Cardiac allograft vasculopathy and donor age affecting permanent pacemaker implantation after heart transplantation

Early Pacemaker Dependency After Heart Transplantation Is Associated with Permanent Pacemaker Implantation, Graft Failure and Mortality

AIMS

Patients after heart transplantation (HTX) often experience post-transplant bradycardia, but little is known about the outcomes of early pacemaker dependency after HTX. We compared post-transplant mortality, graft failure, and the requirement for the permanent pacemaker implantation of patients with and without early pacemaker dependency after HTX.

METHODS

We screened all adult patients for early pacemaker dependency after HTX (defined as immediately after surgery) who underwent HTX at Heidelberg Heart Center between 1989 and 2022. Patients were stratified by diagnosis and type of early pacemaker dependency after HTX (sinoatrial or atrioventricular conduction disturbance).

RESULTS

A total of 127 of 699 HTX recipients (18.2%) had early pacemaker dependency after HTX, including 52 patients with sinoatrial conduction disturbances (40.9%) and 75 patients with atrioventricular conduction disturbances (59.1%). Patients with early pacemaker dependency after HTX showed both increased 1-year overall mortality after HTX (55.9% vs. 15.2%, p < 0.001) and higher mortality due to graft failure (25.2% vs. 4.2%, p < 0.001). Multivariate analysis revealed early pacemaker dependency after HTX (HR: 5.226, 95% CI: 3.738-7.304, p < 0.001) as an independent risk factor for 1-year mortality after HTX. Patients with early pacemaker dependency after HTX had a higher rate of 30-day (7.1% vs. 0.4%, p < 0.001) and 1-year (11.8% vs. 0.5%, p < 0.001) permanent pacemaker implantation after HTX compared to patients without early pacemaker dependency after HTX.

CONCLUSIONS

Patients with early pacemaker dependency after HTX had a significantly higher rate of post-transplant mortality, graft failure, and the requirement for permanent pacemaker implantation.

Impact of the operative technique on mid- and long-term results following paediatric heart transplantation

AIMS

The aim of this study is to evaluate and compare the impact of the bicaval technique versus the biatrial technique (by Lower and Shumway) in paediatric heart transplant patients. Only a few studies investigate this matter regarding the long-term outcome after paediatric heart transplantation. We compared the two surgical methods regarding survival, the necessity of pacemaker implantation.

METHODS AND RESULTS

All 134 patients (aged <18 years) - (group-1) biatrial (n = 84), versus (group-2) bicaval (n = 50), who underwent heart transplantation between October 1988 and December 2021, were analysed. Freedom from events were estimated using the Kaplan-Meier method. Potential differences were analysed using the log rank test and Cox proportional hazard models. Mean ± standard deviation: Bypass time (per minutes) was higher in the group 1 as compared with group 2 (P = 0.050). Survival was not significantly different (P = 0.604) in either groups. Eighteen patients required permanent pacemaker implantation in the group 1 and only one patient required it in the group 2 (P = 0.001).

CONCLUSIONS

Paediatric heart transplantation using bicaval technique results similar long-term survival compared with the biatrial technique. The incidence of atrial rhythm disorders was significantly higher in the biatrial group, requiring a higher frequency of pacemaker implantation in this group. As a results, the bicaval technique has replaced the biatrial technique in our centre.

Pacemaker Implantation Following Heart Transplantation - Incidence and Risk Factors. Single-Center Experience

BACKGROUND

Bradyarrhythmias, requiring pacemaker (PM) implantation, are common complications following orthotopic heart transplantation (HTx). Currently used heart transplantation methods are primarily the bicaval technique and the total heart transplantation technique. The aim of the study was to assess the incidence and risk factors, including donor parameters, of conduction disorders requiring pacing after HTx.

METHODS

A population of 111 (52 ± 13 years, 91 (82%) men) heart recipients was divided into a group requiring PM implantation post-HTx and a group not requiring PM. We compared groups in terms of donor parameters, time of graft ischemia, transport and transplantation, and surgical techniques as the potential risk factors for significant bradyarrhythmias.

RESULTS

Ten of 111 patients with HTx (9%) required PM implantation. The indication in 7 cases was sinus node dysfunction (SND), in 3 patients it was complete atrioventricular block (AV-block). In the PM group, the age of 48 ± 6 vs 40 ± 11 years (P = .0227) and the body mass index (BMI) 28 ± 3 vs 26 ± 4 kg/m2 (P = .0297) of the donor were significantly higher. There was no influence of organ transport time, ischemia time, and transplantation time. All patients requiring PM implantation were transplanted using the bicaval anastomosis: 10 (100%) vs 71 (70%) in the group not requiring PM (P = .044).

CONCLUSIONS

The need for PM implantation post-HTx despite using new techniques is still common, especially in the group operated with the bicaval method. In addition, higher donor's age and BMI are risk factors of PM implantation, what is of importance as qualification criteria of donor hearts have been gradually extended.

[Anesthesia for organ transplant patients]

Organ transplant patients who must undergo nontransplant surgical interventions can be challenging for the anesthesiologists in charge. On the one hand, it is important to carefully monitor the graft function in the perioperative period with respect to the occurrence of a possible rejection reaction. On the other hand, the ongoing immunosuppression may have to be adapted to the perioperative requirements in terms of the active substance and the route of administration, the resulting increased risk of infection and possible side effects (e.g., myelosuppression, nephrotoxicity and impairment of wound healing) must be included in the perioperative treatment concept. Furthermore, possible persistent comorbidities of the underlying disease and physiological peculiarities as a result of the organ transplantation must be taken into account. Support can be obtained from the expertise of the respective transplantation center.

Perioperative Management of Heart Transplantation: A Clinical Review

In this clinical review, the authors summarize the perioperative management of heart transplant patients with a focus on hemodynamics, immunosuppressive strategies, hemostasis and hemorrage, and the prevention and treatment of infectious complications.

Theophylline Use to Prevent Permanent Pacing in the Contemporary Era of Heart Transplantation: The Rotterdam Experience

Introduction

Sinus node dysfunction and atrioventricular conduction disorders occur increasingly after orthotopic heart transplantation (HTX) due to aging donors and may require permanent pacemaker (PM) implantation. Theophylline has been used in the past in selected cases as an alternative to PM implantation.

Purpose

The aim of this study was to investigate the rate and success of oral theophylline administration after orthotopic heart transplantation preventing permanent PM implantation.

Methods

We included all patients treated with theophylline post HTX due to bradyarrhythmia's in our center from January 1985 to January 2020. Data was obtained retrospectively through electronic patient files. Re-transplants and patients who died within 1 month post HTX were excluded from the analysis.

Results

Of the total of 751 heart transplant recipients, 73 (9,7%) patients (mean age 46 ± 15.2 years; 73% male) were treated with theophylline for bradyarrhythmia's early post HTX. Of these patients, 14 (19%) patients needed a permanent PM during hospitalization and 10(14%) patients stopped using theophylline because of adequate heart rhythm. In the end, 49 (6.5% of the total) patients were discharged with a theophylline (mean maintenance doses of 354 ± 143 mg). At the outpatient clinics, additional 6 (12%) patients needed a PM within 7 months after discharge, with the rest stable sinus rhythm.

Conclusion

In this retrospective data analyses oral theophylline remained a viable alternative to permanent PM implantations in patients post HTX with increased heart rates, facilitating the withdrawal of chronotropic support and avoiding the need of permanent PM implantation.