Patient Background: An 82-year-old woman with severe symptomatic aortic stenosis was evaluated for transcatheter aortic valve replacement (TAVR). Her baseline electrocardiogram (ECG) showed right bundle branch block (RBBB) and a prolonged QRS duration.

Assessment and Diagnosis: She underwent TAVR. Her baseline right bundle branch block (RBBB; adjusted odds ratio [ORadj], 2.49) and each 1-millisecond increase in QRS duration (ORadj, 1.01) were identified as independent predictors of permanent pacemaker implantation (PPI).

Clinical Outcome: Approximately 21.5% of patients undergoing TAVR require PPI, most commonly due to third-degree atrioventricular (AV) block (46.4%).

Suggested Treatment Plan: When PPI is necessary, physiological pacing techniques—such as His-bundle or left bundle branch pacing—should be considered to minimize electromechanical dyssynchrony.

Patient Education: Patients should be counseled on the increased risk of PPI after TAVR and its association with higher long-term mortality.

Follow-up: Ongoing follow-up is essential. PPI is an independent predictor of mortality, with an estimated 7-year mortality of 43.3% in PPI recipients versus 30.9% in those without PPI.

1. What ECG markers help predict pacemaker need post-TAVR? Answer Baseline right bundle branch block and increased QRS duration are key predictors. Prosthetic valve type, particularly self-expanding designs, also influences pacemaker need.
2. What pacing strategies can reduce long-term mortality after TAVR? Answer His-bundle or left bundle branch pacing helps reduce dyssynchrony. In low-dependency cases, AV conduction algorithms are useful. Leadless pacing is promising but needs more data.