Incidence, Risk Factors, Prognosis, and Electrophysiological Mechanisms of Atrial Arrhythmias After Lung Transplantation

Abstract

Objective To investigate incidence and timing, risk factors, prognostic significance, and electrophysiological mechanisms of atrial arrhythmia (AA) after lung transplantation. Background Although new-onset AA is common after thoracic surgery and is associated with poorer outcomes, prognostic and mechanistic data is sparse in lung transplant populations. Method A total of 293 consecutive isolated lung transplant recipients without known AA were retrospectively reviewed. Mean follow-up was 28±17 months. Electrophysiology studies (EPS) were performed in 25 patients with AA. Results The highest incidence of new-onset AA after lung transplantation occurred within 30 days postoperative AA, (25 % of all patients). In multivariable analysis, postoperative AA was associated with double lung transplantation (OR 2.79; p=0.005) and lower mean pulmonary artery pressure (OR 0.95; p=0.027). Patients with postoperative AA had longer hospital stays (21 days vs 12 days; p<0.001). Postoperative AA was independently associated with late AA (HR 13.52; p<0.001) but not mortality (HR 1.55; p=0.14). In EPS, there were 14 patients with atrial flutter alone and 11 with atrial flutter and fibrillation. Of all EPS patients, 20 (80%) had multiple AA mechanisms, including peritricuspid flutter (48%), perimitral flutter (36%), right atrial incisional reentry (24%), focal tachycardia from recipient pulmonary vein (PV) antrum (32 %), focal PV fibrillation (24%), and left atrial roof flutter (20%). Left atrial mechanisms were present in 80% (20/25) of EPS patients and originated from the anastomotic PV antrum. Conclusions Postoperative AA was independently associated with longer length of stay and late AA but not mortality. Pleomorphic PV antral arrhythmogenesis from native PV antrum is the main cause of AA after lung transplantation.

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

“…The PRISMA flow diagram detailing the disposition of retrieved publications is shown in Figure . Nine studies were included in our final analysis, yielding a total of 2653 patients (Table ). Of these, 791 had postoperative AAs, giving an overall incidence of 29.8%.…”

“…The peak onset of AAs after lung transplant varied from 2 to 7 days. Of note, five studies grouped atrial fibrillation and atrial flutter together, with a combined incidence of 31.8% (487/1532). Four studies divided AAs into atrial fibrillation (AF) and atrial flutter/supraventricular tachycardia (AFL/SVT) and found a total incidence of AAs of 27.1% (304/1121), of which 89.1% (271/304) were AF.…”

“…Outcomes associated with postoperative AAs after lung transplantation, however, are not as well characterized. While many authors have found an effect on postoperative LOS, there are conflicting reports of the impact of postoperative AAs on complications and mortality . Furthermore, these studies span more than 20 years of lung transplantation and were often underpowered to detect a difference in mortality or complications.…”

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

“…Lung transplantation (LT) has been performed increasingly over the past 2 decades [1,2]. Atrial arrhythmias (AA), including atrial fibrillation (AF), atrial flutter (AFL), and atrial tachycardia (AT), are highly prevalent complications after LT, with a reported incidence ranging from 25% to 45% depending on their definition and methods of detection [3][4][5][6][7][8][9]. At present, there is inconsistent evidence supporting the association between mortality after LT and postoperative AA [3,6,10,11].…”

Editorial commentary: What can lung transplantation teach us about the mechanisms of atrial arrhythmias?

“…An interesting subset of lung transplant patients may have atrial tachycardias using donor-to-recipient conduction across an anastomotic line. This has been supported by 2 case reports [3,15] but disputed by some studies including a series of 25 patients in whom electrophysiological mapping showed that all PV antral arrhythmias arose from recipient not donor myocardium [16]. …”