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Challenges in Clinical Electrocardiography |

Syncope Following Orthotopic Heart Transplant Sinoatrial or Atrioventricular Nodal Block?

Jennifer M. Wright, MD1; Michael E. Field, MD1
[+] Author Affiliations
1Department of Medicine, University of Wisconsin, Madison
JAMA Intern Med. 2016;176(7):1010-1012. doi:10.1001/jamainternmed.2016.1995.
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A man in his 60s with prior heart transplantation presented with intermittent syncope. Cardiac ultrasonography and laboratory examination showed normal left ventricular function and clinical examination did not reveal any evidence of rejection. During an episode of lightheadedness, the following 12-lead electrocardiogram (ECG) was obtained (Figure 1).

Figure 1. 12-Lead ECG in a Patient With Remote Orthotopic Heart Transplantation

The underlying rhythm appears to be atrial flutter with intermittent pauses up to 1.8 seconds. There is an incomplete right bundle branch block.

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Figure 1.
12-Lead ECG in a Patient With Remote Orthotopic Heart Transplantation

The underlying rhythm appears to be atrial flutter with intermittent pauses up to 1.8 seconds. There is an incomplete right bundle branch block.

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Figure 2.
12-Lead ECG in a Patient With Remote Orthotopic Heart Transplantation

Discreet P-waves (black arrowheads) with a different morphology from the flutter waves (red arrowheads) occur before each QRS complex except during the pauses. Just prior to the first junctional escape beat is a P-wave that does not conduct as the timing is nearly isorhythmic with the junctional escape beat.

aA junctional escape beat ends the pause.

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Figure 3.
Diagram of the Suture Line in a Biatrial Anastomosis Orthotopic Heart Transplantation

With the technique of the biatrial anastomosis, which is not commonly used today, a portion of the recipient right atrium is sutured to the donor right atrium. Typically there is no conduction across the suture line. During pacemaker implantation, the atrial lead was temporarily positioned in the recipient and then ultimately more anteriorly in the donor portion of the right atrium and electrical recordings were made in both segments. As shown by the electrogram, when the lead was positioned in the recipient portion of the right atrium, atrial flutter was recorded and when the lead was placed in the donor portion, sinus rhythm was recorded. The atrial lead was ultimately positioned anteriorly in the donor right atrium and used for atrial pacing. RA, right atrium. EGM, electrogram. SVC, superior vena cava. IVC, inferior vena cava.

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