The PROMOTE trial enrolled 2,110 patients without prior pacemakers undergoing TAVR. This research examined whether preemptively implanting pacemakers in patients with new conduction abnormalities could reduce risk or improve outcomes. Prophylactic PPI was triggered by defined electrocardiogram (ECG) criteria, like persistent QRS widening beyond 150 milliseconds or PR intervals exceeding 240 milliseconds, along with progressive conduction changes.
Out of 329 patients who eventually received a pacemaker post-TAVR, 80 patients (24.3%) fell into the prophylactic category. Also, 90% of these cases were driven by the emergence of new, persistent left bundle branch block coupled with the threshold ECG abnormalities.
When this study compared outcomes at 30 days, both prophylactic and non-prophylactic PPI patients had similar clinical results. Mortality, rehospitalization, and adverse event rates did not differ significantly between the two groups. However, those receiving prophylactic PPI demonstrated a median ventricular pacing rate of just 2%, compared with 73% among those implanted for non-prophylactic reasons. Furthermore, 42.6% of prophylactic recipients required virtually no pacing support (<1% pacing), while only 14.5% in the non-prophylactic group reached this threshold.
An additional observation centered on patients undergoing electrophysiological studies (EPS). Even when a prolonged His–ventricle interval (≥70 ms) was confirmed before prophylactic implantation, pacing burdens at follow-up remained minimal and comparable to patients who had not undergone EPS. This suggested that EPS guidance did not significantly influence pacemaker dependency outcomes.
These findings suggest that nearly one in four post-TAVR pacemaker recipients undergo implantation based on prophylactic criteria rather than symptomatic or high-risk events. Yet, most of these patients exhibit minimal reliance on the device afterward.
Overall, this study highlighted the need to carefully reconsider the systematic use of prophylactic pacemaker implantation after TAVR. Although pacing prevents potential late conduction events, the majority of prophylactic cases show very low device dependency at follow-up, raising concerns about over-implantation. The implications are far-reaching as TAVR becomes more widely adopted in lower-risk populations.
Source:
Fischer, Q., Nombela-Franco, L., Muntané-Carol, G., Veiga, G., Regueiro, A., Nazif, T., Serra, V., Asmarats, L., Ribeiro, H. B., Latib, A., Poulin, A., Cheema, A. N., Tirado-Conte, G., Gomez-Hospital, J. A., Gil Ongay, A., Gabani, R., Arzamendi, D., Brener, M., Calabuig, A., … Rodés-Cabau, J. (2025). Prophylactic permanent pacemaker implantation after transcatheter aortic valve replacement. JACC. Clinical Electrophysiology. https://doi.org/10.1016/j.jacep.2025.07.028
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