Atrial fibrillation after cardiac transplantation: experience in 498 consecutive cases

Some contemporary surgical treatments for atrial fibrillation involve creating only a subset of the lesions made in the classic Cox Maze procedure. This subset often consists of pulmonary vein isolation and partial cardiac denervation. Orthotopic heart transplantation, by necessity, results in pulmonary vein isolation, albeit with total cardiac denervation. Although postoperative atrial fibrillation (POAF) and atrial fibrillation may differ in cause, they have similar underlying mechanisms and often respond to the same treatments. Therefore, we reviewed the incidence of POAF in heart transplant recipients to assess the antiarrhythmic effects of pulmonary vein isolation and cardiac denervation.

We reviewed the charts of 498 consecutive patients who underwent orthotopic heart transplantation at a single institution during a 15-year period.

Twenty-seven patients (5.4%) experienced POAF within 60 days of transplant. In 9 of these patients, POAF occurred within 2 weeks of a biopsy-proven transient rejection episode; excluding these patients from the analysis revealed a non-rejection-associated POAF rate of 18 of 489 patients (3.7%).

Despite the long ischemic times, extensive manipulation of the transplanted heart, and the postoperative administration of proarrhythmic inotropic agents that cardiac transplantation typically involves, this procedure is associated with a low incidence of POAF, particularly if patients in whom rejection and POAF were temporally related are excluded. These findings suggest that complete cardiac denervation and pulmonary vein isolation protect heart transplant recipients from POAF, thus supporting the notion that similar lesions may be useful in the treatment of other types of atrial fibrillation.