B-PO05-204 LATE ONSET ATYPICAL ATRIAL FLUTTER IN A TRANSPLANTED HEART

Abstract

Cardiac denervation, allograft rejection and vasculopathy increase the risk of cardiac arrhythmias and pose management challenges in a heart transplant patient. To discuss the management of atrial arrhythmia in a transplanted heart. N/A A 71-year-old Caucasian woman with a history of orthotopic heart transplant in 2001, paroxysmal atrial fibrillation, and transplant vasculopathy status post left circumflex artery stent presented with palpitations. External monitoring revealed supraventricular tachycardia. Twelve lead ECG confirmed an atrial flutter with variable block. Echocardiography showed normal ventricular function. Cardiac biopsy showed focal moderate cellular allograft rejection. Left heart catheterization did not show significant coronary obstruction. The finding of graft rejection prompted commencement of steroids. Following steroid therapy, repeat biopsy was negative for rejection; however, atrial arrhythmia persisted requiring multiple cardioversions. Antiarrhythmic drug therapy caused intolerable side effects. An electrophysiology study revealed atypical mitral flutter in the donor atria. Catheter ablation of the anterior mitral line terminated the flutter. Allograft rejection causes inflammation and fibrosis leading to slowing of conduction in the atria forming the substrate for intra-atrial arrhythmia. Bi-atrial anastomosis might have increased the risk of transmitral flutter in the donor heart. Catheter ablation should be considered for late onset atrial arrhythmia in transplant patients.