Heart transplantation associated arrhythmias
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
- Patients with end-stage cardiac disease who are managed with heterotopic heart transplantation, very commonly have arrhythmias post-transplantation, especially in the early postoperative period.
- Most arrhythmias are benign like premature atrial complexes and premature ventricular complexes that do not result in symptoms.
- More dangerous and life-threatening arrhythmias may also occur, which result in significant morbidity and mortality.
Classification
| Types of Arrhythmias | Occurrence | Common mechanism | Treatment | ||
| Tachyarrhythmias | Supra-ventricular tachy- arrthymia
(SVT) |
Atrial fibrillation | Common in early postoperative period Over all frequency 47.3% (Elkaryoni et al.) |
1. Graft manipulation (primary graft failure) | 1. Evaluate and manage the trigger
2. Persistent cases: Catheter ablation |
| 2. Inflammatory changes (pericardial inflammation) | |||||
| 3. Autonomic hypersensitivity | |||||
| 4. Ischemia | |||||
| 5. Denervation | |||||
| 6. Early rejection | |||||
| 7. Inotrpes | |||||
| Atrial flutter | Common in immediate postoperative period (>1 month) Over all frequency 7.6% (Elkaryoni et al.) |
1. AR - 28% cases
2. Remodelling of atria (late onset ) 3. Atrial suture lines - conduction barriers 4. Recipient to donor atrial conduction 5. Increased risk with bi-atrial method 6. Increased risk with older donor age |
1. Evaluate and manage the trigger
2. Persistent cases: Radiofrequency ablation | ||
| Other SVTs | Focal atrial tachycardia | Formation of depolarization foci near the atrial scar that take control of the heart rhythm. Foci can be found in donor atrium or in the atrial remnant of recipient which passes into the donor. | Focal catheter ablation | ||
| Atrial reenterant tachycardia & Nodal reenterant tachycardia | Requires a preexisting route in the donor that allows a macroreentrant. | Radiofrequency ablation (RFA) | |||
| Atrial macro-reentrant tachycardia | site of origin is mostly in the upper right atrium, around the native and donor suture line | Radiofrequency ablation (RFA) | |||
| Recipient-to-donor atrial conduction tachycardia | site of origin usually right atrial anastomosis. | Radiofrequency ablation (RFA) | |||
| Ventricular tachycardias Over all frequency 7.6% (Elkaryoni et al.) |
Non-sustained | Early post-transplat period | 1.Acute rejection
2. Graft vasculopathy
3. Severe cardiac allograft vasculopathy (in symptomatic cases) |
ICD placement (in symptomatic cases) | |
| Sustained | Early post-transplat period | 1. Acute rejection (if presenting during immediate post operative period)
2. Allopathic vasculopathy 3. LV dysfunction |
Prompt for coronary angiography and cardiac biopsy | ||
| Ventricular fibrillation | 1.1% | Transplant coronary artery disease | |||
| Bradyarrhytmia | Sick sinus syndrome (SSS) | 0.5 %
(Elkaryoni et al.) |
1. Sympathetic denervation
2. Ischemic injury to the sinus node 3. Graft ischemia or rejection 4. Drug effects |
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| Sudden cardiac arrrest | 3.7%
(Elkaryoni et al.) |
1. SSS
2. Cardiac allograft vasculopathy 3. Transplant coronary artery disease |
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| Heart Block | 0.3%
(Elkaryoni et al.) |
1. Postoperative injury
2. Progressive conduction system disease associated with coronary artery disease
3. LV dysfunction
4. Chronic rejection
5. Injury from endomyocardial biopsies. |
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- Post heart transplant Arrhythmias can be divided into tachyarrhythmias (heart rate > 100/min) and bradyarrhythmia (heart rate < 60 /min). Tachycardias are further classified based on place of origin, such as supraventricular arrhythmias originate between sinus node and the AV node, where as ventricular arrhythmias originate below the AV node at the ventricular level.
- Tachyarrhythmias
- Supraventricular tachyarrhythmias (SVT)
- Are most common POA noticed after HT.
- Overall AF is reported to be more common as compared to AFl (47.3% vs 7.6%).
- However older studies report AF (0.3 to 24%) second after AFl (2.8 to 30%)
- Atrial Fibrillation (AF)
- EKG findings: irregularly irregular rhythm, absent P waves, ventricular rate of 100-180 beats/minute, variability in QRS complexes intervals, narrow QRS complexes.
- Mechanism:
- Early postoperative period: associated with pericardial inflammation, graft manipulation, primary graft failure, allograft rejection (AR) (37.5%), and autonomic changes(such as due to denervation), ischemia, and inotropes.[1]
- Postoperative period (> 1 month): seen to be associated with allograft vasculopathy (in 21% cases), rejection (in 46% cases) or infection.[2]
- Occurrence:
- In relation to technique of heart transplantation: meta-analysis reports pooled estimated incidence of AF:[3]
- Biatrial technique: 18.7% (95%CI: 10.3%-31.5%)
- Bicaval technique: 11.1% (95%CI: 6.5%-18.4%)
- Frequency in relation to timing of onset postoperative period:
- POAF (</= 1 month): 6.2%
- POAF (> 1 month): 4%
- In relation to technique of heart transplantation: meta-analysis reports pooled estimated incidence of AF:[3]
- Supraventricular tachyarrhythmias (SVT)
Pathophysiology
Risk Factors
- Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
Treatment
Medical Therapy
- There is no treatment for [disease name]; the mainstay of therapy is supportive care.
- The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
- [Medical therapy 1] acts by [mechanism of action 1].
- Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
Surgery
- Surgery is the mainstay of therapy for [disease name].
- [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
- [Surgical procedure] can only be performed for patients with [disease stage] [disease name].
Prevention
- There are no primary preventive measures available for [disease name].
References
- ↑ Thajudeen, Anees; Stecker, Eric C.; Shehata, Michael; Patel, Jignesh; Wang, Xunzhang; McAnulty, John H.; Kobashigawa, Jon; Chugh, Sumeet S. (2012). "Arrhythmias After Heart Transplantation: Mechanisms and Management". Journal of the American Heart Association. 1 (2). doi:10.1161/JAHA.112.001461. ISSN 2047-9980.
- ↑ Boyle, Noel G; Shivkumar, Kalyanam; Vaseghi, Marmar; Taleski, Jane; Hamon, David (2014). "Arrhythmias in the Heart Transplant Patient". Arrhythmia & Electrophysiology Review. 3 (3): 149. doi:10.15420/aer.2014.3.3.149. ISSN 2050-3377.
- ↑ Chokesuwattanaskul, Ronpichai; Bathini, Tarun; Thongprayoon, Charat; Preechawat, Somchai; O'Corragain, Oisin A.; Pachariyanon, Pavida; Ungprasert, Patompong; Cheungpasitporn, Wisit (2018). "Atrial fibrillation following heart transplantation: A systematic review and meta-analysis of observational studies". Journal of Evidence-Based Medicine. 11 (4): 261–271. doi:10.1111/jebm.12323. ISSN 1756-5391.