Clinical Heart and Vascular Center

Brady- and Tachyarrhythmias Following Heart Transplantation: Significance and Management Strategies

By Jose Joglar, M.D.

Professor of Internal Medicine
Vice Chair for Internal Medicine Clinical Affairs, Parkland Health & Hospital System

Dr. Jose Joglar

It was my pleasure to participate in the cardiovascular seminar “Arrhythmias and Heart Failure: Breaking the Vicious Cycle” at #AHA22. Within context of the seminar’s focus on the management of arrhythmias in patients with heart failure, my lecture addressed the clinical significance and management of arrhythmias in patients who have received a heart transplant. Because arrhythmias frequently complicate the care of heart transplant recipients, understanding how to prevent and treat these disorders effectively is important.

Several factors contribute to arrhythmias, including autonomic denervation, acute and chronic rejection, and transplant vasculopathy. To minimize risk of future arrhythmias, the bicaval technique is now the surgical standard because it avoids a suture line across the right atrium and preserves sinus node function. Of the supraventricular arrhythmias, atrial fibrillation is common during the early postoperative period but rare later unless acute rejection is present. On the other hand, atrial flutters are common even in stable patients. Bradyarrhythmias also occur following heart transplantation. Indeed, permanent pacemaker (PPM) implantation is required in a subset of patients for sinus node dysfunction or atrioventricular block. The etiology is generally multifactorial, although rejection and transplant vasculopathy, in the proper clinical context, must be ruled out. When pacemakers are implanted, the higher risk of infection in this population must be considered.

“Several factors contribute to arrhythmias, including autonomic denervation, acute and chronic rejection, and transplant vasculopathy.”

Jose Joglar, M.D.

Heart transplant recipients are also at a higher risk of sudden cardiac death than the general population, often from cardiac allograft vasculopathy. The latter is a serious long-term complication following heart transplantation. It manifests as an accelerated form of coronary disease that affects both intramural and epicardial coronary arteries and veins and can cause both allograft failure and sudden death. The role of implantable defibrillators in preventing sudden death in heart transplant recipients remains uncertain.


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