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Long-term follow-up of heart transplant recipients requiring permanent pacemakers
C Raghavan1, J D Maloney, J Nitta
1Department of Medicine, Baylor College of Medicine, Houston, Tex, USA.
Insights
Many heart transplant patients with early sinus node dysfunction do not require permanent pacemakers. However, atrioventricular block often necessitates long-term pacing support after heart transplantation.
Area of Science:
- Cardiology
- Transplantation Medicine
- Electrophysiology
Background:
- Permanent pacemaker implantation post-heart transplantation lacks clear indications.
- Uncertainty exists regarding the necessity and timing of pacemakers in heart transplant recipients.
Purpose of the Study:
- Analyze the temporal progression of donor sinus node dysfunction and atrioventricular block.
- Identify predictors of persistent pacing needs.
- Evaluate pacemaker complication rates post-transplantation.
Main Methods:
- Retrospective analysis of 22 pacemaker implantations in 286 heart transplantations.
- Data collected between February 1984 and April 1994.
- Key parameters analyzed included donor/recipient age, ischemic time, heart rate, and rejection episodes.
Main Results:
- 19 patients received early pacemakers (mean 24 days) primarily for sinus node dysfunction; 13/19 became pacer-independent by 3 months.
- Two patients received late pacemakers for symptomatic complete heart block (3 and 47 months).
- Donor/recipient age, ischemic time, and rejection episodes did not correlate with long-term pacing needs.
Conclusions:
- Many early cases of sinus node dysfunction resolve, negating the need for permanent pacing.
- Atrioventricular block identified early post-transplantation typically requires long-term pacing.
- Prospective trials are needed to define optimal pacing strategies and benefits in heart transplant recipients.
Background:
Permanent pacemaker implantation after heart transplantation is contentious. Indications for these devices in this population are uncertain. The goals of this project were to (1) analyze the time course of donor sinus node dysfunction and atrioventricular block after heart transplantation; (2) evaluate which selected parameters (donor age, ischemic time, heart rate before pacer insertion, and number of rejection episodes) might relate to persistent permanent pacing need, and (3) assess pacemaker complications during follow-up.
Methods:
A retrospective analysis of pacemaker implantations (22 cases) was performed in 286 consecutive heart transplantations performed between February 1984 and April 1994 at The Methodist Hospital and Baylor College of Medicine, Houston, Texas.
Results:
Permanent pacemakers were inserted early after transplantation in 19 patients (mean 24 days); 14 pacemakers were for sinus node dysfunction (bradycardia in five, sinus arrest with junctional escape in eight, and optimization of hemodynamics in one). Symptomatic complete heart block prompted insertion late in two patients (3 and 47 months), and symptomatic sinus pause was the indication for late insertion in one. Recipient mean age was 52.4 years, with mean donor age 29.7 years in patients with pacemakers. By 3 months, 13 of 19 patients receiving pacemakers early (mean preinsertion heart rate 58.3 beats/min) became pacer independent with subsequent mean intrinsic heart rate of 97 beats/min. Recipient or donor age, ischemic time, and rejection episodes did not appear related to long-term pacing need early or late after transplantation.
Conclusions:
Inferences from these observations include the fact that many patients with early sinus node dysfunction and bradycardia are not pacer dependent at 3 months. However, those with atrioventricular block early appear to require long-term pacing support. However, the possibility that more aggressive and long-term oral chronotropic medication use after transplantation would obviate early permanent pacemaker need is not addressed. Finally, prospective clinical trials are necessary to precisely characterize benefit of permanent pacemakers and define optimal pacing modes after heart transplantation.