Atrial arrhythmias after lung transplantation: Incidence and risk factors in 652 lung transplant recipients

Practicality and Safety of Electrical Pulmonary Vein Isolation and Left Atrial Appendage Ligation in Lung Transplant Recipients With Pretransplant Atrial Fibrillation

Background

Lung transplant surgery creates surgical pulmonary vein isolation (PVI) as a routine part of the procedure. However, many patients with pretransplant atrial fibrillation continue to have atrial fibrillation at 1 y. We hypothesized that the addition of electrical PVI and left atrial appendage isolation/ligation (LAL) to the lung transplant procedure restores sinus rhythm at 1 y in patients with pretransplant atrial fibrillation.

Methods

We retrospectively reviewed all adult lung transplant recipients at the University of California Los Angeles from April 2006 to August 2021. All patients with pretransplant atrial fibrillation underwent concomitant PVI/LAL and were compared with lung transplant recipients without preoperative atrial fibrillation. In-hospital outcomes; 1-y survival; and the incidence of stroke, cardiac readmissions, repeat ablations, and sinus rhythm (composite endpoint) were examined at 1 y for the PVI/LAL cohort.

Results

Sixty-one lung transplant recipients with pretransplant atrial fibrillation underwent concomitant PVI/LAL. No patient in the PVI/LAL cohort required cardiac-related readmission or catheter ablation for atrial fibrillation within 1 y of transplantation. Freedom from the composite endpoint of death, stroke, cardiac readmission, and repeat ablation for atrial fibrillation at 1 y was 85% (95% confidence interval, 73%-92%) for lung transplant recipients treated with PVI/LAL.

Conclusions

The addition of PVI/LAI to the lung transplant operation in patients with pretransplant atrial fibrillation was safe and effective in maintaining sinus rhythm and baseline risk of stroke at 1 y.

Observational Study of the Association between Atrial Fibrillation and In-Hospital Mortality during Hospitalization for Solid Organ Transplants in Spain from 2004 to 2021

(1) Background: We analyzed the association between atrial fibrillation or atrial flutter (AF) and in-hospital mortality (IHM) among patients who underwent solid organ transplants in Spain from 2004 to 2021. (2) Methods: We gathered information from all hospital admissions for lung, liver, kidney, and heart transplants. (3) Results: A total of 71,827 transplants were analyzed (4598 lung transplants; 18,127 liver transplants; 45,262 kidney transplants; and 4734 heart transplants). One third of these were for women. Overall, the prevalence of AF was 6.8% and increased from 5.3% in 2004-2009 to 8.6% in 2016-2021. The highest prevalence of AF was found for heart transplants (24.0%), followed by lung transplants (14.7%). The rates for kidney and liver transplants were 5.3% and 4.1%, respectively. The AF code increased over time for all of the transplants analyzed (p < 0.001). The patients' IHM decreased significantly from 2004-2009 to 2016-2021 for all types of transplants. AF was associated with a higher IHM for all of the types of transplants analyzed, except for heart transplants. (4) Conclusions: The prevalence of AF among patients admitted for solid organ transplants was highest for those who underwent heart transplants. The mortality rate during the patients' admission for lung, liver, kidney, or heart transplants decreased over time. AF was independently associated with a higher risk of dying in the hospital for those who underwent lung, liver, or kidney transplants.

Management of Atrial Arrhythmias After Lung Transplant

The overall survival in patients undergoing lung transplantation is poor. Although postsurgical atrial arrhythmias seem to play a major role in the morbidity and mortality of this population, data regarding the clinical and interventional management of this complication are still controversial. Through a review of the literature in the field, we observed that not only the surgical technique is clearly arrhythmogenic, but the new administration of peri-procedure beta-blockers and amiodarone for arrhythmia prevention and treatment, respectively, seems harmful in these postsurgical patients. However, low-dose beta-blockers administered after surgery seem feasible in arrhythmia prevention in specific patient subgroups, and, aside from amiodarone, alternative antiarrhythmic agents can be safely and effectively used to treat symptomatic patients on top of adequate rate control. Finally, as to complex atrial arrhythmias occurring late after lung transplant surgery, radiofrequency catheter ablation seems a feasible treatment option. In light of this evidence and considering the absence of clear recommendations in the field, we suggest a practical approach that may help the clinician in the management of this postsurgical complication. However, as most of these considerations are drawn from small-sized and retrospective studies, more evidence is needed in the future to clarify which medical and interventional strategies may best treat these postsurgical arrhythmias and thus potentially improve the outcome of these frail patients.

Atrial arrhythmias following lung transplant: a single pediatric center experience

Background

Outcomes after lung transplant (LTx) in children have slowly improved. Although atrial arrhythmia (AA) is a common and adverse complication following LTx among adults, there is limited data on pediatric recipients. We detail our pediatric single-center experience while providing further insights on occurrence and management of AA following LTx.

Methods

A retrospective analysis of LTx recipients at a pediatric LTx program from 2014 to 2022 was performed. We investigated timing of occurrence and management of AA following LTx, and its effect on post-LTx outcome.

Results

Three out of nineteen (15%) pediatric LTx recipients developed AA. The timing of occurrence was 9-10 days following LTx. Those patients in the older age group (age >12 years old) were the only ones who developed AA. Developing AA did not have a negative effect on hospital stay duration or short-term mortality. All LTx recipients with AA were discharged home on therapy that was discontinued at 6 months for those who was on mono-therapy without recurrence of AA.

Conclusions

AA is an early post-operative complication in older children and younger adults undergoing LTx at a pediatric center. Early recognition and aggressive management can mitigate any morbidity or mortality. Future investigations should explore factors that place this population at risk for AA in order to prevent this complication post-operatively.

Listing Dilemmas: Age, Frailty, Weight, Preexisting Cancers, and Systemic Diseases

Selection of lung transplant candidates is an evolving field that pushes the boundaries of what is considered the norm. Given the continually changing demographics of the typical lung transplant recipient as well as the growing list of risk factors that predispose patients to poor posttransplant outcomes, we explore the dilemmas in lung transplant candidate selections pertaining to older age, frailty, low and high body mass index, preexisting cancers, and systemic autoimmune rheumatic diseases.

Postoperative management of children after lung transplantation

Pediatric lung transplantation is a highly specialized treatment option at a select few hospitals caring for children. Advancements in surgical and medical approaches in the care of these children have improved their care with only minimal improvement in outcomes which remain the lowest of all solid organ transplants. A crucial time period in the management of these children is in the perioperative period after performance of the lung transplant. Supporting allograft function, preventing infection, maintaining fluid balance, achieving pain control, and providing optimal respiratory support are all key factors required for this highly complex pediatric patient population. We review commonly encountered complications that these patients often experience and provide strategies for management.

Factors affecting complications development and mortality after single lung transplant

Lung transplantation (LT) is a life-saving therapeutic procedure that prolongs survival in patients with end-stage lung disease. Furthermore, as a therapeutic option for high-risk candidates, single LT (SLT) can be feasible because the immediate morbidity and mortality after transplantation are lower compared to sequential single (double) LT (SSLTx). Still, the long-term overall survival is, in general, better for SSLTx. Despite the great success over the years, the early post-SLT period remains a perilous time for these patients. Patients who undergo SLT are predisposed to evolving early or late postoperative complications. This review emphasizes factors leading to post-SLT complications in the early and late periods including primary graft dysfunction and chronic lung allograft dysfunction, native lung complications, anastomosis complications, infections, cardiovascular, gastrointestinal, renal, and metabolite complications, and their association with morbidity and mortality in these patients. Furthermore, we discuss the incidence of malignancy after SLT and their correlation with immunosuppression therapy.

Cardiovascular complications in cystic fibrosis: A review of the literature

Cystic fibrosis is a genetic disease caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, leading to dysfunction of the CFTR protein. CFTR dysfunction leads to disease in the respiratory and gastrointestinal systems. Disorders of the cardiovascular system in individuals with CF are usually attributed to secondary effects from progressive lung disease. However, CFTR has been localized to vascular endothelium and smooth muscle, suggesting that CFTR dysfunction may directly impact cardiovascular function. As treatments for CF improve and life-expectancy increases, the risk of vascular disease may increase in prevalence related to primary and secondary CFTR dysfunction, chronic systemic inflammation, nutritional health and hyperglycemia in individuals with CF related diabetes. Here we review the available literature on CF and the cardiovascular system, examining the secondary effects and evidence for direct CFTR dysfunction in the heart, aorta, pulmonary vessels, and vasculature, as well as future directions and treatment options.

Need for anticoagulation and use of direct oral anticoagulants in lung transplant recipients

Limited information is available about use of direct oral anticoagulants (DOACs) in lung transplant recipients (LTRs). The purpose of this study is to describe the indications and use of long-term anticoagulation, including the safety and tolerability of DOACs, in LTRs. This was a single-center retrospective study. LTRs who received therapeutic anticoagulation were identified. Patient characteristics, indications for treatment, and complications of therapy were obtained. A total of 203 patients underwent lung transplantation of which 118 patients (58.1%) had an indication for anticoagulation. Patients with an indication for anticoagulation were older than those without (59 ± 14 years versus 48 ± 17 years, p < 0.001) and were more likely to be male (72.0% versus 50.6%, p = 0.002). Of the patients with indication for anticoagulation, 74 (62.7%) received it. Fifty-one (68.9%) of patients receiving anticoagulation were treated with DOACs. In the patients receiving anticoagulation, there were 14 major bleeding events in 13 patients, of which 3 were receiving DOACs and the remainder were receiving heparin or warfarin. The need for anticoagulation is common in LTRs for both atrial arrhythmias and venous thromboembolism. However, many patients with atrial arrhythmias do not receive anticoagulation. The use of DOACs is well tolerated and safe in LTRs.

The Utility of the Sit-to-Stand Test for Inpatients in the Acute Hospital Setting After Lung Transplantation

OBJECTIVE

Measurement of physical function is important to guide physical therapy for patients post-lung transplantation (LTx). The Sit-to-Stand (STS) test has proven utility in chronic disease, but psychometric properties post-LTx are unknown. The study aimed to assess reliability, validity, responsiveness, and feasibility of the 60-second STS post-LTx.

METHODS

This was a measurement study in 62 inpatients post-LTx (31 acute postoperative; 31 medical readmissions). Interrater reliability was assessed with 2 STS tests undertaken by different assessors at baseline. Known group validity was assessed by comparing STS repetitions in postoperative and medical groups. Content validity was assessed using comparisons to knee extensor and grip strength, measured with hand-held dynamometry. Criterion validity was assessed by comparison of STS repetitions and 6-minute walk distance postoperatively. Responsiveness was assessed using effect sizes over inpatient admission.

RESULTS

Median (interquartile range) age was 62 (56-67) years; time post-LTx was 5 (5-7) days postoperative and 696 (244-1849) days for medical readmissions. Interrater reliability was excellent (intraclass correlation coefficient type 2,1 = 0.96), with a mean learning effect of 2 repetitions. Repetitions were greater for medical at baseline (mean 18 vs 8). More STS repetitions were associated with greater knee extensor strength (postoperative r = 0.57; medical r = 0.47) and 6-minute walk distance (postoperative r = 0.68). Effect sizes were 0.94 and 0.09, with a floor effect of 23% and 3% at baseline (postoperative/medical) improving to 10% at discharge. Patients incapable of attempting a STS test were excluded, reducing generalizability to critical care. Physical rehabilitation was not standardized, possibly reducing responsiveness.

CONCLUSIONS

The 60-second STS demonstrated excellent interrater reliability and moderate validity and was responsive to change postoperatively.

IMPACT

The 60-second STS represents a safe, feasible functional performance tool for inpatients post-LTx. Two tests should be completed at each time point.

Clinical significance of postoperative atrial arrhythmias in patients who underwent lung transplantation

BACKGROUND/AIMS

Atrial arrhythmia (AA) occasionally occurs after lung transplantation (LT); however, risk factors for AA and their impact on clinical outcomes are inconsistent. We aimed to investigate the incidence, predisposing factors, and clinical outcomes of AA after LT.

METHODS

We retrospectively evaluated 153 consecutive patients who underwent LT between January 2010 and August 2016. An AA episode was defined as a documented atrial fibrillation (AF), atrial flutter, or atrial tachycardia on 12-lead electrocardiography or episodes lasting ≥ 30 seconds on telemetry monitoring.

RESULTS

The mean follow-up time was 22.0 ± 19.1 months. Postoperative AA occurred in 46 patients (30.1%) after LT. Patients with postoperative AA were older, had larger body surface area, and had an increased incidence of paroxysmal AF prior to transplantation, idiopathic pulmonary fibrosis, and postoperative tracheostomy than patients without AA. Preoperative right atrial pressure (RAP) (odds ratio [OR], 1.19; p = 0.005) and longer periods of mechanical ventilation (OR, 1.03; p = 0.008) were found to be independent risk factors for AA after surgery. Development of AA was a significant predictor of long-term overall mortality (hazard ratio, 2.75; p = 0.017).

CONCLUSION

Patients with elevated preoperative RAP and long-term ventilator care had a higher risk of AA after LT. Further, AA after LT was associated with poor long-term survival.

Postoperative management of lung transplant recipients

Despite advances in surgical technique, lung transplantation is associated with worse survival when compared with other solid organ transplantations. Graft dysfunction and infection are the leading causes of mortality in the first 30 days following transplantation. Primary graft dysfunction (PGD) is a form of reperfusion injury that occurs early after transplantation. Management of PGD is mainly supportive with use of lung protective ventilation. Inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation may be used in severe cases. Bacterial pneumonias are the most common infectious complication in the immediate post transplant period, but invasive fungal infections may also occur. Other potential complications in the postoperative period include atrial arrhythmias and neurologic complications such as stroke. There is a lack of multicenter, randomized trials to guide ventilation strategies, infection prophylaxis, and treatment of atrial arrhythmias, therefore prevention and management of post-transplant complications vary by transplant center.

Patent foramen ovale repair at the time of double lung transplantation: Necessary or not?

INTRODUCTION

Patient foramen ovale (PFO) is a common and often incidental intraoperative finding during lung transplantation (LTx). We sought to characterize the potential outcomes related to the decision making of whether the PFO was repaired or left unrepaired.

METHODS

We retrospectively evaluated bilateral LTx recipients between 2005 and 2015 from our prospective database. Incidence of postoperative stoke, 90-day mortality, and overall survival was compared between the PFO-positive and PFO-negative groups, and secondly compared between repaired PFO (rPFO) and non-repaired PFO (nrPFO) groups.

RESULTS

A total of 831 LTx recipients were analyzed: 185 PFO-positive (140 nrPFO, 45 rPFO) and 646 PFO-negative. Study groups were similar with regard to age and comorbidity. The presence of PFO was not associated with a difference in postoperative stroke (P = .89) or 90-day mortality (P = .64). In patients with PFO, intraoperative repair resulted in a lower, but non-significant rate of stroke (0% vs 5%; P = .20) and no difference in mortality (P = .26). As expected, PFO and PFO repair were both associated with a higher incidence of cardiopulmonary bypass utilization, but no difference in pump-related complications.

CONCLUSIONS

The protective effect of PFO repair remains unclear. However, it is not associated with an increased incidence of stroke or postoperative mortality following LTx.

Atrial arrhythmias after lung transplantation

Atrial arrhythmias are a common complication after lung transplant (LT), occurring in about 16-46% of LT patients early postoperatively, and in about 14% during longer-term follow-up. They have a significant impact on postoperative in-hospital length of stay and may have an impact on overall mortality. In this report, we review the incidence and risk factors of post lung transplant AA, their pathogenesis and their impact on short- and long-term outcomes. Pharmacological management options are reviewed. In brief, early atrial arrhythmias tend to be mostly atrial fibrillation and are treated acutely with a rate control strategy followed if needed by rhythm control for 4-6 weeks. Late atrial arrhythmias >6 months after LT tend to be more frequently organized atrial flutters amenable to ablation therapy. Long-term anticoagulation is controversial especially in patients with bilateral lung transplant who received surgical pulmonic vein isolation, however anticoagulation is still favored especially in single LT patients. More studies are needed to further document the pathophysiology of early versus late atrial arrhythmias and whether long-term anticoagulation is needed.

Adverse outcomes associated with postoperative atrial arrhythmias after lung transplantation: A meta-analysis and systematic review of the literature

BACKGROUND

Postoperative atrial arrhythmias (AAs) are common after lung transplantation, but studies are mixed regarding their impact on outcomes. We therefore performed this systematic review and meta-analysis to determine whether AAs after lung transplantation impede postoperative recovery.

METHODS

MEDLINE, EMBASE, CINAHL, and the Cochrane Register were searched to identify studies comparing outcomes in adult patients undergoing lung transplantation who experienced postoperative AAs in the immediate postoperative period vs those without postoperative AAs. Our primary outcome was perioperative mortality, and secondary outcomes were length of stay (LOS), postoperative complications, and mid-term (1-6 years) mortality.

RESULTS

Nine studies including 2653 patients were included in this analysis. Of this group, 791 (29.8%) had postoperative AAs. Patients with postoperative AAs had significantly higher perioperative (OR 2.70 [95% CI: 1.73-4.19], P<.0001) mortality, longer hospital LOS (MD 8.29 [95% CI: 4.37-12.21] days, P<.0001), more frequent requirement for tracheostomy (OR 4.67 [95% CI: 2.59-8.44], P<.0001), and higher mid-term mortality (OR 1.71 [95% CI: 1.28-2.30], P=.0003).

CONCLUSIONS

AAs after lung transplantation are frequent and associated with significantly higher mortality, longer hospital LOS, and requirement for tracheostomy. Given their impact on recovery, prophylactic strategies against AAs need to be developed.

Noteworthy Literature Published in 2016 for Thoracic Organ Transplantation Anesthesiologists

This article is first in the series to review the published literature on perioperative issues in patients undergoing thoracic solid organ transplantations. We present recent literature from 2016 on preoperative considerations, organ preservation, intraoperative anesthesia management, surgical techniques, postoperative complications, and the impact of perioperative management on short- and long-term outcomes that are pertinent to thoracic transplantation anesthesiologists.

Incidence, Predictors, and Outcomes of Early Atrial Arrhythmias After Lung Transplant: A Systematic Review and Meta-Analysis

OBJECTIVES

This study sought to determine the incidence, predictors, and prognostic implications of early post-lung transplant atrial arrhythmias (AAs).

BACKGROUND

Although frequently encountered, the prognostic implications of early AAs after lung transplant remain uncertain.

METHODS

A systematic review of MEDLINE and the Cochrane Library was conducted for all studies that reported early post-lung transplant AAs. Random-effects DerSimonian-Laird risk ratios (RRs) were calculated for categorical variables and standardized mean difference (SMD) for continuous variables.

RESULTS

A total of 12 studies with 3,203 patients (mean age 57 ± 3 years; 52% males) were included. The incidence of early post-lung transplant AAs during hospitalization was 26.6% at mean follow-up duration of 6.7 days. Predictors of post-lung transplant AAs included advanced age (SMD: 0.50; 95% confidence interval [CI]: 0.35 to 0.64), male gender (RR: 1.37; 95% CI: 1.28 to 1.47), history of smoking (RR: 1.23; 95% CI: 1.05 to 1.46), hypertension (RR: 1.35; 95% CI: 1.13 to 1.59), hyperlipidemia (RR: 1.39; 95% CI: 1.18 to 1.63), coronary artery disease (RR: 1.40; 95% CI: 1.12 to 1.7), left atrial diameter (SMD: 0.25; 95% CI: 0.07 to 0.44), and restrictive lung disease (RR: 1.34; 95% CI: 1.13 to 1.59). Post-lung transplant AAs were associated with increased all-cause mortality (adjusted RR: 1.63; 95% CI: 1.22 to 2.19) at mean follow-up of 27.8 months and length of hospital stay (36.5 ± 16.5 days vs. 26.1 ± 14.3 days; p < 0.001).

CONCLUSIONS

Early AAs post-lung transplant are associated with increased mortality and length of hospital stay. Advanced age, male sex, smoking, hypertension, hyperlipidemia, coronary artery disease, increased left atrial diameter, and restrictive lung disease are independent predictors of early AAs in post-lung transplant patients.