Management of Post-heart Transplant Atrial Fibrillation

AF is the most common atrial arrhythmia encountered after orthotopic heart transplantation, with distinct pathophysiology and clinical implications. While early postoperative AF is typically transient, late-onset AF is increasingly recognised as a marker of graft dysfunction, rejection or vasculopathy. Risk factors include advanced recipient age, prolonged ischaemic time and immunosuppressive therapy. The denervated status of the transplanted heart alters typical electrophysiology, complicating diagnosis and management. Management requires individualised strategies balancing rate versus rhythm control, careful drug interaction monitoring and thromboembolic risk assessment. Emerging evidence supports catheter ablation in select cases, although data remain limited. Immunosuppressants, particularly calcineurin inhibitors and azathioprine, may increase AF susceptibility. Given the lack of transplant-specific AF guidelines, a multidisciplinary approach is essential. Improved understanding of AF in orthotopic heart transplantation is critical to optimising graft longevity and patient survival. Future studies are needed to guide evidence-based management and surveillance.