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Communications to the Editor |

Atrial Fibrillation, Atrial Flutter, or Both After Pulmonary Transplantation FREE TO VIEW

M. Teresa Lazaro, MD; Piedad Ussetti, MD; Jose L. Merino, MD
Author and Funding Information

Affiliations: Hospital Universitario Puerta de Hierro,  Hospital Universitario La Paz, Madrid, Spain,  Duke University Medical Center, Durham, NC

Correspondence to: M. Teresa Lazaro, MD, Hospital Universitario Puerta de Hierro, San Martin de Porres, 4, 28035 Madrid, Spain; e-mail: teresa_lazaro@separ.es



Chest. 2005;127(4):1461-1462. doi:10.1378/chest.127.4.1461-a
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To the Editor:

We read with interest the recent report of Nielsen et al (August 2004).1 This is an important study that addressed the prevalence and predictors for atrial arrhythmias after pulmonary transplantation (PT). Nevertheless, some points should be reviewed due to possible misinterpretation.

Atrial fibrillation and atrial flutter were grouped together and termed “AF” in the results and analysis in the present study. However, it should be noted that they are mechanistically and therapeutically different entities, which should not be grouped under the same term.2Atrial flutter is defined as macroreentry around one or more atrial anatomic obstacles (commonly, the tricuspid annulus or surgical incisions), which can be abolished by catheter ablation.3A high incidence of atrial flutter has been reported in patients with PT.45 Atypical atrial flutter following PT is thought to be secondary to macroreentry around the anastomosis between the left atrium and pulmonary veins.6On the other hand, the final etiologic mechanism of atrial fibrillation is unknown, and the best treatment for it is unclear. Electrical isolation of the pulmonary veins and the surrounding left atrium myocardium leads to atrial fibrillation abolishment in many patients.7 A similar electrical situation occurs in PT, in which the donor pulmonary veins and the surrounding left atrium tissue are not electrically connected to the recipient’s atria.

Therefore, current scientific evidence makes atrial flutter rather than atrial fibrillation more likely to occur after PT. Thus, separate descriptions and analyses of the incidence and predictive factors of these two different arrhythmias should have been performed in this study, and this warrants further investigation.

Nielsen, TD, Bahnson, T, Davis, RD, et al (2004) Atrial fibrillation after pulmonary transplant.Chest126,496-500
 
Cosio, FG, Delpon, E New antiarrhythmic drugs for atrial flutter and atrial fibrillation: a conceptual breakthrough at last?Circulation2002;105,276-278
 
Saoudi, N, Cosio, F, Waldo, A, et al A classification of atrial flutter and regular atrial tachycardia according to electrophysiological mechanisms and anatomical bases: a Statement from a Joint Expert Group from The Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology.Eur Heart J2001;22,1162-1182
 
Gandhi, SK, Bromberg, BI, Mallory, GB, et al Atrial flutter: a newly recognized complication of pediatric lung transplantation.J Thorac Cardiovasc Surg1996;112,984-991
 
Lazaro, MT, Merino, JL, Fernandez-Lozano, I, et al Incidence and characteristics of new developed atrial flutter and monomorphic atrial tachycardia after lung transplantation [abstract]. Pacing Clin Electrophysiol. 2000;;23 ,.:691
 
Gandhi, SK, Bromberg, BI, Schuessler, RB, et al Left-sided atrial flutter: characterization of a novel complication of pediatric lung transplantation in an acute canine model.J Thorac Cardiovasc Surg1996;112,992-1001
 
Pappone, C, Rosanio, S, Oreto, G, et al Circumferential radiofrequency ablation of pulmonary vein ostia: a new anatomic approach for curing atrial fibrillation.Circulation2000;102,2619-2628
 
To the Editor:

We appreciate the comments by Lazaro and colleagues regarding our recent article (August 2004).1 The authors suggest that our work would benefit from a separate analysis of patients with atrial fibrillation from those with atrial flutter (both grouped under the term AF in our study). They cite differences in the etiology of atrial fibrillation and flutter as to why a separate analysis would be useful. Unfortunately, little is known mechanistically about the development of atrial dysrrhythmias after lung transplant. Furthermore, both atrial fibrillation and flutter were observed in some patients in our study at different times postoperatively. Thus, trying to dichotomize all our patients into one category or the other would be difficult. We agree that future studies of the lung transplant population should include more detailed ECG and electrophysiologic monitoring, in order to better understand the mechanisms of atrial fibrillation and flutter in this population. We would emphasize, however, that AF, as defined in our analysis, is appropriate and clinically meaningful because we demonstrated specific risk factors and associations with clinical outcomes using this definition in a large cohort of lung transplant recipients.

References
Nielsen, TD, Bahnson, T, Davis, RD, et al Atrial fibrillation after pulmonary transplant.Chest2004;126,496-500
 

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Tables

References

Nielsen, TD, Bahnson, T, Davis, RD, et al (2004) Atrial fibrillation after pulmonary transplant.Chest126,496-500
 
Cosio, FG, Delpon, E New antiarrhythmic drugs for atrial flutter and atrial fibrillation: a conceptual breakthrough at last?Circulation2002;105,276-278
 
Saoudi, N, Cosio, F, Waldo, A, et al A classification of atrial flutter and regular atrial tachycardia according to electrophysiological mechanisms and anatomical bases: a Statement from a Joint Expert Group from The Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology.Eur Heart J2001;22,1162-1182
 
Gandhi, SK, Bromberg, BI, Mallory, GB, et al Atrial flutter: a newly recognized complication of pediatric lung transplantation.J Thorac Cardiovasc Surg1996;112,984-991
 
Lazaro, MT, Merino, JL, Fernandez-Lozano, I, et al Incidence and characteristics of new developed atrial flutter and monomorphic atrial tachycardia after lung transplantation [abstract]. Pacing Clin Electrophysiol. 2000;;23 ,.:691
 
Gandhi, SK, Bromberg, BI, Schuessler, RB, et al Left-sided atrial flutter: characterization of a novel complication of pediatric lung transplantation in an acute canine model.J Thorac Cardiovasc Surg1996;112,992-1001
 
Pappone, C, Rosanio, S, Oreto, G, et al Circumferential radiofrequency ablation of pulmonary vein ostia: a new anatomic approach for curing atrial fibrillation.Circulation2000;102,2619-2628
 
Nielsen, TD, Bahnson, T, Davis, RD, et al Atrial fibrillation after pulmonary transplant.Chest2004;126,496-500
 
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