title: Long-term outcomes and clinical predictors for pacemaker-requiring bradyarrhythmias after cardiac transplantation: analysis of the UNOS/OPTN cardiac transplant database.
abstract: BACKGROUND
  Pacemaker-requiring bradyarrhythmias after cardiac transplantation are common, and rarely can lead to sudden cardiac death. Prior outcomes studies have been limited to single-center data.
  
  
  OBJECTIVE
  This study sought to define the long-term outcomes and clinical predictors for pacemaker-requiring bradyarrhythmias in the cardiac transplant population.
  
  
  METHODS
  This study used multivariable analysis of the United Network for Organ Sharing/Organ Procurement and Transplantation Network (UNOS/OPTN) database of sequential U.S. cardiac transplant recipients from 1997 to 2007 stratified by postoperative bradyarrhythmias requiring a pacemaker. The primary end point was all-cause mortality.
  
  
  RESULTS
  Among 35,987 cardiac transplant recipients (age 46.1 ± 18.3 years, 76% male, 22% bicaval technique) with a follow-up of 6.3 ± 4.7 years, pacemaker-requiring bradyarrhythmias occurred in 3,940 patients (10.9%). Pacemaker recipients demonstrated improved survival (median 8.0 years vs. 5.2 years, P < .001), decreased 5-year mortality (13.8% vs. 17.7%, P < .001), and overall crude mortality (42.9% vs. 45.9%, P < .001). Multivariable propensity-score-adjusted analysis demonstrated improved survival among pacemaker recipients (adjusted hazard ratio 0.84, 95% confidence interval [CI] 0.80 to 0.88, P < .001) after adjustment for donor/recipient age, UNOS listing status, donor heart ischemic time, surgical technique, graft rejection, and other common comorbidities. The bicaval surgical technique was strongly protective against a postoperative pacemaker requirement (odds ratio [OR] 0.33, 95% CI 0.29 to 0.36, P < .001) in multivariable analysis. Among the other variables studied, only increasing donor age (OR 1.04, 95% CI 1.00 to 1.09, P < .001) and recipient age (OR 1.09, 95% CI 1.0 to 1.12, P < .001) were associated with a permanent pacemaker requirement.
  
  
  CONCLUSIONS
  Cardiac transplant recipients with pacemaker-requiring bradyarrhythmias have an excellent long-term prognosis. Increased mortality in the nonpacemaker group merits further investigation. Biatrial surgical technique and increasing donor/recipient age are associated with postoperative pacemaker requirement.
authors.affiliation: Cardiovascular Medicine/Electrophysiology, Cleveland Clinic, Heart and Vascular Institute, Cleveland, Ohio 44195, USA. cantild@ccf.org
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Cantillon
authors.forename: Khaldoun G
authors.initials: KG
authors.lastname: Tarakji
authors.forename: Tingfei
authors.initials: T
authors.lastname: Hu
authors.forename: Amy
authors.initials: A
authors.lastname: Hsu
authors.forename: Nicholas G
authors.initials: NG
authors.lastname: Smedira
authors.forename: Randall C
authors.initials: RC
authors.lastname: Starling
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Wilkoff
authors.forename: Walid I
authors.initials: WI
authors.lastname: Saliba
mesh_terms: D000328:Adult; D000368:Aged; D001919:Bradycardia / Q000209:etiology* / Q000628:therapy*; D002304:Cardiac Pacing, Artificial; D005260:Female; D016027:Heart Transplantation / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial; D016896:Treatment Outcome