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Leave a Reply Cancel reply Your email address will not be published. Atrial Flutter is the most common type of arrhythmia in patients after a heart transplant. In non-transplanted patients, the isthmus-dependent atrial flutter is formed by a counterclockwise circuit, which compromises the tricuspid valve, the Thebesian valve, the opening of the superior and inferior vena cava, and the crista terminalis. In transplanted patients, a similar circuit is formed, with the difference that the posterior line of the latter conforms the atrial suture line This type of arrhythmia is more common in the biauricular technique Mitral annular flutter is less common and has no major incidence on a particular type of surgical technique.
Just like atrial fibrillation, the development of flutter is also associated with periods of acute rejection, infection or vasculopathy, and their identification should stimulate the active search of these entities in the transplanted patient. When these causes are discarded and treated, as well as ventricular dysfunction and valvular pathology, catheter ablation is recommended to form an electrical block line between the tricuspid ring and the atrial suture for the right atrial-dependent flutter 48 , whereas ablation of the anterior line of the circuit is recommended for the left atrium Focal atrial tachycardia is caused by the formation of depolarization foci near the atrial scar that take control of the heart rhythm.
Scars, together with fibrosis, predispose to the formation of areas of slow electrical conduction, and provide the substrate for the production of macroreentrants and the development of focal atrial tachycardia. Elsik et al. Definitive treatment is focal catheter ablation.
Atrial reentrant and nodal reentrant tachycardia require a preexisting route in the donor that allows a macroreentrant. Although they have been described in the literature, they are uncommon in transplanted patients. Radiofrequency ablation is curative Ventricular extrasystoles and non-sustained ventricular tachycardia may be common in the early post-transplant period.
The subsequent development of sustained and non-sustained ventricular tachycardia suggests an episode of acute rejection or graft vasculopathy 18 , while taking into account other rare etiologies that may have similar clinical features and may be reversible, such as idiopathic fascicular ventricular tachycardia The most common arrest rhythm in cardiac denervation in sudden death events is asystole, followed by pulseless electrical activity; both are non-defibrillating rhythms, so the use of automatic implantable defibrillators remains controversial 17, Bradyarrhythmias may appear during the early or late period after a heart transplant, and can be caused by sinus node dysfunction or errors in the electrical conduction, with functional or dysfunctional sinus node.
In the early postoperative period, the transplanted heart usually requires positive chronotropic agents or temporary pacemaker implantation. As for late sinus dysfunction, the role of graft rejection in its development is controversial. Sinus dysfunction may be paroxysmal or persistent, and may be manifested as sinus bradycardia or as a total stop of the sinoatrial node 53, To control these entities, a therapeutic test can be performed with isoprenaline, dopamine, dobutamine or theophylline in search of increased heart rate and recovery of sinus rhythm.
If this therapy fails, the use of pacemakers should be considered 21, The Colombian guide to cardiovascular electrophysiology 56 provides the following recommendations for the implantation of a permanent pacemaker:. Class I: it is indicated in symptomatic, inappropriate, persistent or not-expected-to-improve bradycardia. Class IIA: it is considered in symptomatic, recurrent and prolonged bradycardia that limits rehabilitation or discharge during the post-surgical recovery phase of the transplant level of evidence C. Class IIB: it is considered in patients with syncope after cardiac transplantation although bradyarrhythmia has not been documented level of evidence C.
Early implantation of a permanent pacemaker occurs when the heart rate has not been normalized with other interventions after three weeks However, after one year of implantation, the frequency of activity of these devices decreases, in most cases due to the recovery of the sinus function 55,57, In the late postoperative period, errors in the conduction of the nerve impulse are predominant, with AV blocks being the leading cause of implantation of cardiac pacemakers in this period.
This phenomenon has been attributed to the development of graft rejection, since electrical conduction tissue has been proven as a typical target of humoral response during this process 52,56, The development of arrhythmias is a frequent issue and, in some cases, puts the life of the patient at risk. This complication is related to multiple triggers. There are factors associated with the surgical procedure itself, such as ischemia times, sinus node injury, and excessive manipulation of the atria due to the surgical technique and cardiac denervation, as well as other mechanisms related to the preoperative and post-surgical periods, such as acute rejection episodes, reinnervation, ventricular biopsies, graft vasculopathy, systemic infections, and drug effects.
The most common arrhythmias are bradycardia, which, in a significant percentage, will require implantation of permanent pacemakers. The most frequent tachyarrhythmia is the isthmus-dependent flutter, which can be treated with catheter ablation. The most common rhythm of cardiac arrest in these patients is asystole, unlike the general population, where more defibrillatory rhythms such as tachycardia and ventricular fibrillation occur.
The detection of any cardiac arrhythmia should lead to think of the possibility that this is the manifestation of an underlying pathological process that puts at risk the viability of the organ and the life of the patient. The medical team is obliged manage this condition in a way that is not limited to symptomatic control and sinus rhythm, but to initiate an active search for its etiology to give optimal therapeutic management to each patient.
To Dr. Rev Urug Cardiol. Should we consider heart rate reduction in cardiac transplant recipients? Clin Cardiol. Rev Esp Cardiol. Heart transplantation: challenges facing the field. Cold Spring Harb Perspect Med. Pacing Clin Electrophysiol. Jacob S, Sellke F. Is bicaval orthotopic heart transplantation superior to the biatrial technique?
Interact Cardiovasc Thorac Surg. Should biatrial heart transplantation still be performed? Arq Bras Cardiol. Bicaval versus standard technique in orthotopic heart transplant: assessment of atrial performance at magnetic resonance and transthoracic echocardiography.
Does the method of heart transplantation affect left ventricular filling? Yuri bin consciously. Jeff Dean Global Marketing Group The grass along the banks of the Rio Darro hung tall and still under the roasting midday sun.
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