Long-term Outcomes and Clinical Predictors for Pacing After Cardiac Transplantation

Background: Prior studies have yielded inconsistent results on bradyarrhythmias requiring a permanent pacemaker (PPM) after cardiac transplant. This study evaluated the predictors for PPM requirement, long-term outcomes, and influence of implant timing and device programming on prognosis after cardiac transplant. Methods: This study prospectively evaluated 1,307 recipients from 1985 to 2007 at Cleveland Clinic by structured follow-up and compared the outcomes of patients with and without bradyarrhythmias requiring PPM after transplantation. The primary end point was all-cause mortality or retransplant. Results: Recipients, aged 50 +/- 15 years (donors, 33 +/- 14 years), were monitored 82 +/- 59 months, with PPM indicated in 106 (8.1%), including 61 (57.5%) early and 44 (42.5%) late. Biatrial technique strong]), predicted PPM requirement (OR [odds ratio], 2.61; 95% confidence interval [CI], 1.63-4.20; p < 0.001), and survival/retransplant outcomes were comparable between those with early, late, and no PPM requirement: 5-year primary event-free rate was 80.4% (early) vs 72.6% (late; p = 0.480) and 80.4% (early) vs 73.2% (none, p = 0.550) and 72.6% (late) vs 73.2% (none; p = 0.960). Excess atrial fibrillation was noted among PPM recipients (PPM, 12.3% vs no PPM, 6.3%; p = 0.02) with high initial DDD programming in 92.5% (98 of 106). Sinus rhythm with intact atrioventricular conduction at 6 months was present in 69 (85%), yet 67 (67%) remained DDD programmed, with mean 26.0% +/- 38.0% tight ventricular pacing. Conclusions: No excess mortality is associated with a PPM after cardiac transplantation, and biatrial technique strongly predicts PPM requirement. Increased atrial fibrillation among PPM recipients may be related to right ventricular stimulation with dual-chamber pacing. J Heart Lung Transplant 2009;28:791-8. Copyright (C) 2009 by the International Society for Heart and Lung Transplantation.