Mid-term follow-up of COVID-19 patients with permanent pacemaker implantation due to bradyarrhythmia at the acute phase of infection.

Funding AcknowledgementsType of funding sources: None.IntroductionTranscatheter aortic valve implantation (TAVI) is a worldwide accepted treatment for severe aortic stenosis (AS). Conduction system disturbances, frequently requiring permanent pacemaker (PM) implantation, remain one of the most common procedural complication. Whether the permanent ventricular pacing has a deleterious impact on the prognosis of this population remains unclear.ObjectivesTo assess the long-term impact of permanent PM implantation in clinical outcomes after TAVI.MethodsWe performed a retrospective analysis of consecutive patients (P) who underwent TAVI between 2009 and 2021 in a single tertiary center.P with a PM implanted before TAVI or with in-hospital mortality were excluded from the analysis. PM implantation post-TAVI was defined as an implant during hospital stay after TAVI or in the first month after discharge. Kaplan Meier survival curves were used to estimate the impact of permanent PM after TAVI, regarding the composite endpoint of all-cause mortality and heart failure (HF) hospitalization during a 4 years follow-up period, and a comparison performed according to the presence or absence of baseline intraventricular conduction disturbances.Results549 P (82±6.6 years, 56.8% female, left ventricular ejection fraction 53±10%, peak gradient 51±15.6 mmHg, aortic valve area 0.7± 0.2 cm2) were included. At baseline, 108 P (20%) had intraventricular conduction disturbances on ECG (50 P with right bundle branch block [RBBB] and 58 P with left bundle branch block [LBBB]). 127 P (23%) required PM implantation after TAVI. Baseline characteristics were similar between P with and without PM implantation, except for age, gender, previous valvular surgery and RBBB (Table 1). At 48 months follow-up, 35% (n=193) met the composite endpoint, that was similar between both groups (35.8% vs. 34.1%, p=0.731). Kaplan-Meier survival curves revealed no difference in the composite endpoint between the two groups (log-rank p=0.170). Further analysis of subgroups according to the presence or absence of baseline intraventricular conduction disturbances revealed a significant difference among the subgroup of P without previous intraventricular conduction disturbances that underwent PM implantation after TAVI (log rank p=0.02) (Fig 1). This difference in the composite endpoint after PM was not found in the subgroups of P with RBBB (log rank p=0.656) or LBBB (log rank p=0.975) at baseline (Fig 2).*ConclusionsPermanent PM implant after TAVI does not have an impact on long-term HF hospitalization and mortality. However, in the specific subgroup of P without previous intraventricular conduction disturbances, PM implantation seems to be associated with worse prognosis.Fig 1. Kaplan meier survival curves

The incidence of conduction disease requiring permanent pacemaker (PPM) implantation following aortic valve replacement (AVR) ranges from 3% to 6%. Data concerning the potential risks for PPM requirement associated with certain valve types have been conflicting and controversial. We sought to evaluate the prevalence, predictors for PPM implantation, and PPM dependency during follow-up in patients undergoing AVR. A total of 214 consecutive patients undergoing AVR were studied retrospectively. A total of 207 patients were included in the statistical analysis. Clinical variables including valve size and types were catalogued and the incidence of PPM evaluated. Cardiac rhythm device clinic records were examined and PPM dependency status was catalogued. Multivariate analyses were performed to determine predictors of PPM implantation and PPM dependency during follow-up. Fifteen patients (7.2%) required PPM postoperatively. After controlling for clinical and surgical characteristics, predictors for PPM included preoperative first-degree atrioventricular block with and without left anterior fascicular block or intraventricular conduction delay [odd ratios (OR) = 12.5, P = 0.001], cardiac arrest postoperatively (OR = 9.4, P = 0.012), and combined aortic and mitral valve surgery (OR = 11.5, P = 0.027). Aortic valve types did not predict complete heart block (CHB) and PPM implantation. Of those patients who underwent PPM implantation, 70% were classified as PPM dependent during long-term follow-up. CHB and PPM implantation continue to be common complications of AVR. Preexisting atrioventricular with intrafascicular or intraventricular conduction disease along with cardiac arrest and dual valve surgery are the most important significant predictors of PPM implantation and PPM dependency during follow-up. The selection of valve types did not predict conduction disease requiring PPM implantation.

Aims Takotsubo syndrome (TTS) is an acute stress-induced cardiomyopathy showing left ventricular (LV) dysfunction without obstructive coronary arteries disease. A sudden massive surge of circulatory catecholamines from an intense physical or emotional stress may play a central role in the pathogenesis of TTS. We report the case of an 87 years-old woman who developed TTS with uncommon presentation after permanent pacemaker (PM) implantation. Methods and results The patient was referred to our hospital for PM implantation because of advanced atrio-ventricular block (3:1). She suffered by rheumatoid arthritis (RA), arterial hypertension, and chronic kidney disease. Echocardiogram, performed before PM implantation, showed normal LV kinesis and normal ejection fraction (EF 60%). She was initially administered with infusion of Isoprenaline 2 mcg/min. The subsequent day, she underwent permanent dual-chamber pacemaker implantation without any complications. After 3 days, the patient complained severe asthenia and fever, together with increase of white blood cells and C reactive protein. Blood cultures were negative. We started antibiotic therapy and, suspecting a reactivation of RA, steroid therapy with infusion of methylprednisolone 40 mg/die. Electrocardiogram showed normal sinus rhythm and paced ventricular rhythm. PM interrogation showed normal function. Surprisingly, echocardiogram showed LV dysfunction with apical and medium segments akinesia, and severe EF reduction (35%). Coronary angiography documented absence of coronary obstructive lesions, assessing diagnosis of TTS. The patient was discharged 1 week after admission in good clinical condition. One week later, an echocardiogram showed apical akinesia, partial recovery of medium segments motility, and slight increase of EF (40%). The excess of catecholamines could lead to decreased cardiac muscular function and to spasm of coronary arteries: these events can lead to acute heart failure and decrease of LVEF. Furthermore, about 90% of patients with TTS are women, especially in postmenopausal period. Peculiarities of this case were the atypical symptoms of TTS and the combination of different predisposing stressors factors: female sex in postmenopausal period, anamnesis of chronic inflammatory disease, use of stress-inducing drugs (methylprednisolone and isoprenaline, the last associated with TTS after PM-implantation), atrio-ventricular block itself, and PM implantation procedure. Our findings remark that even a low-risk procedure could be a possible cause of TTS in patient with such risk factors. In our opinion, in this subset of patients, conscious sedation could be useful to reduce the stress load, together with an early procedure and consequently the minimal use of exogenous stress drugs like Isoprenaline, even if the patient is in a good clinical condition. Conclusions This case highlights TTS as a potential complication after PM implantation, especially in post-menopausal women with high pre-existing stress load.

Permanent pacemakers are an established treatment for sick sinus syndrome and high-grade atrioventricular block. Permanent cardiac pacemaker implantations may damage the myocardium. This study evaluated markers of myocardial injury, oxidative stress and inflammation in elderly patients with permanent pacemaker implantations. Various markers were measured at 1, 2, 3 and 4 months after permanent pacemaker implantations in elderly patients. The levels of high-sensitivity troponin T (hsTnT), lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1), malondialdehyde-modified low-density lipoprotein (MDA-LDL), oxidized low-density lipoprotein (OX-LDL), tumour necrosis factor-α (TNF-α), toll-like receptor 4 (TLR4) and nuclear factor-kappa B (NF-κB) were increased in 2-month group compared with control and 1- month groups (P<0.001), and were further increased at 4-month group compared with 2- and 3- month groups after pacemaker implantations (P<0.001). Patients with dual-chamber pacemakers had higher levels of hsTnT, LOX-1, MDA-LDL, OX-LDL, TNF-α, TLR4 and NF-κB than patients with single chamber pacemakers (P<0.001). Patients who underwent the pacemakers with the active fixation leads had raised levels of hsTnT, LOX-1, MDA-LDL, OX-LDL, TNF-α, TLR4 and NF-κB compared patients with pacemakers using the passive fixation leads (P<0.001). Myocardial blood flows in 3-month and 4-month groups were lower than 1-month and 2-month groups (P<0.001). Levels of hsTnT, LOX-1, MDA-LDL, OX-LDL, TNF-α, TLR4 and NF-κB were elevated in elderly patients with permanent pacemaker implantations and the activations of oxidative stress and pro-inflammatory signalling pathways may be associated with myocardial damages and ischemia after pacemaker implantations in elderly patients.

Funding Acknowledgements Type of funding sources: None. Introduction Transcatheter aortic valve replacement (TAVR) is an established procedure to treat patients (pts) with symptomatic severe aortic stenosis. Although conduction disturbances remain the most frequent complication, there is a lack of consensus on their management, which leads to significant differences in permanent pacemaker (PPM) implantation rates between centers. Purpose To evaluate new conduction disturbances and PPM implantation in pts undergoing TAVR, peri-procedure and up to 1 year. Methods We retrospectively analyzed all pts who underwent TAVR at a tertiary center from October 2014 to November 2019; pts with a previous PPM were excluded (n = 30). Clinical and ECG data were collected at presentation and up to 1 year after implantation, including systematic interrogation of implanted PPM. Results 340 pts underwent TAVR (57% female, mean age 80 ± 8years). CoreValve Evolut R was the most used valve (41% of pts), followed by CoreValve Evolut Pro (21%) and Acurate Neo (13%). Of the 77% pts who were in sinus rhythm pre-TAVR, 79% had normal atrioventricular (AV) conduction and 20% 1st degree AV block (AVB); 60% had no intraventricular (IV) conduction disturbance, 9% left bundle branch block (LBBB), 7% right bundle branch block (RBBB) and 7% RBBB plus fascicular block. After TAVR, 50.9% of pts exhibited new conduction disturbances. Regarding AV conduction, 12.4% of pts developed advanced AVB and 20% of pts without previous disturbances developed 1st degree AVB. Concerning IV conduction, the most frequent disturbance was de novo LBBB (n = 109, 32,2%) which resolved in 56% of cases after 6 months. Among pts with previous RBBB, 42% developed advanced AVB; the presence of previous RBBB was the major risk factor for advanced AVB [OR = 8.5 (95% CI 4.1-17.5; p &amp;lt; 0.001)] and PPM implantation [OR = 5.2 (95% CI 2.7-10.0; p &amp;lt; 0.001)], followed by previous 1st degree AVB [OR = 2.3 (95% CI 1.2-4.4; p = 0.016) for PPM implantation]; previous FA or LBBB were not associated with advanced AVB or PPM implantation. Overall, 19% of pts implanted a PPM post-TAVR (n = 63). The main reason was advanced AVB (60%), followed by LBBB plus 1st degree AVB (22%), isolated LBBB (5%) and alternating bundle branch block (ABBB) (5%). At first PPM evaluation, pts with advanced AVB had a median percentage of ventricular pacing (VP) of 80% (52% had VP &amp;gt;90% and 14% &amp;lt;1%) and one year after-TAVR the median percentage of VP was 83%. Concerning pts with LBBB plus 1st degree AVB, median VP at first assessment was 4% (38% had &amp;lt; 1% of VP). In pts with isolated LBBB or ABBB, median VP at first evaluation was 13% and 11%, respectively. Conclusion LBBB was the most frequent de novo conduction disturbance after TAVR, with more than half of the cases resolving in the first 6 months. RBBB, on the other hand, was the major risk factor for advanced AVB and PPM implantation. Advanced AVB was associated with a high percentage of VP at 1-year follow-up, unlike pts with milder degrees of conduction delay.

Expanding indications for transcatheter aortic valve implantation (TAVI) highlighted the importance of complications such as new left bundle branch block (LBBB) or permanent pacemaker (PPM) implantation. However, studies on the long-term outcomes of these conduction abnormalities (CA) are limited. This study aims to examine the progression of CA within the first year after TAVI and their long-term prognostic value. TAVI patients were divided into 1) PPM implantation within the first year, 2) post-TAVI LBBB persisting until 1 year (permanent LBBB), and 3) no-CA. Endpoint was all-cause mortality after 1 year. Among 794 patients initially included, 30% developed new LBBB, which persisted in 17% until discharge; 12% received a PPM during the hospitalization. One-year follow-up was available in 502 patients: 11% were classified as permanent LBBB (n = 56), 18% as PPM (n = 89), and the rest as no-CA (n = 357). Baseline characteristics were comparable, except for valve type, with self-expanding more common among the PPM group. At 1-year follow-up, lower left ventricular ejection fraction and global longitudinal strain were observed in the PPM and permanent LBBB groups compared to the no-CA group (55% ± 9% and 15% ± ​4% vs. 54% ± 11% and 15% ± 4% vs. 58% ± 9% and 17% ± ​4%, respectively, p ​< 0.001). At long-term follow-up (median: 4 [interquartile range: 3-6] years), higher mortality was observed in the PPM group (ꭓ2 = 10.168, p = 0.006). In addition, PPM implantation (hazard ratio: 1.654, p = 0.011) and global longitudinal strain at 1 year (hazard ratio: 0.950, p = 0.027), as well as pre-TAVI EuroSCORE II and New York Heart Association III-IV at 1 year, were independently associated with the outcome. Post-TAVI CAs are dynamic within the first year. Patients who needed PPM implantation did not show significant improvement in left ventricular function after TAVI and had higher long-term mortality.

Introduction Transcatheter aortic valve replacement (TAVR) revolutionized the treatment of aortic stenosis [1]. Although TAVR is an effective treatment for AS patients, it is associated with high incidence of new-onset conduction disturbances and pacemaker implantations. The two most common conduction disturbances after TAVR are new onset left bundle branch block (LBBB) and high-degree atrioventricular block (HDAVB) [2]. While patients with HDAVB require a permanent pacemaker implantation (PPM), the management of LBBB is not completely established yet. According to the ESC 2021 guidelines, a PPM is indicated in patients with persistent HDAVB or new onset alternating BBB after TAVR. Yet, the recommendations regarding other conduction abnormalities are not well defined. In patients with persistent new onset LBBB, ambulatory continuous ECG monitoring or electrophysiology study (EPS) are recommended [3]. Purpose To evaluate the clinical outcomes of patients with conduction disorders after TAVR who were managed according to electrophysiology-guided algorithm (Figure 1), including mortality, late pacemaker’s implantations, and heart failure hospitalizations. Predictors of periprocedural LBBB and HDAVB were also assessed. Methods Retrospective population-based cohort study including all patients who developed new onset LBBB after TAVR at a tertiary University Medical Center from October 1, 2018, to December 31, 2022, and were managed according to specific electrophysiology-guided algorithm. Results The study cohort included 230 consecutive patients who underwent TAVR. Mean age was 80.3 and 56.5% were females (Figure 2). Twenty patients (8.7%) developed HDAVB and required a PPM, whereas 40 patients (17.4%) developed persistent LBBB. According to the algorithm, 8 patients (20%) with a QRS&amp;lt;130ms were discharged without PPM [group A], 20 patients (50%) with a QRS of 130-160ms underwent EPS, and 12 patients (30%) with a QRS&amp;gt;160ms [Group C] received a PPM. Among the EPS group: 9 patients (22.5%) with HV&amp;gt;65ms underwent PPM [group B2], while 11 patients with HV&amp;lt;65ms (27.5%) were discharged without PPM [group B1]. During a one-year follow-up only one patient required late PPM [group B1]. Mortality was higher among the subgroups with PPM [B2 and C] compared to the subgroups without a PPM [A and B1]: 4 vs. 1 patient accordingly. Conclusions The presented electrophysiology-guided algorithm for patients with persistent LBBB after TAVR appears safe and efficient, with a modest incidence of PPM (17.6% of the total cohort) during hospitalization and a minimal need for late PPM at one year follow-up. Importantly, there was no excess of mortality among patients who were discharged without a pacemaker implantation. Thus, we suggest that the presented algorithm may serve as a reliable strategy to distinguish between individuals with new onset persistent LBBB after TAVR who require PPM compared to those in whom a PPM can be safely avoided.

Permanent pacemaker (PM) implantation is common after transcatheter aortic valve implantation (TAVI). Left ventricular mechanical dispersion (MeDi) by speckle tracking echocardiography is a marker of fibrosis that causes alterations in the conduction system. We hypothesized that MeDi can be a predictor of the need for PM implantation after TAVI. Consecutively, 200 TAVI patients were enrolled. Transthoracic echocardiography and electrocardiography examinations were recorded before TAVI to evaluate global longitudinal strain (GLS), MeDi, and conduction disturbances. PM implantation information was obtained 3 months after TAVI. Patients were stratified into PM or no PM group. Mean age was 80 + 7 years (44% women). Twenty-nine patients (16%) received PM. MeDi, QRS duration, existence of right bundle branch abnormality (RBBB), and first-degree atrioventricular (AV) block were significantly different between groups. MeDi was 57 ± 15 ms and 48 ± 12 ms in PM and no PM groups, respectively (P < 0.001). In multivariate analysis, MeDi predicted the need for PM after TAVI independently of GLS, QRS duration, RBBB, and first-degree AV block [odds ratio (OR): 1.73, 95% confidence interval (CI): 1.22-2.45] with an area under the curve (AUC) of 0.68 in receiver operating characteristic (ROC) curves. Moreover, RBBB was an independent predictor of PM need after TAVI (OR: 8.98, 95% CI: 1.78-45.03). When added to RBBB, MeDi had an incremental predictive value with an AUC of 0.73 in ROC curves (P = 0.01). MeDi may be used as an echocardiographic functional predictor of the need for PM after TAVI.

Background Acute spinal cord injury (SCI) is associated with severe cardiovascular complications. Information regarding the need for permanent cardiac pacing in SCI patients is scarce and based on case reports and small case series. We aimed to investigate the extent of permanent pacemaker (PPM) implantation procedures as well as to identify predictors for PPM insertion among SCI patients in a U.S contemporary, nationwide, all-comer registry. Methods Using the National Inpatient Sample (NIS) database, patients hospitalized with a primary diagnosis of SCI in the US between 2016-2019 and underwent PPM implantation were identified. Patients with cardiac implantable electronic device in-situ were excluded. Baseline demographics, clinical characteristics, injury type, in-hospital procedures and outcomes including time to PPM implantation, length of stay and mortality were collected. Outcome analysis performed after propensity score matching (PSM). Predictors of PPM implantation were identified via a multivariable logistic regression model. Results A total of 35880 patients, were hospitalized with a primary diagnosis of SCI during the study period, and 240 (0.7%) received a PPM. Median age of patients receiving PPM was 69 years, 75% were males, and 67% had high level SCI injury (level C1-5). Time to PPM implantation was 9 days (IQR 4-19). PPM implantation was associated with higher rates of cervical spine injuries, traumatic brain injury (TBI), chest and upper limbs injuries, respiratory failure and other signs of severe illness. Longer hospital stay and higher in-hospital mortality rate was observed in patients receiving a PPM. Multivariate analysis identified the following independent risk factors for PPM implantation: cervical SCI [OR 77.07 (11.13-553.42), p&amp;lt;0.001], TBI [OR 3.84(1.59-9.28), p=0.003] and tracheostomy/respiratory ventilation&amp;gt; 96 h [OR 31.766(7.91-127.54), p=&amp;lt;0.001]. Conclusion Cervical SCI, need for tracheostomy and prolonged mechanical ventilation were the strongest predictors for PPM implantation in patients hospitalized for SCI in a nationwide registry.

Commentary: The issue of pacemaker implantation after surgical ablation for atrial fibrillation

Introductionartificial pacemakers generate electrical impulses and regulate the heart´s conduction system. They are often used to treat individuals with bradycardia. Permanent pacemaker implantation is a lifesaving procedure especially in patients with symptomatic bradyarrhythmias. The objectives was to evaluate the clinical attributes and outcomes of permanent pacemaker implantation in Ile-ife, Nigeria.Methodswe retrospectively reviewed medical records of 22 patients who had pacemaker implantation from January 2015 to December 2019. Patient´s demographics, clinical presentation, diagnosis, comorbidities, type of device, complications and long-term follow up were studied.Resultssixteen males (72.7%) and 6 females (27.3%) were recruited into the study with ages ranging between 54 and 84 years and a mean of 70.3 +8.7 years. The commonest symptom was easy fatigability (45.5%) followed by syncope (31.8%). The main indication for permanent pacemaker implantation was complete heart block (86.4%). Seventeen (77.3%) patients had hypertension as the comorbidity present at diagnosis. Single chamber (VVIR) pacemaker was implanted in 13(59.1%) patients while dual chamber (DDDR) was implanted in 9(40.9%) patients. Hematoma, pneumothorax and acute lead dislodgement were the complications observed in 3 patients. There was no statistical significance between the type of device implanted and the occurrence of complications, p-value 0. 186. There was no mortality and 15 patients (68.2%) are currently attending regular 6 monthly follow-up.Conclusioncomplete heart block is the most common indication for permanent pacemaker implantation and the procedure is safe with minimal complications and satisfactory outcomes.

Efficacy of cilostazol for sick sinus syndrome to avoid permanent pacemaker implantation: A retrospective case–control study

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Executive Summary.

Stress-induced cardiomyopathy (SCMP) after permanent pacemaker (PPM) implantation is rare. Here, we report an additional case which was initially misdiagnosed as another disease due to atypical symptoms after PPM implantation. Case presentation: A 79-year-old woman with dizziness and dyspnea for one month visited Cardiology Department. She had a history of hypertension, dyslipidemia, diabetes-mellitus and stage IV chronic kidney disease. We confirmed complete atrioventricular block. Left ventricular ejection fraction (LVEF) was normal. PPM implantation was successfully performed without complications. The next day she felt very well with no symptoms. On the second day, she suddenly developed a fever and complained severe left neck pain. She had cough, sputum and general weakness without chest pain. C-reactive protein level increased and systolic blood pressure was decreased. We started antibiotics considering infection. We also checked implantation site, but there were no signs of infection. On the third day, echocardiography showed decreased LVEF (30%), akinesia of apical and medium segments of LV wall with preserved kinetics of basal segments without pericardial effusion (Figure 1). There was no significant stenosis on coronary angiography and we confirmed SCMP. After few days, her blood pressure and symptoms were improved. We prescribed sacubitril-valsartan, bisoprolol and furosemide. At 10 days after implantation, she was discharged with improved symptoms. Conclusion: Our case emphasizes that even successful implantation of PPM without complications can be a potential risk of SCMP. In the absence of typical cardiac symptoms after PPM implantation, a poor general condition may also be considered as a sign of SCMP. Therefore, it is necessary to monitor the patient for at least three more days after PPM implantation.

Background Conduction abnormalities leading to permanent pacemaker (PPM) implantation are common complications following transcatheter aortic valve replacement (TAVR). Whether PPM implantation placement is associated with adverse outcomes is unclear. The purpose of this study was to evaluate the incidence, predictors, and clinical outcomes of PPI following TAVR. Methods Based on the administrative hospital-discharge database, we collected information for all patients treated with TAVR between 2010 and 2019 in France. Results A total of 49,201 patients with aortic stenosis treated with transcatheter aortic valve replacement (TAVR) using the balloon-expandable (BE) Edwards SAPIEN valve or the self-expanding (SE) Medtronic CoreValve were found in the database. Among them, 10,019 (20.4%) had prior PPM implantation, including 476 (4.8%) treated with cardiac resynchronization therapy (CRT). New PPM implantation was required within 30 days of TAVR in 11,010 patients (22.4%), which varied among those receiving self-expanding valves (24.7%) versus balloon-expanding valves (20.9%). There were 349/10,010 patients (3.1%) treated with cardiac resynchronization therapy (CRT) within 30 days following TAVR. In a multivariable analysis comprising 38 variables (including among others underlying conduction disorders, Euroscore 2, Charlson comorbidity index, frailty score and type of implanted valve), prior PPM implantation was associated with an increased risk of all-cause death (adjusted hazard ratio [HR]: 1.10 95% CI 1.04–1.16). New PPM implantation was associated with even higher risk of mortality (adjusted HR: 1.21 95% CI 1.15–1.28). By contrast, previous CRT was associated with a lower risk of death during follow-up (adjusted HR: 0.78 95% CI 0.63–0.96), while PPM with CRT within 30 days of TAVR was not associated with a different risk of death (adjusted HR: 1.00 95% CI 0.80–1.24). Prior PPM and new PPM implantation were also associated with an increased risk of rehospitalization for heart failure (adjusted HR: 1.26 95% CI 1.19–1.32 and 1.18 95% CI 1.12–1.24, respectively). Previous CRT was associated with a non-significant lower risk of rehospitalization for heart failure (adjusted HR: 0.92 95% CI 0.77–1.09). Conclusions Both previous PPM and early PPM implantation following TAVR are commonly seen in patients treated with TAVR, and they are associated with a higher risk of death and rehospitalisation for heart failure when compared to patients with no PPM. The fact that CRT when implanted before TAVR was associated with a better survival may deserve consideration when elaborating future optimal approaches for management of conduction disturbances in patients treated with TAVR. Funding Acknowledgement Type of funding source: None