A Silent Arrhythmia How Would You Manage This Patient?

HomeCirculationVol. 143, No. 22A Silent Arrhythmia: How Would You Manage This Patient? Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessCase ReportPDF/EPUBA Silent Arrhythmia: How Would You Manage This Patient? Jacinthe Boulet, MD CM, Emmanuelle Massie, MD and Mark Liszkowski, MD Jacinthe BouletJacinthe Boulet https://orcid.org/0000-0003-1782-9213 Department of Medicine, Division of Cardiology, Montreal Heart Institute, Canada. *J. Boulet and E. Massie contributed equally. Search for more papers by this author , Emmanuelle MassieEmmanuelle Massie Department of Medicine, Division of Cardiology, Montreal Heart Institute, Canada. *J. Boulet and E. Massie contributed equally. Search for more papers by this author and Mark LiszkowskiMark Liszkowski Correspondence to: Mark Liszkowski, MD, 5000 Rue Belanger, Montreal, Quebec City, Canada H1T 1C8. Email E-mail Address: [email protected] https://orcid.org/0000-0003-4518-1864 Department of Medicine, Division of Cardiology, Montreal Heart Institute, Canada. Search for more papers by this author Originally published1 Jun 2021https://doi.org/10.1161/CIRCULATIONAHA.121.054894Circulation. 2021;143:2205–2207ECG ChallengeA 61-year-old man status post–bicaval heart transplant in 2016 for end-stage nonischemic cardiomyopathy presented to the heart transplant clinic in his usual state of health with the ECG shown in Figure 1. He was previously known for atrial fibrillation diagnosed in 2014 and type II diabetes. The donor was not known for any relevant past medical history. His perioperative course was complicated by cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation before transplant, kidney failure, mesenteric ischemia status post–right hemicolectomy, and reanastomosis. His posttransplant course was relevant for an acute cellular rejection grade 3A 7 months posttransplant, urosepsis secondary to Escherichia coli, prostatitis, and chronic kidney disease. His last ECG revealed a left ventricular ejection fraction of 60%, normal right ventricular function, moderate tricuspid and mitral regurgitation, and severe left atrial dilation (85 mL/m2). In the clinic, the patient did not report any recent history of palpitations, chest pain, or dyspnea. The review of systems was negative. He was compliant with his medication, which included tacrolimus 1 mg PO BID, sirolimus 4 mg PO daily, prednisone 3 mg PO daily, and bisoprolol 1.25 mg PO daily. If you encounter such a patient in your clinic, how would you manage this arrhythmia?Download figureDownload PowerPointFigure 1. A silent arrhythmia.Please turn the page to read the diagnosis.Response to ECG ChallengeThe ECG (Figure 2) shows normal sinus rhythm of the transplanted heart, with positive P waves being the most apparent in V1 and underlying atrial fibrillation from the remnant native left atrium. The latter is electrically disconnected from the donor heart, as shown by sinus rhythm and AV synchrony with a narrow QRS complex. Figure 3 shows normal sinus rhythm without underlying atrial fibrillation in the recipient atrial tissue.Download figureDownload PowerPointFigure 2. Intra-atrial dissociation between the native recipient atrial tissue showing atrial fibrillation (red arrows) and the donor atria in normal sinus rhythm (black arrows).Download figureDownload PowerPointFigure 3. Baseline ECG in sinus rhythm.Atrial arrhythmias in heart transplant recipients are increasingly recognized because of improved outcomes and survival seen after heart transplantation. A spectrum of atrial arrhythmias in both recipient and donor atria have been described in biatrial heart transplant recipients. Several mechanisms may lead to the development of late atrial arrhythmias post–heart transplantation, including focal triggers from suture lines, atrial remodeling, rejection, cardiac allograft vasculopathy, ventricular dysfunction, and recipient-to-donor atrial conduction.1 Suture lines in the right atrium facilitate incisional atrial arrhythmias in addition to the remnant atrial tissue introducing areas of scarring.2 It has been observed that bicaval anastomosis decreases the incidence of re-entrant atrial tachycardia but not atrial fibrillation or flutter.1 Posttransplantation atrial arrhythmias are associated with increased all-cause mortality, especially if they occur in the first month after transplant.3 Evidence is lacking regarding the most appropriate management to adopt in these patients, especially in patients with bicaval heart transplantation and with atrial arrhythmias originating from remnant native atrial tissue. Medical management with rate or rhythm control, as well as catheter ablation, is usually not indicated in patients with atrial fibrillation or atrial flutter originating from the native atria, because it is most often electrically isolated and nonconductive.2 Nevertheless, it is recommended that all heart transplant recipients with atrial fibrillation and atrial flutter should receive anticoagulation therapy, although the benefit of anticoagulation is not as well documented in these patients as it is in the non transplant population. In a study by Chang et al, patients with atrial tachyarrhythmias originating from the donor heart showed a higher incidence of nonfatal strokes compared with patients in sinus rhythm (13.7% vs. 3.6%).3 Therefore, the authors suggest anticoagulation according to the CHADS2 (Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes, Prior Stroke or transient ischemic attack or thromboembolism) score, although there are no data on thromboembolic risk in patients with arrhythmias originating from the recipient atrial tissue with intra-atrial dissociation. When anticoagulation is needed, apixaban and rivaroxaban should be preferred because their interaction with cyclosporin is less than that described with warfarin and dabigatran.2In this case of a post–bicaval heart transplant patient with asymptomatic atrial fibrillation arising from his remnant left atrium, there was no indication to address rhythm or rate control in the absence of conduction between the recipient and the donor. The electrophysiology service suggested anticoagulation to err on the cautious side of thromboembolism prevention, despite minimal evidence available in the literature on intra-atrial dissociated arrhythmias. Apixaban 5 mg PO twice daily was added to the patient’s medical regimen. The patient remained asymptomatic from his underlying arrhythmia and experienced no thromboembolism on subsequent follow-up appointments.Sources of FundingNone.Disclosures None.Footnotes*J. Boulet and E. Massie contributed equally.For Sources of Funding and Disclosures, see page 2207.https://www.ahajournals.org/journal/circCorrespondence to: Mark Liszkowski, MD, 5000 Rue Belanger, Montreal, Quebec City, Canada H1T 1C8. Email Mark.[email protected]orgReferences1. Hamon D, Taleski J, Vaseghi M, Shivkumar K, Boyle NG. Arrhythmias in the heart transplant patient.Arrhythm Electrophysiol Rev. 2014; 3:149–155. doi: 10.15420/aer.2014.3.3.149CrossrefMedlineGoogle Scholar2. Lehmann GC, Van Hare GF, Avari Silva JN. Atrial tachycardia in an electrically dissociated native right atrium after heart transplantation.HeartRhythm Case Rep. 2016; 2:356–359. doi: 10.1016/j.hrcr.2016.04.004CrossrefMedlineGoogle Scholar3. Chang HY, Lo LW, Feng AN, Chiang MC, Yin WH, Young MS, Chang CY, Chuang YC, Hartono B, Chen SA, et al.. Long-term follow-up of arrhythmia characteristics and clinical outcomes in heart transplant patients.Transplant Proc. 2013; 45:369–375. doi: 10.1016/j.transproceed.2012.09.116CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails June 1, 2021Vol 143, Issue 22Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.121.054894PMID: 34061582 Originally publishedJune 1, 2021 PDF download Advertisement SubjectsArrhythmiasAtrial FibrillationTransplantation