The Rogue P-wave: Atrial Dissociation Following Bicaval Heart Transplantation

Abstract

We report the first case, to our knowledge, of atrial dissociation in a patient who underwent bicaval orthotopic heart transplantation. It was believed that atrioventricular dissociation prompting pacemaker implantation likely represented donor sinus bradycardia/arrest with intact atrioventricular conduction with surgically isolated recipient atrial activity.

Double heart after heart transplantation

“…This phenomenon, also known as a complete pseudo-atrioventricular block, occasionally occurs due to residual recipient atrial tissue after undergoing transplantation. 1 …”

“…The incidence of atrial arrhythmias after orthotropic heart transplantation is reportedly 5–25% and that of bradyarrhythmias is up to 25%, with a majority being sinus node dysfunction. 1 , 3 Tachyarrhythmia and bradycardia are more common after biatrial anastomosis than after the more widely used bicaval technique; the biatrial technique anastomoses the donor and recipient atria resulting in a dual P -wave phenomenon owing to the coexistent, electrically isolated donor and recipient sinus nodes. However, arrhythmic complications, including a complete pseudo-atrioventricular block, can occur even with the bicaval anastamosis technique.…”

First reported dual-chamber leadless pacemaker in a patient with orthotopic heart transplant

“… 1 , 3 , 5 Early postoperative sinus node dysfunction can be related to cardiac denervation or autonomic dysfunction, surgical injury to the sinus node, sinus node ischemia, or acute rejection. 1 , 4 , 6 , 7 Notably, the rate of early sinus node dysfunction and the need for permanent pacemaker post-OHT has significantly decreased with the use of bicaval anastomosis compared with biatrial anastomosis. 1 , 4 , 7 Indications for permanent pacing in the later postoperative phase (>30 days post-OHT) include late sinus node dysfunction and high-grade atrioventricular block related to coronary allograft vasculopathy with nodal ischemia and chronic graft rejection.…”

“… 1 , 4 , 6 , 7 Notably, the rate of early sinus node dysfunction and the need for permanent pacemaker post-OHT has significantly decreased with the use of bicaval anastomosis compared with biatrial anastomosis. 1 , 4 , 7 Indications for permanent pacing in the later postoperative phase (>30 days post-OHT) include late sinus node dysfunction and high-grade atrioventricular block related to coronary allograft vasculopathy with nodal ischemia and chronic graft rejection. 1 , 4 , 6 Owing to the high infection risk in this immunosuppressed population, leadless pacemakers are emerging as a safe and effective alternative to conventional transvenous pacemakers in heart transplant recipients.…”