Comparison of Leadless and Transvenous Pacemakers in Post-TAVR Patients: A Large-Scale Real-World Analysis

BackgroundPermanent pacemaker implantation (PPI) is required in up to 30% of patients following transcatheter aortic valve replacement (TAVR), mainly due to conduction disturbances. While transvenous pacemakers (TVPM) have traditionally been used, leadless pacemakers (LLPM) could improve outcomes and reduce complications, especially in high-risk populations. MethodsWe conducted a retrospective, observational, propensity-matched cohort study using the TriNetX Global Collaborative Network. Patients who underwent TAVR followed by single chamber PPI within 30 days were identified and divided into two groups: LLPM and TVPM. Those with pre-existing pacemakers or concomitant cardiac surgery were excluded. Propensity score matching (1:1) was performed on demographic, clinical, laboratory, echocardiographic, and medication variables. Clinical outcomes such as all-cause mortality, heart failure, atrial fibrillation, procedural and device-related complications during follow-up were assessed. Kaplan-Meier analyses and Cox proportional hazards models were used. ResultsAmong 1,425 identified patients (469 LLPM, 956 TVPM), 367 matched pairs were analyzed. At 5-year follow-up, there was no significant difference in all-cause mortality (27.2% LLPM vs. 29.4% TVPM; HR 1.07, 95% CI 0.81-1.40; p=0.637). LLPM was associated with a significantly lower incidence of heart failure (16.1% vs. 25.6%; HR 0.61, 95% CI 0.44-0.84; p=0.002). Atrial fibrillation during follow-up was lower in the LLPM group (18.0% vs. 25.6%; HR 0.69, 95% CI 0.50-0.95; p=0.018). Procedure and device-related complication rates were low and similar between groups. ConclusionsIn this large real-world cohort, LLPM was associated with a reduced risk of heart failure and atrial fibrillation compared to TVPM, without differences in overall mortality or safety. These data support considering leadless pacing in selected post-TAVR patients, although prospective randomized studies are required to confirm these findings. Clinical PerspectiveO_ST_ABSWhat Is KnownC_ST_ABSO_LIPermanent pacemaker implantation is frequent after transcatheter aortic valve replacement (TAVR) and may negatively impact outcomes through device related complications, pacing-induced dyssynchrony and tricuspid interference. C_LIO_LILeadless pacemakers eliminate transvenous leads and pockets, reducing the risk of lead-related and infectious complications. C_LI What the Study AddsO_LIIn this large real-world propensity-matched analysis, leadless pacemakers were associated with fewer heart failure and atrial fibrillation events compared with transvenous devices, without differences in mortality or procedural safety. C_LIO_LIThese findings support the use of leadless pacing as a safe and potentially morbidity-sparing option in selected post-TAVR patients. C_LI