Newly acquired complete right bundle branch block early after heart transplantation is associated with lower survival

Abstract

Aims Right bundle branch block (RBBB) after heart transplantation (HTX) is a common finding, but its impact on post-transplant survival remains uncertain. This study investigated the post-transplant outcomes of patients with complete RBBB (cRBBB) ≤ 30 days after HTX. Methods This registry study analysed 639 patients receiving HTX at Heidelberg Heart Center between 1989 and 2019. Patients were stratified by diagnosis of cRBBB ≤ 30 days after HTX. Analysis included recipient and donor data, medication, echocardiographic features, graft rejections, atrial fibrillation, heart rates, permanent pacemaker implantation and mortality after HTX including causes of death. Results One hundred thirty-nine patients showed cRBBB ≤ 30 days after HTX (21.8%), 20 patients with pre-existing cRBBB in the donor heart (3.2%) and 119 patients with newly acquired cRBBB (18.6%). Patients with newly acquired cRBBB had a worse 1-year post-transplant survival (36.1%, P < 0.01) compared with patients with pre-existing cRBBB (85.0%) or without cRBBB (86.4%), along with a higher percentage of death due to graft failure (P < 0.01). Multivariate analysis indicated cRBBB ≤ 30 days after HTX as significant risk factor for 1-year mortality after HTX (HR: 2.20; 95% CI: 1.68-2.87; P < 0.01). Secondary outcomes showed a higher rate of an enlarged right atrium (P = 0.01), enlarged right ventricle (P < 0.01), reduced right ventricular function (P < 0.01), 30-day atrial fibrillation (P < 0.01) and 1-year permanent pacemaker implantation (P = 0.02) in patients with cRBBB after HTX. Conclusions Newly acquired cRBBB early after HTX is associated with increased post-transplant mortality.

Atrial fibrillation before heart transplantation is a risk factor for post‐transplant atrial fibrillation and mortality

“…A P value of < 0.05 was considered statistically significant. 4,15,16,[24][25][26] Univariate analyses were performed to examine differences between groups including recipient data, previous open-heart surgery, principal diagnosis for HTX, donor data, transplant sex mismatch, perioperative data, medication including immunosuppressive drug therapy, echocardiographic features, graft rejections, heart rates, permanent pacemaker (PPM) implantation, transient ischaemic attack (TIA), and stroke after HTX. Causes for 1-year mortality after HTX were grouped into the following categories: graft failure, acute rejection, infection/sepsis, malignancy, and thromboembolic event/bleeding.…”

“…According to the ethical approval, no additional written informed consent was required for this observational study as only data of the clinical routine were used. 4,15,16,[24][25][26] Our study included all adult patients (≥ 18 years) who received first HTX at Heidelberg Heart Center, Heidelberg, Germany, between 1989 and 2019. Patients with a second HTX were not included.…”

“…Diagnosis of AF before HTX as well as diagnosis of AF ≤ 30 days after HTX was based upon all available records pertaining to heart rhythm. 4,15,16,[24][25][26] At Heidelberg Heart Center, cardiac surgeons are able to perform all three HTX techniques (biatrial, bicaval, and total orthotopic HTX). Regarding these three HTX techniques, total orthotopic HTX was mostly used (277 HTX), followed by bicaval HTX (198 HTX) and biatrial HTX (164 HTX) in this study.…”

“…Routine follow-up included medical history, physical examination, resting 12-lead ECG, echocardiography, endomyocardial biopsy, and blood tests including immunosuppressive drug levels. 4,15,16,[24][25][26][27] Restoration of sinus rhythm in patients with early post-transplant AF was successfully achieved with pharmacological (amiodarone) or electrical cardioversion (defibrillator) if AF did not spontaneously convert to sinus rhythm. As patients with AF have a higher risk for thromboembolic complications such as stroke, [28][29][30] patients with AF after HTX routinely received appropriate anticoagulation therapy, mostly in form of unfractionated heparin or low molecular weight heparin.…”

“…months, steroids (prednisolone) were tapered incrementally and were finally discontinued 6 months after HTX (if clinically possible). 4,15,16,[24][25][26]…”