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.................................................................................................................................................. 8.3 Pacing after transcatheter aortic

valve implantation For extended literature on patients with pre-procedural RBBB and post-procedural LBBB see sections 8.3.1 and 8.3.2 in the Supplementary data. Rates of permanent pacemaker implantation after TAVI range between 3.4% and 25.9% in randomized trials and large registries.490502 Whereas the association between pacing after TAVI and outcome is controversial,503509 RV pacing may lead to deterioration in LV function.183,510,511 Thus, efforts to minimize unnecessary permanent pacing are warranted. Predictors for permanent pacing (Table 10 and supplementary table 14), especially RBBB, which has been identified as the most consistent and powerful predictor for permanent pacemaker implantation, should be incorporated into procedural planning including transcatheter heart valve selection, implantation height, and balloon inflations. Patients with pre-existing advanced conduction system disease who may have an indication for permanent pacing irrespective of the TAVI procedure need consultation with an electrophysiologist before the procedure. There is currently no evidence to support permanent pacemaker implantation as a ‘prophylactic’ measure before TAVI in asymptomatic patients or in patients who do not meet the standard indications for pacemaker implantation. A recommended approach for the management of conduction abnormalities after TAVI is detailed in Figure 12. Patients without new conduction disturbances post-TAVI are at very low risk of developing high-degree AVB.533535 Conversely, management of patients with persistent complete or high-degree AVB should follow standard guidelines. Permanent pacemaker implantation appears warranted in patients with intraprocedural AVB that persists for 24- 48 h after TAVI or appears later. Data to guide the management of patients with other conduction abnormalities at baseline or post-procedure are more limited. Given the close anatomical proximity of the aortic valve and the left bundle branch, the most frequent conduction abnormality after TAVI is new-onset LBBB.504,536538 Only a small minority of these patients require pacemaker implantation.536,537 Thus, EPS539541 or long-term monitoring536 in lieu of pacemaker implantation may be considered542,543 (see section 8 in the Supplementary data). Several high-risk subgroups of patients with new LBBB have been identified (see Figure 12, and section 8 in the Supplementary data). In such patients with dynamic progression of conduction abnormalities after TAVI (new BBB with dynamic prolongation of QRS and/or PR), an extended monitoring period in hospital of up to 5 days should be considered. Conversely, patients with new-onset LBBB but QRS

Recommendations for cardiac pacing after cardiac surgery and heart transplantation

Recommendations Classa Levelb

1) High-degree or complete AVB after cardiac surgery A period of clinical observation of at least 5 days is indicated to assess whether the rhythm disturbance is transient and resolves. However, in the case of complete AVB with low or no escape rhythm when resolution is unlikely, this observation period can be shortened.473,478 I C 2) Surgery for valvular endocarditis and intraoperative complete AVB Immediate epicardial pacemaker implantation should be considered in patients with surgery for valvular endocarditis and complete AVB if one of the following predictors of persistence is present: pre-operative conduction abnormality, Staphylococcus aureus infection, intracardiac abscess, tricuspid valve involvement, or previous valvular surgery.481 IIa C 3) SND after cardiac surgery and heart transplantation Before permanent pacemaker implantation, a period of observation of up to 6 weeks should be considered.473 IIa C 4) Chronotropic incompetence after heart transplantation Cardiac pacing should be considered for chronotropic incompetence persisting for >6 weeks after heart transplantation to improve quality of life.485 IIa C 5) Patients requiring pacing at the time of tricuspid valve surgery Transvalvular leads should be avoided and epicardial ventricular leads used. During tricuspid valve surgery, removal of pre-existing transvalvular leads should be considered and preferred over sewing in the lead between the annulus and a bioprosthesis or annuloplasty ring. In the case of an isolated tricuspid annuloplasty based on an individual riskbenefit analysis, a preexisting RV lead may be left in place without jailing it between ring and annulus. IIa C 6) Patients requiring pacing after biological tricuspid valve replacement/tricuspid valve ring repair When ventricular pacing is indicated, transvenous implantation of a coronary sinus lead or minimally invasive placement of an epicardial ventricular lead should be considered and preferred over a transvenous transvalvular approach.487 IIa C

Continued 7) Patients requiring pacing after mechan-

ical tricuspid valve replacement Implantation of a transvalvular RV lead should be avoided. III C

AVB = atrioventricular block; RV = right ventricular; SND = sinus node dysfunction. aClass of recommendation. bLevel of evidence. ESC 2021

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