PERMANENT PACEMAKER FOR REJECTION EPISODES AFTER HEART-TRANSPLANTATION - A POOR PROGNOSTIC SIGN

Background. The development of arrhythmias early or late after heart t ransplantation has been associated with acute and chronic rejection. T his study aims to document the importance of this relationship and its value as a prognostic sign in those patients who required a permanent pacemaker for rejection episodes. Methods. A retrospective analysis o f 158 orthotopic heart transplantations performed in 157 patients betw een December 1988 and April 1995 was done. The clinical course and the outcome of 6 patients who underwent insertion of a permanent pacemake r for bradyarrhythmias caused by acute or chronic allograft rejection were compared with the course and outcome of 9 patients who had pacema ker placement as a result of sinus node dysfunction not associated wit h rejection. Results. The mortality rate was 100% for patients whose i ndication for permanent pacing was severe acute or chronic rejection. Conversely, 8 of the 9 patients who underwent pacemaker placement for sinus node dysfunction not associated with rejection are long-term sur vivors; the one late death was due to a noncardiac cause. Conclusions. We observed a strong relationship between bradyarrhythmias requiring a permanent pacemaker and severe acute or chronic allograft rejection. This association suggests a poor prognosis and indicates that these p atients should be managed aggressively. Such management includes close immunologic surveillance for cellular and humoral rejection, increase d frequency of endomyocardial biopsies and coronary angiography, and e arly consideration for retransplantation.