RAPID VENTRICULAR PACING�RVP DURING TAVR DEPLOYMENT

The Leaflet Lounge

Kristina Mack MSN-ED, BSN, RN, CCRN-CMC, CV-BC

August 2026

DISCLAIMER

The information in the presentation is for educational use only.

TAVR causes conduction disturbances mainly because part of the heart’s electrical system lies just beneath the aortic valve. This is the exact area where the transcatheter valve is expanded and anchored.

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After leaving the AV node, the bundle of His passes through the central fibrous body and along the membranous interventricular septum, just below the junction of the right and noncoronary aortic cusps. The proximal left bundle branch then runs superficially along the left ventricular outflow tract. A TAVR prosthesis extends from the aortic annulus into this outflow tract, placing its lower frame very close to the His–Purkinje system (Chen et al., 2020).

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(Nuche et al., 2024)

During balloon valvuloplasty and valve deployment, several processes can affect this tissue:

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• Direct mechanical compression from the prosthetic stent frame and its outward radial force.
• Stretching or contusion from balloon inflation and displacement of the heavily calcified native valve.
• Local edema, inflammation, or small hematoma, which can temporarily impair conduction.
• Less commonly, irreversible tissue injury, resulting in persistent block.

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A recent prospective electrophysiology study found that TAVR can impair conduction at both the AV node and the His bundle/infra-nodal system. Many abnormalities improved afterward, consistent with reversible compression and edema in some patients (Medline et al., 2026).

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Rapid ventricular pacing (RVP) is deliberately used during transcatheter aortic valve replacement (TAVR). RVP is used to temporarily drive the heart to a rate of 180-220 beats per minute to reduce cardiac output.

• Diastolic filling time becomes extremely short.
• The ventricle will eject very little blood with each beat.
• Stroke volume, pulse pressure, and systolic blood pressure fall sharply.
• Flow across the aortic valve and movement of the heart is decreased.

RVP will create a short, controlled period of very low cardiac output so the balloon or the prosthetic valve is not pushed out of position by a forceful heartbeat. Dislodgement of the prosthetic valve is called embolization (Matsuo et al., 2025).

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The heart has not electrically “stopped”; it is just contracting rapidly while producing minimal effective forward flow (Matsuo et al., 2025).

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(Braasch et al., 2024)

We will use a traditional temporary right ventricular pacing wire.

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RVP will be controlled by the circulating cath lab nurse during the procedure.

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The physician may have the team perform a test run before crossing the aortic valve to verify stable capture thresholds and ensure safe backup pacing.

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Image from Medtronic

CONSIDERATIONS

STEPS

For rapid ventricular pacing, the temporary pacemaker is typically set to:

• An asynchronous ventricular mode (VOO)
• Or a high-rate demand mode (VVI)
• At a fast rate of 180 to 220 bpm for balloon-expandable valve
• Or a controlled, lower-rate of 100 to 160 bpm for a self-expandable valve
• With the output (amplitude) turned up to maximum or a high output to ensure absolute continuous capture.

Test ventricular capture

Before valve deployment, the team briefly activates the pacemaker at a slower rate and confirms:

• Every pacing stimulus produces a ventricular QRS complex.
• The pacing output has an adequate safety margin.
• The arterial pressure waveform responds appropriately.
• Backup pacing is available in case TAVR produces heart block.

This prevents discovering a failure to capture at the critical moment of valve deployment.

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Position the valve or valvuloplasty balloon

The balloon or transcatheter valve is positioned across the native aortic annulus. Fluoroscopy and, when applicable, echocardiography are used to verify depth, alignment, and co-axiality.

The team coordinates the ***Deployment Cadence***.

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Begin rapid ventricular pacing or controlled, lower-rate pacing

As the pacemaker rate is increased, the team watches for:

• Consistent electrical capture on ECG.
• A marked narrowing of the arterial pulse pressure.
• A fall in systolic arterial pressure.

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Inflate the balloon or deploy the valve

While the blood pressure and cardiac output are suppressed:

• A pre-dilatation balloon may be inflated to open the stenotic native valve.
• A balloon-expandable transcatheter valve may be deployed.
• A post-dilatation balloon may be inflated to improve valve expansion or reduce paravalvular leak.

The pacing burst is kept as brief as possible. For balloon-expandable deployment, the balloon is inflated, held briefly, and then completely deflated.

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Deflate first, then stop pacing!

Pacing is continued until the balloon is fully deflated.

• Stopping too early could allow a forceful ventricular ejection while the balloon is still expanded, potentially moving the device (embolization)

Once the balloon is deflated:

• Rapid pacing is stopped.
• The patient’s intrinsic rhythm resumes.
• Blood pressure and pulse pressure usually recover within several beats.
• The team checks for arrhythmia, heart block, ischemic changes, or persistent hypotension.

Deployment Cadence:

1. If the patient is intubated, the operating physician will direct anesthesia to “hold lungs”
2. “Pacer ready?”
3. “Pacer on”
4. Confirm pressure of BP <50 and pulse pressure <10 (balloon-expandable valve) or use controlled pacing for stability (self-expanding valve)
5. The MD will inject contrast
6. “Pigtail back”
7. “Balloon up” slowly (during valvuloplasty, balloon-expandable deployment, and post-dilation)
8. “Balloon down” (during valvuloplasty, balloon-expandable deployment, and post-dilation)
9. Confirm that the balloon is fully closed
10. “Pacer off”
11. “Lungs up” (if they’re intubated)

The simplified sequence is:

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Position valve → start RVP → confirm blood-pressure drop → deploy valve → deflate balloon → stop RVP → confirm recovery.

Assess the result and conduction system

After deployment, angiography, pressure measurements, and echocardiography may be used to assess:

• Valve position
• Coronary flow
• Transvalvular gradient
• Paravalvular regurgitation
• Pericardial effusion
• New conduction abnormalities

The temporary wire can then function as backup pacing if TAVR has caused high-grade AV block. When there is no new conduction disturbance, it may be removed in the procedure room. With new bundle-branch block, PR/QRS prolongation, or transient or persistent complete heart block, a secure temporary lead may be retained while the patient is monitored.

IMPORTANT RISKS

Because RVP intentionally causes profound transient hypotension, prolonged or repeated pacing can contribute to myocardial ischemia or injury, especially in patients with poor ventricular function or coronary disease.

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Other potential problems include failure to capture and ventricular arrhythmias. A conventional right-ventricular temporary wire also carries risks such as venous bleeding, lead displacement, right-ventricular perforation, and cardiac tamponade. This is why the team verifies capture beforehand and minimizes the number and duration of pacing bursts (Matsuo et al., 2025).

The left bundle branch is exposed along the upper ventricular septum, so a new left bundle branch block is a common finding. More extensive injury can produce high-grade or complete AV block.

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This is particularly dangerous in someone with a pre-existing right bundle-branch block. Because the right bundle is already nonfunctional, new injury to the left-sided conduction system may eliminate the remaining pathway to the ventricles, leading to complete heart block (Maznyczka et al., 2026).

There is an increased risk of conduction disturbances if:

• The valve is implanted deeper into the left ventricular outflow tract (LVOT).
• The patient has a short membranous septum
• Less distance between the annulus and Bundle of His
• Implantation depth exceeds membranous-septum length.
• There is substantial sub-annular or LVOT calcification.
• The prosthesis is oversized.
• A valve design applies more or longer-lasting radial force
• Self-expanding valves have historically had higher pacemaker rates, although risk varies by device and implantation technique.
• Baseline conduction disease—especially RBBB—is present.

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(Miyashita et al., 2023)

(Bartusik-Aebisher et al., 2025)

Resources:

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Bartusik-Aebisher, D., Serafin, I., & Aebisher, D. (2025). New-Onset Left Bundle Branch Block and Other Conduction Disturbances After TAVR: Incidence, Predictors, and Clinical Implications. Prosthesis, 7(4), 71. https://doi.org/10.3390/prosthesis7040071

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Braasch, M. C., Alakhtar, A. M., Zajarias, A., & Kaneko, T. (2024). Transcatheter aortic valve replacement embolization: A fleeing, formidable, yet defeatable foe. JTCVS Structural and Endovascular, 4, 100030. https://doi.org/10.1016/j.xjse.2024.100030

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Chen, S., Chau, K. H., & Nazif, T. M. (2020). The incidence and impact of cardiac conduction disturbances after transcatheter aortic valve replacement. Annals of Cardiothoracic Surgery, 9(6), 452–467. https://doi.org/10.21037/acs-2020-av-23

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Matsuo, K., Arai, T., Nagai, M., Hori, Y., Hoya, H., Gatate, Y., Yoshitake, A., & Nakano, S. (2025). Impact of Rapid Pacing Time on Myocardial Injury in Transcatheter Aortic Valve Implantation for Non–End-stage Renal Disease Patients. CJC Open, 7(12), 1592–1601. https://doi.org/10.1016/j.cjco.2025.08.011

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Maznyczka, A., Pilgrim, T., Philippon, F., Rodés-Cabau, J., & Backer Ole, De. (2026). Conduction disturbances after transcatheter aortic valve implantation. European Heart Journal, 47(30), 4032–4054. https://academic.oup.com/eurheartj/article-abstract/47/30/4032/8490579?redirectedFrom=fulltext&login=false

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Medline, A., Waks, J. W., D’Avila, A., Tung, P., Clarke, J.-R., Poulin, M.-F., Pinto, D. S., Ultimo, B., Kiernan, K., Laham, R. J., & Buxton, A. E. (2026). Electrophysiological observations during and after transcatheter aortic valve replacement. Heart Rhythm, S1547-5271(26)02369-6. https://doi.org/10.1016/j.hrthm.2026.05.015

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Miyashita, H., Moriyama, N., Sugiyama, Y., Jalanko, M., Dahlbacka, S., Vähäsilta, T., Vainikka, T., Viikilä, J., & Laine, M. (2023). Conduction Disturbance After Transcatheter Aortic Valve Implantation With Self- or Balloon-Expandable Valve According to the Implantation Depth. The American Journal of Cardiology, 203, 17–22. https://doi.org/10.1016/j.amjcard.2023.05.025

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Nuche, J., Ellenbogen, K. A., Mittal, S., Windecker, S., Benavent, C., Philippon, F., & Josep Rodés-Cabau. (2024). Conduction Disturbances After Transcatheter Aortic Valve Replacement. кардиология узбекистана, 17(22), 2575–2595. https://doi.org/10.1016/j.jcin.2024.07.032

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Thank you!