Abstract
Introduction: The perioperative incidence of conduction disorders remains high in lung transplant recipients secondary to hemodynamic changes, cardiac manipulation, the effects of immunosuppressive medications, and pre-existing cardiac pathology. We describe a rare case of complete heart block in a lung transplant recipient with a history of significant cardiac issues. Description: A 70-year-old man with a history of coronary artery disease requiring coronary artery bypass graft 8 years prior and aortic stenosis post transcatheter aortic valve replacement 2 years prior underwent lung transplant evaluation for idiopathic pulmonary fibrosis. Given technical challenges, he underwent single right lung transplantation. The patient had a complex postoperative course with prolonged respiratory failure requiring tracheostomy, shunting requiring patent foramen ovale closure, persistent QTc elevation despite multiple medication changes, elevated hemidiaphragm requiring surgical plication. He had an underlying sinus rhythm with right bundle branch block and left anterior fascicular block at presentation. Immunosuppressive therapy after transplant included tacrolimus, mycophenolate mofetil, and prednisone. Ten weeks after transplant, the patient was undergoing physical therapy when telemetry showed a 3-second sinus pause followed by 16 minutes of second degree Mobitz II AV block before returning to 1:1 atrioventricular rate. He recalled only feeling like he had to “burp.” On questioning, the patient reported prior episodes during therapy sessions where he was told that his heart rate was in the 40s on oximetry and suddenly went up. He also reported that he was offered a pacemaker post CABG, but was unclear why. These findings were deemed concerning for significant His-Purkinje disease and not reversible with medication withdrawal. Given multiple recurrences of such events, he underwent successful permanent pacemaker placement, recovered thereafter, and continues to do well. Discussion: Our patient's history of coronary artery disease and valvular heart disease heightened his risk for postoperative cardiac events. Our case illustrates that a thorough preoperative assessment and ongoing monitoring of cardiac function are essential in managing lung transplant recipients. Continuous telemetry monitoring may be beneficial in the immediate postoperative period to promptly identify and manage arrhythmias. Additionally, regular cardiac evaluations, including echocardiograms and Holter monitoring, may aid in the early detection of conduction abnormalities and guide timely interventions.