Highlight
- Prospective, multicenter validation of a stratified management algorithm for conduction disturbances (CDs) post-TAVR.
- Algorithm feasibility and safety confirmed, with extremely low sudden cardiac death rates.
- Permanent pacemaker implantation rates remain high, particularly in patients with procedural high-degree block.
- No significant differences in 30-day mortality across stratification groups.
Background
Transcatheter aortic valve replacement (TAVR) is a transformative procedure for patients with severe aortic stenosis, particularly in populations at increased surgical risk. However, conduction disturbances (CDs) are common procedural complications due to proximity of the aortic annulus to the cardiac conduction system. These can manifest as new-onset left bundle branch block (LBBB), high-degree atrioventricular (AV) block, or complete heart block. CDs after TAVR pose a clinical challenge, as they may necessitate permanent pacemaker (PPM) implantation, increase healthcare costs, and potentially affect long-term outcomes.
Management strategies for CDs post-TAVR have been variable, with decisions often based on institutional protocols or operator preference rather than standardized evidence-based algorithms. The PROMOTE study sought to fill this gap by prospectively validating a prespecified, stratified management algorithm in a large, multicenter cohort.
Study Design
The PROMOTE study was a prospective multicenter investigation enrolling 2,110 consecutive TAVR patients without prior permanent pacemakers. Participants were stratified into three groups based on baseline conduction status and periprocedural events:
- NCD group: No prior right bundle branch block (RBBB) and no periprocedural CDs.
- RBBB-NCD group: Prior RBBB but no periprocedural CDs.
- CD group: Any occurrence of periprocedural CDs.
The algorithm provided management recommendations tailored to each group, focusing on ECG surveillance, telemetry duration, and pacing thresholds for PPM implantation. Primary endpoints were 30-day PPM implantation rates and mortality (all-cause and sudden cardiac death).
Key Findings
Of the 2,110 patients, 32.0% were in the NCD group, 5.1% in the RBBB-NCD group, and 62.9% in the CD group. By 30 days, 329 patients (15.6%) underwent PPM implantation. Stratified rates were:
- NCD group: 5.5% PPM rate
- RBBB-NCD group: 15.9% PPM rate
- CD group: 20.7% PPM rate
Further stratification showed markedly higher rates in subtypes of CDs: 17.4% for procedural new-onset LBBB and 57.2% for high-degree AV block/complete heart block.
Importantly, no statistically significant differences were observed in 30-day all-cause mortality (NCD: 1.2%, RBBB-NCD: 0%, CD: 0.7%; P = .45) or sudden cardiac death (NCD: 0.2%, RBBB-NCD: 0%, CD: 0.1%; P = .99) among the groups.
Expert Commentary
The PROMOTE study provides compelling evidence that a pre-defined, stratified approach to CDs after TAVR can be implemented safely across multiple centers. The extremely low risk of sudden cardiac death affirms the safety of conservative monitoring in selected cases. However, persistent high PPM rates, especially in severe conduction disorders, highlight the continued procedural risk to conduction pathways. Existing anatomical and procedural factors—such as deep prosthesis implantation, oversizing, and calcification near conduction tissue—likely contribute to this risk.
From a translational perspective, technology refinement such as lower-profile valves, repositionable devices, and improved imaging guidance could attenuate CD risk. Furthermore, integrating electrophysiological studies or advanced conduction mapping during TAVR might improve patient selection for early versus delayed PPM implantation.
The study’s prospective nature and multicenter design bolster its generalizability, though results may differ in lower-volume centers or among operators with limited experience.
Conclusion
The PROMOTE study validates a structured management algorithm for CDs following TAVR, demonstrating feasibility, safety, and extremely low sudden cardiac death risk. While mortality outcomes are reassuring, high PPM implantation rates—particularly in high-degree AV block—remain a challenge. Preventive strategies focusing on procedural techniques and device design are needed to further reduce conduction-related complications. This work paves the way for standardized protocols that can harmonize CD management worldwide.
Funding and ClinicalTrials.gov
Funding details are as cited in the source publication. Clinical trial registration: NCT identifier not explicitly reported in provided excerpt; consult original publication for registry details.
References
Rodés-Cabau J, Nombela-Franco L, Muntané-Carol G, Veiga G, Regueiro A, Nazif T, Serra V, Asmarats L, Ribeiro HB, Latib A, Poulin A, Cheema AN, Jiménez-Quevedo P, Gomez-Hospital JA, Ongay AG, Gabani R, Arzamendi D, Brener M, Calabuig A, Scotti A, Gelain MAS, Labinaz M, Cepas-Guillén P, Nuche J, Côté M, Del Portillo JH, Philippon F. Prospective validation of a prespecified algorithm for the management of conduction disturbances after transcatheter aortic valve replacement: The PROMOTE study. Heart Rhythm. 2025 Oct;22(10):2635-2643. doi:10.1016/j.hrthm.2024.12.019.
