Pavri B B, O'Nunain S S, Newell J B, Ruskin J N, William G
Cardiac Unit, Massachusetts General Hospital, Boston 02114, USA.
J Am Coll Cardiol. 1995 Jun;25(7):1673-80. doi: 10.1016/0735-1097(95)00047-8.
We studied the duration and prognostic significance of atrial arrhythmias in the denervated transplanted heart, specifically the occurrence of atrial fibrillation in the absence of vagal modulation.
Substantial animal data indicate that vagally induced dispersion of atrial refractoriness plays a central role in the induction and maintenance of atrial fibrillation.
We studied the occurrence of atrial arrhythmias in the denervated hearts of 88 consecutive orthotopic transplantations in 85 patients by means of continuous telemetry and all available electrocardiographic tracings.
Fifty percent of recipients (44 of 88) developed at least one atrial arrhythmia. Atrial fibrillation occurred 23 times (21 recipients), atrial flutter 39 times (26 recipients), ectopic atrial tachycardia 3 times (3 recipients) and supraventricular tachycardia 18 times (11 recipients). The number of atrial fibrillation and atrial flutter episodes did not differ (23 vs. 39, p = 0.072), but the mean duration of atrial flutter was longer than that of atrial fibrillation (37.0 +/- 10 vs. 6.6 +/- 3.6 h, p = 0.014). Atrial fibrillation was associated with an increased risk of subsequent death (10 of 21 recipients with vs. 15 of 67 without atrial fibrillation, risk ratio 3.15 +/- 0.18, p = 0.005 by Cox proportional hazards model). All 5 recipients who developed "late" atrial fibrillation (> 2 weeks after transplantation) died versus 5 of 16 who developed atrial fibrillation within the first 2 weeks (p = 0.007). Causes of death included rejection (three recipients), allograft failure (two recipients), infection (three recipients) and multiorgan failure (two recipients). Atrial fibrillation was not associated with age, gender, ischemic time, reason for transplantation, echocardiographic variables, invasive hemodynamic variables or biopsy grade. Mean time from atrial arrhythmia to echocardiography was 2.7 +/- 3.3 days; that to biopsy was 4.8 +/- 6.3 days. Atrial flutter was not associated with subsequent death. Only 7 (15.9%) of 44 recipients demonstrated moderate or severe allograft rejection at the time of the arrhythmia.
Atrial arrhythmias occur frequently in the denervated transplanted heart, often in the absence of significant rejection. Late atrial fibrillation may be associated with an increased all-cause mortality.
我们研究了去神经支配的移植心脏房性心律失常的持续时间及其预后意义，特别是在无迷走神经调节情况下房颤的发生情况。
大量动物数据表明，迷走神经诱导的心房不应期离散在房颤的诱发和维持中起核心作用。
我们通过连续遥测和所有可用的心电图记录，研究了85例患者连续88次原位心脏移植术后去神经支配心脏的房性心律失常发生情况。
50%的受者（88例中的44例）发生了至少一种房性心律失常。房颤发生23次（21例受者），房扑39次（26例受者），异位房性心动过速3次（3例受者），室上性心动过速18次（11例受者）。房颤和房扑发作次数无差异（23次对39次，p = 0.072），但房扑的平均持续时间长于房颤（37.0±10小时对6.6±3.6小时，p = 0.014）。房颤与随后死亡风险增加相关（21例发生房颤的受者中有10例死亡，67例未发生房颤的受者中有15例死亡，Cox比例风险模型得出风险比为3.15±0.18，p = 0.005）。所有5例发生“晚期”房颤（移植后>2周）的受者均死亡，而16例在最初2周内发生房颤的受者中有5例死亡（p = 0.007）。死亡原因包括排斥反应（3例受者）、移植物功能衰竭（2例受者）、感染（3例受者）和多器官功能衰竭（2例受者）。房颤与年龄、性别、缺血时间、移植原因、超声心动图变量、有创血流动力学变量或活检分级无关。从房性心律失常到超声心动图检查的平均时间为2.7±3.3天；到活检的平均时间为4.8±6.3天。房扑与随后死亡无关。44例受者中只有7例（15.9%）在心律失常发生时出现中度或重度移植物排斥反应。
去神经支配的移植心脏中房性心律失常频繁发生，且常无明显排斥反应。晚期房颤可能与全因死亡率增加有关。
