Atrial fibrillation following lung transplantation: double but not single lung transplant is associated with long-term freedom from paroxysmal atrial fibrillation.

INTRODUCTION The cornerstone of catheter ablation for atrial fibrillation (AF) is pulmonary vein electrical isolation (PVI). Recurrent AF post-PVI is a major limitation of the procedure with PV reconnection present in most patients. Single (SLT) and double (DLT) lung transplant surgery involves a 'cut and sew' PV antral isolation analogous to a catheter-based approach providing an opportunity to assess the efficacy of durable PVI. METHODS AND RESULTS A total of three hundred and twenty-seven consecutive lung transplant patients were compared with 201 control non-transplant thoracic surgery (THR) patients between 1998 and 2008. The primary analysis was the incidence of 'early' post-operative AF and 'late' AF (AF occurring following discharge from hospital after the index operation). Risk factors for the development of late AF were analysed using regression analysis. Acute post-operative AF was more common post-lung transplant (DLT 58/200 (29%) and SLT 36/127 (28%) vs. THR 28/201 (13.9%), P < 0.001) occurring at 4.7 ± 5.0 days in DLT, 3.4 ± 2.5 days after SLT, and 7.4 ± 11.2 days in the thoracic group (P < 0.001). At a mean follow-up of 5.4 ± 2.9 years late AF occurred in 1/200 (0.5%) in DLT vs. 16/127 (12.6%) in SLT and 23/201 (11.4%, P < 0.001) in THR groups. Kaplan-Meier survival analysis demonstrated the association of DLT with long-term freedom from AF. Significant variables [hazard ratio (HR) on univariate regression analysis fo late AF were: DLT 0.06, age 1.09, LA diameter 1.2, hypertension 3.0, preoperative AF 12.2, early AF 8.8, rejection 3.2]. CONCLUSION Double but not SLT provides long-term freedom from AF despite a similar early post-operative incidence. This supports the critical role of the pulmonary veins in the pathogenesis of atrial fibrillation and the importance of durable electrical isolation of the pulmonary veins as the cornerstone in strategies for the long-term prevention of AF.