Long-term atrial arrhythmias incidence after heart transplantation

https://doi.org/10.1016/j.ijcard.2020.04.019Get rights and content

Highlights

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    Heart transplantation creates electrical barriers, similar to surgical AF ablation.

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    Heart transplantation carriers may experience non-AF paroxysmal atrial arrhythmias.

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    Persistent AF in heart transplantation carriers is extremely rare.

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    Complete electrical left atrial posterior wall isolation prevents persistent AF.

Abstract

Objectives

Atrial arrhythmias after heart transplantation have rarely been investigated. The aim of this study is to assess incidence, type and predictors of atrial arrhythmias during a long-term follow-up in a large population of heart-transplanted patients.

Methods

Consecutive patients undergone to heart transplantation at our Centre from 1990 to 2017 were enrolled. All documented atrial arrhythmias were systematically reviewed during a long-term follow-up after heart transplantation. Atrial fibrillation (AF), atrial flutter and tachycardias were defined according to current guidelines.

Results

Overall, 364 patients were included and followed for 120 ± 70 months. During the follow-up period 108 (29.7%) patients died and 3 (0.8%) underwent re-transplantation. Sinus rhythm was present in 355 (97.5%) patients. Nine patients had persistent atrial arrhythmias: 8 (2.2%) presented atypical flutter and one (0.3%) patient AF. Paroxysmal sustained arrhythmias were detected in 42 (11.5%) patients, always atrial flutters. At univariate analysis several echocardiographic (left ventricular end-diastolic diameter, TEI index, mitral and tricuspid regurgitation grade) hemodynamic (systolic and diastolic pulmonary pressure, capillary wedge pressure) and clinical (dyslipidaemia, weight, pacemaker implantation) parameters related to higher incidence of atrial arrhythmias.

Conclusion

Persistent atrial arrhythmias, and most of all AF, are rare among heart transplantation carriers, despite substantial comorbidities resulting in significant mortality. It can be speculated that the lesion set provided by the surgical technique, a complete and transmural electrical isolation of the posterior left atrium wall, represents an effective lesion set to prevent persistent AF.

Introduction

Heart transplantation is considered the standard treatment for selected cases of advanced end-stage heart failure [1]. The surgical technique, originally described by Lower and Shumway is characterized by the surgical incision on the posterior wall of both left and right atria, resulting in a final suture combining the LA posterior wall and the sinus of venae cavae of the recipient with the atrial cuffs of the graft [2]. To date, little has been reported concerning incidence and predictors of atrial arrhythmias in the long-term of patients after heart transplantation.

On top of this, the treatment of persistent atrial fibrillation (AF) in the general population is affected by poor outcome; indeed, not as good as for paroxysmal AF [3]. The standard catheter ablation (CA) approach of pulmonary vein isolation alone achieves poor results in patients with persistent AF, and additional substrate modification is often required to obtain satisfactory results. In fact, an ideal ablation set for persistent AF has not been established. Linear lesions in the left atrium (LA), resembling surgical maze procedure [4,5], and the ablation of complex fractioned atrial electrograms [6] or rotors [7] have been proposed, with promising but sometimes contrasting results.

In this setting, the “cut and sew” performed during heart transplantation results in a complete electrical isolation of the recipient's posterior LA wall, pulmonary veins and venae cavae from the rest of the atria. This technique may therefore represent an in vivo, indirect model of a truly transmural lesion isolating the posterior wall and the venae cavae.

The present observational, retrospective study on a large population of heart transplantation recipients aims to assess incidence, type and predictors of atrial arrhythmias during a long-term follow-up, in order to provide additional knowledge concerning the ideal atrial surgical lesion set to treat persistent AF in the general population.

Section snippets

Study design

Consecutive patients undergone to heart transplantation at the Cardiac Surgery Division, “Città della Salute e della Scienza” Hospital, University of Turin, Italy, from 1990 to 2017, were retrospectively included. Inclusion criteria were: age over 18 years old, and orthotopic heart transplantation due to any underlying disease. Exclusion criteria were: death within the first month after transplant, and follow-up shorter than 6 months. The retrospective registry protocol was approved by the

Results

Overall, 364 patients undergoing heart transplantation at our Centre between 1990 and 2017 were enrolled. Among them 288 (79%) were males, and mean age at the time of transplant was 50.9 ± 13 years. All patients underwent heart transplantation with biatrial technique, apart from one patient suffering from a congenital heart disease that contra-indicated this technique and underwent bicaval technique. Three (0.8%) underwent a second heart transplant for severe primary graft dysfunction of the

Discussion

The aim of the present study was to assess long-term incidence of atrial arrhythmias and in particular of AF in a large population of heart transplanted patients. The main findings are:

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    a limited number of patients (2.2%) suffered from persistent incisional atypical flutter, as a consequence of surgical scars in the atria, while 11.5% patients suffered from paroxysmal episodes of atrial flutter;

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    persistent AF is extremely rare (one case); the presence of relevant comorbidities (justifying high

Limitations

First, the aim of this study was to assess long-term incidence of atrial arrhythmias in patients undergone heart transplantation. In our analysis the patients who died within the first month after transplant were excluded, aiming to exclude perioperative mortality. This may represent a selection bias excluding the most fragile ones. Although comorbidities were quite common also in the analysed cohort of patients, the sickest patients may have been excluded. Second, the retrospective design of

Conclusion

Persistent atrial arrhythmias are rare among heart transplanted patients, despite significant LA enlargement and comorbidities resulting in significant morbidity and mortality. In particular, persistent AF is extremely rare, likely relating to the surgical biatrial technique, resulting in electrical isolation of the entire posterior LA wall and caval veins sinus. Atrial anastomosis represents an in vivo model of complete and transmural atrial compartmentalization, and our findings support the

Funding source

None.

CRediT authorship contribution statement

Matteo Anselmino: Conceptualization, Methodology, Writing - review & editing. Mario Matta: Data curation, Investigation, Writing - original draft. Andrea Saglietto: Data curation, Formal analysis, Investigation. Chiara Gallo: Data curation, Investigation. Fiorenzo Gaita: Supervision. Giovanni Marchetto: Writing - original draft. Mauro Rinaldi: Supervision, Writing - review & editing. Gaetano Maria De Ferrari: Supervision. Massimo Boffini: Conceptualization, Methodology, Writing - review &

Declaration of competing interest

The authors have no potential conflicts of interest to disclose.

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