Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (J.A.J., M.L., M.D.).
Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY (E.Y.W.).
Circ Arrhythm Electrophysiol. 2021 Mar;14(3):e007954. doi: 10.1161/CIRCEP.120.007954. Epub 2021 Mar 9.
Orthotropic heart transplantation remains the most effective therapy for patients with end-stage heart failure, with a median survival of ≈13 years. Yet, a number of complications are observed after orthotropic heart transplantation, including atrial and ventricular arrhythmias. Several factors contribute to arrhythmias, such as autonomic denervation, effect of the surgical technique, acute and chronic rejection, and transplant vasculopathy among others. To minimize risk of future arrhythmias, the bicaval technique and minimizing ischemic time are current surgical standards. Sinus node dysfunction is the most common indication for early (within 30 days) pacemaker implantation, whereas atrioventricular block incidence increases as time from transplant increases. Atrial fibrillation can occur in the first few weeks following transplantation but is uncommon in the long term unless secondary to a precipitant such as acute rejection. The most common atrial arrhythmias are atrial flutters, which are mainly typical, but atypical circuits can be observed such as those that involve the remnant donor atrium in regions immediately adjacent to the atrioatrial anastomosis suture line. Choosing the appropriate pharmacological therapy requires careful consideration due to the potential interaction with immunosuppressive agents. Despite historical concerns, adenosine is effective and safe at reduced doses if administered under cardiac monitoring. Catheter ablation has emerged as an effective treatment strategy for symptomatic supraventricular tachycardias, including ablation of atypical flutter circuits. Cardiac allograft vasculopathy is an important risk factor for sudden cardiac death, yet the role of prophylactic implantable cardioverter-defibrillator implant for sudden death prevention is unclear. Current indications for implantable cardioverter-defibrillator implantation are as in the nontransplant population. A number of questions for future research are posed.
原位心脏移植仍然是治疗终末期心力衰竭患者的最有效方法，中位生存期约为 13 年。然而，在原位心脏移植后会观察到一些并发症，包括心房和心室心律失常。一些因素导致心律失常，如自主神经去神经支配、手术技术的影响、急性和慢性排斥反应以及移植血管病等。为了最大限度地降低未来发生心律失常的风险，双腔静脉技术和减少缺血时间是目前的手术标准。窦房结功能障碍是早期（30 天内）植入起搏器的最常见指征，而随着移植时间的增加，房室传导阻滞的发生率增加。心房颤动可在移植后几周内发生，但在长期内并不常见，除非继发于急性排斥等诱因。最常见的房性心律失常是心房扑动，主要是典型的，但也可以观察到非典型的环，如那些涉及与心房吻合缝线相邻的供体残留心房的环。由于与免疫抑制剂的潜在相互作用，选择合适的药物治疗需要仔细考虑。尽管存在历史上的担忧，但如果在心脏监测下给予低剂量，腺苷是有效且安全的。导管消融已成为治疗有症状的室上性心动过速的有效治疗策略，包括消融非典型扑动环。心脏同种异体移植血管病是心脏性猝死的重要危险因素，但预防性植入式心脏复律除颤器植入预防猝死的作用尚不清楚。目前植入式心脏复律除颤器植入的指征与非移植人群相同。提出了一些未来研究的问题。
