Terbutaline for Management of Relative Bradycardia Post-Orthotopic Heart Transplant: A Single Center Experience

Background: Vagal nerve denervation during the heart transplant procedure results in higher resting heart rates in these recipients compared to the general population. Relative bradycardia (RB) is a common and often temporary post-operative complication that can be managed with agents like terbutaline; however, little data exist on the efficacy, safety, and necessity of long-term terbutaline use post-heart transplant. Methods: This was a single-center, retrospective, descriptive study conducted at a large academic medical center investigating oral terbutaline use for RB management in heart transplant recipients. Outcomes included time to and reason for terbutaline discontinuation post-transplant, adverse event rates, and permanent pacemaker (PPM) placement rates. Results: In the 229 patients included, the median (IQR) time to terbutaline initiation was 8 (5, 12) days post-heart transplant, with a median (IQR) time to discontinuation of 56 (20, 96) days from the first dose. In most cases, terbutaline was successfully tapered off outpatient due to the resolution of RB. Tachyarrhythmias occurred in 29 (12.7%) patients without long-term sequelae. At 3 months post-transplant, PPM had been placed for chronotropic support in 15 patients (6.6%) with a median time (IQR) to PPM placement of 24 (19, 77) days from transplant. Conclusion: This study's overall low PPM placement rate suggests that early sinus node dysfunction can be treated with pharmacotherapy without committing to a permanent device, and that terbutaline can be used safely in early post-heart transplant recipients. If patients require long-term chronotropic support, the risk-benefit of PPM placement versus continued terbutaline should be considered.