2026 FSA Podium and Poster Abstracts

Introduction: Management of orthotopic heart transplant (OHT) recipients requires a specialized understanding of denervated cardiac physiology. These patients are uniquely dependent on intrinsic conduction or implanted electronic devices, as they lack autonomic responses to hemodynamic stress. This case describes an intraoperative PEA arrest in a 30-year-old OHT perform a pre- patient where the failure to procedural cardiac device interrogation contributed to a catastrophic failure of the heart's primary "safety net" during severe coronary vasospasm.

Case Description: A 30-year-old female with a history of Danon Disease and OHT (2018) presented with syncope and chest pain following a one-week lapse in immunosuppression. She was scheduled for urgent coronary angiography and endomyocardial biopsy under Monitored Anesthesia Care (MAC). The patient had an indwelling AICD (placed 2009, generator change 2016); however, no formal interrogation was performed prior to the procedure to confirm battery longevity, capture thresholds, or current programming.

During coronary engagement, instrumentation of the left anterior descending artery triggered profound coronary vasospasm, leading to a "shut down" of the left coronary system. The patient rapidly progressed to a 2:1 heart block and then PEA arrest. Despite the indwelling AICD, the device failed to provide backup pacing or override the bradyarrhythmia, leaving the denervated heart without any chronotropic support.

Anesthesia immediately converted to General Anesthesia with endotracheal intubation. Due to the lack of effective internal pacing, a temporary transvenous pacemaker was urgently placed alongside an Impella CP for mechanical circulatory support. After five minutes of ACLS, ROSC was achieved. Subsequent angiography showed complete resolution of the vasospasm, and the patient was eventually discharged in stable condition.

Discussion: This case illustrates a critical patient safety gap in the perioperative management of transplant recipients. Because an orthotopic heart transplant (OHT) patient cannot mount a sympathetic tachycardic response to ischemia or hypotension due to denervation, they are "unprotected" without a functional pacemaker. The presence of an indwelling device can lead to a false sense of security and complacency. Without interrogation, the anesthesiologist cannot know if the cardiac implanted electronic device (CIED) is at its end-of-life or if the settings are appropriate for the procedure. This event highlights the need for a standardized quality improvement protocol requiring CIED interrogation for all OHT patients undergoing interventional procedures, particularly those with complex medical histories and lapses in follow-up.

Conclusion: In a denervated heart, a non-interrogated pacemaker is a latent clinical failure. This case demonstrates that pre-procedural verification of device functionality is not a secondary task, but a vital prerequisite for ensuring patient safety in the setting of unpredictable intraoperative events like coronary vasospasm.