Clinical and procedural characteristics predicting need for chronotropic support and permanent pacing post-heart transplantation

Background: Postoperative bradycardia can complicate orthotopic heart transplantation (OHT). Previous studies suggested donor age and surgical technique as possible risk factors. However, risk factors in the era of bicaval anastomosis have not been elucidated.

Objective: We sought to examine the association between donor/recipient characteristics with need for chronotropic support and permanent pacemaker (PPM) implantation in patients with OHT.

Methods: All patients treated with OHT between January 2003 and January 2018 at the Hospital of the University of Pennsylvania were retrospectively evaluated until June 2018. Chronotropic support was given upon postoperative inability to increase the heart rate to patient's demands and included disproportionate bradycardia and junctional rhythm.

Results: A total of 820 patients (mean age 51.3 ± 12.6 years; 607, 74% men) underwent 826 OHT procedures (787 patients, 95.3% bicaval anastomosis). Patients who were exposed to amiodarone (odds ratio [OR] 2.30; 95% confidence interval [CI] 1.58-3.34; P < .001) and have older donor (OR 1.02; 95% CI 1.01-1.04; P = .001) were more likely to develop need for chronotropic support. In multivariable analysis, recipient age (OR 1.03; 95% CI 1.00-1.06; P = .04) and biatrial anastomosis (OR 6.12; 95% CI 2.48-15.09) were significantly associated with PPM implantation within 6 months of OHT. No association was found between pre-OHT amiodarone use and PPM implantation. No risk factors assessed were associated with PPM implantation 6 months post-OHT.

Conclusion: Surgical technique and donor age were the main risk factors for the need for chronotropic support post-OHT, whereas surgical technique and recipient age were risk factors for early PPM implantation.