Atrial fibrillation (AF) occurs after heart transplantation (HT), but data on incidence and long-term outcomes remain limited. This retrospective study published in the Heart Rhythm assessed predictors of early and late AF, stroke risk, and survival after HT.

Adult patients undergoing HT between January 1, 2005, and September 30, 2024, at a high-volume center were included. AF was categorized as early (<30 days post-HT) or late (≥30 days). Recipient and donor clinical variables were analyzed. Separate CHA2DS2-VASc scores incorporating recipient and donor age were calculated. Predictors of AF were evaluated using logistic regression.

Among 1,072 patients (median age 55 [IQR 45–63] years; 75% male), AF occurred in 11% (n=111), most frequently as late or combined early and late AF. Donor age, post-HT extracorporeal membrane oxygenation, and pericardial effusion were independently associated with early AF. Rejection, cardiac allograft vasculopathy, and early AF were independently associated with late AF. Stroke occurred in 9% and was independently associated with pre-HT mechanical circulatory support and ischemic time, but not AF. CHA2DS2-VASc scores incorporating donor and recipient factors were associated with stroke risk, and the donor-derived score was also associated with AF. Survival was similar through 3 years; at 5 years, survival was lower in patients with AF (72% vs. 86%; p<0.01).

AF occurred in 11% of HT recipients and was associated with lower 5-year survival. Both donor and recipient factors were associated with AF and stroke risk stratification.