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Arrhythmias following cardiac transplantation

Howard J Eisen, MD
Luke S Kusmirek, MD, FACC
Section Editors
Sharon A Hunt, MD
Leonard I Ganz, MD, FHRS, FACC
Deputy Editor
Susan B Yeon, MD, JD, FACC


Cardiac arrhythmias are common in the orthotopic heart transplant recipient, particularly in the early postoperative period. Premature atrial complexes and premature ventricular complexes are especially frequent, with a reported incidence of over 60 percent. Fortunately, these arrhythmias have little clinical importance. However, other cardiac arrhythmia, such as sinus node dysfunction and ventricular tachycardia, may result in significant morbidity or mortality.


There are several mechanisms for arrhythmogenesis in the transplanted heart, with early postoperative arrhythmia resulting from different mechanisms than those occurring later. Surgical trauma to the sinoatrial and atrioventricular nodes, ischemia during preservation, surgical suture lines, and, over the long term, rejection and accelerated atherosclerosis may contribute to the formation of an arrhythmogenic substrate. As an example, one autopsy study of 18 hearts found that acute rejection involved the conduction system as severely as the myocardium [1]. With chronic rejection, there was often obstructive vasculopathy of the sinus node artery.

In occasional cases, severe rejection isolated to the conduction system with sparing of the rest of the myocardium occurs and presents as bradycardia with syncope [2].

In addition, the denervated donor heart has increased sensitivity to sympathetic amines, adenosine, and acetylcholine, which may contribute to both tachyarrhythmias and bradyarrhythmias [3-5]. The sympathetic effect may be presynaptic in origin; it is not due to increased beta receptor density [3,4]. Because of this increased sensitivity, adenosine should not be used (as it often is) to slow the rate in supraventricular tachyarrhythmias to elucidate the underlying arrhythmia mechanism. Such use can result in prolonged bradycardia or a period of asystole.


In the denervated heart, the normal resting sinus rate is usually greater than 80 bpm and may exceed 100 bpm in hearts transplanted from young donors. The heart rate is higher than in normals because of the loss of vagal neural inputs, which have a negative chronotropic effect. (See "Sinus tachycardia: Evaluation and management".)

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Literature review current through: Nov 2017. | This topic last updated: Feb 02, 2017.
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