title: Long-term outcomes and clinical predictors for pacing after cardiac transplantation.
abstract: BACKGROUND
  Prior studies have yielded inconsistent results on bradyarrhythmias requiring a permanent pacemaker (PPM) after cardiac transplant. This study evaluated the predictors for PPM requirement, long-term outcomes, and influence of implant timing and device programming on prognosis after cardiac transplant.
  
  
  METHODS
  This study prospectively evaluated 1,307 recipients from 1985 to 2007 at Cleveland Clinic by structured follow-up and compared the outcomes of patients with and without bradyarrhythmias requiring PPM after transplantation. The primary end point was all-cause mortality or retransplant.
  
  
  RESULTS
  Recipients, aged 50 +/- 15 years (donors, 33 +/- 14 years), were monitored 82 +/- 59 months, with PPM indicated in 106 (8.1%), including 61 (57.5%) early and 44 (42.5%) late. Biatrial technique strongly predicted PPM requirement (OR [odds ratio], 2.61; 95% confidence interval [CI], 1.63-4.20; p < 0.001), and survival/retransplant outcomes were comparable between those with early, late, and no PPM requirement: 5-year primary event-free rate was 80.4% (early) vs 72.6% (late; p = 0.480) and 80.4% (early) vs 73.2% (none, p = 0.550) and 72.6% (late) vs 73.2% (none; p = 0.960). Excess atrial fibrillation was noted among PPM recipients (PPM, 12.3% vs no PPM, 6.3%; p = 0.02) with high initial DDD programming in 92.5% (98 of 106). Sinus rhythm with intact atrioventricular conduction at 6 months was present in 69 (85%), yet 67 (67%) remained DDD programmed, with mean 26.0% +/- 38.0% right ventricular pacing.
  
  
  CONCLUSIONS
  No excess mortality is associated with a PPM after cardiac transplantation, and biatrial technique strongly predicts PPM requirement. Increased atrial fibrillation among PPM recipients may be related to right ventricular stimulation with dual-chamber pacing.
authors.affiliation: Department of Cardiovascular Medicine, Cleveland Clinic, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland, OH 44195, USA. cantild@ccf.org
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Cantillon
authors.forename: Eiran Z
authors.initials: EZ
authors.lastname: Gorodeski
authors.forename: Marco
authors.initials: M
authors.lastname: Caccamo
authors.forename: Nicholas G
authors.initials: NG
authors.lastname: Smedira
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Wilkoff
authors.forename: Randall C
authors.initials: RC
authors.lastname: Starling
authors.forename: Walid
authors.initials: W
authors.lastname: Saliba
mesh_terms: D000328:Adult; D000368:Aged; D001919:Bradycardia / Q000209:etiology / Q000628:therapy*; D002304:Cardiac Pacing, Artificial; D016027:Heart Transplantation / Q000009:adverse effects*; D006801:Humans; D008875:Middle Aged; D010138:Pacemaker, Artificial; D011379:Prognosis; D011446:Prospective Studies; D016896:Treatment Outcome