
Conclusion: PPI following TAVR is associated with a significant increase in all-cause mortality across short-, mid-, and long-term follow-up durations. These findings highlight the pressing need for further investigation into conduction-sparing procedural strategies, and strategies to reduce long-term pacing-related complications, particularly in younger and lower-risk TAVR populations.