Cardiac allograft vasculopathy and donor age affecting permanent pacemaker implantation after heart transplantation

Abstract

AimsThe need for permanent pacemakers (PMs) after heart transplantation (HT) is increasing. The aim was to determine the influence of cardiac allograft vasculopathy (CAV), donor age, and other risk factors on PM implantations early and late after HT and its effect on survival. Methods and results A retrospective, single-centre study was performed including HTs from 1984 to July 2018. Early PM was defined as PM implantation ≤90 days and late PM as PM > 90 days. Risk factors for PM and survival after PM were determined with (time-dependent) multivariable Cox regression. Out of 720 HTs performed, 62 were excluded (55 mortalities ≤30 days and 7 retransplantations). Of the remaining 658 patients, 95 (14%) needed a PM: 38 (6%) early and 57 (9%) late during follow-up (median 9.3 years). Early PM risk factors were donor age [hazard ratio (HR) 1.06, P < 0.001], ischaemic time (HR 1.01, P < 0.001), and in adults amiodarone use before HT (HR 2.02, P = 0.045). Late PM risk factors were donor age (HR 1.03, P = 0.024) and CAV (HR 3.59, P < 0.001). Late PM compromised survival (HR 2.05, P < 0.001), while early PM did not (HR 0.77, P = 0.41). Conclusions Risk factors for early PM implantation were donor age, ischaemic time, and in adults amiodarone use before HT. Late PM implantation risk factors were donor age and CAV. Late PM diminished survival, which is probably a surrogate marker for underlying progressive cardiac disease.

Pacemaker Implantation following Heart Transplantation: Analysis of a Nation-Wide Database

“…We found no survival difference between pacemaker and non-pacemaker groups at 1 year post-transplantation, consistent with several published single-center studies [ 7 , 8 , 11 , 12 , 13 ]. Of note, Wellmann et al excluded early mortality within 3 months post transplantation, because the authors believed that patients who died early never had the chance to receive a pacemaker, and noted no long-term survival benefit [ 7 ].…”

“…As years pass, the era effect that we have observed yields a lower incidence of implantation; this may mask true differences in mortality. Prior studies have also demonstrated differential survival in early vs. late post-operative pacemaker implantation, but the limitations of our dataset prevented us from making these comparisons [ 8 , 13 ].…”

Theophylline Use to Prevent Permanent Pacing in the Contemporary Era of Heart Transplantation: The Rotterdam Experience

“…In the last few decades, early permanent pacemaker (PPM) implantation has been increasingly utilized to treat persistent bradycardia following bradyarrhythmias occurring after transplantation, mainly due to the increasing age of suitable donors in Europe, especially in the Netherlands (1).…”

“…The prevalence of both theophylline uses (12 patients before and 61 patients after 2000) as well as need of a PPM increased significantly along with increasing donor ages in the past two decades. Figure 1 shows the percentage of theophylline use vs. permanent pacemaker implant at discharge before and after the year 2000, a year in which the baseline immunosuppressive treatment and donor ages changed significantly in our center (1,4). There were no significant correlations with successful vs. not successful treatment regarding the recipient age (mean 46.6 ± 14.0 vs. 43.8±14.9 years), donor age (mean 40.6 ± 14.7 vs. 42.5 ± 12.7 years), gender, preoperative use of amiodaron (53 vs. 67%), or underlying heart diseases (28 vs. 33 % ischemic heart diseases).…”

“…Our single-center experience confirms that the use of theophylline for post-HTx bradyarrhythmias successfully increased the baseline heart rate, facilitated the withdrawal of chronotropic support, and deferred the need for permanent pacing. We recently reported that the most common indication for early PPM implantation was sinus node dysfunction (SND) while atrioventricular block was more frequent in late PM implantation (1). Patients who had an older donor had an increased risk of having a PM implanted both early and late after HT.…”