Coexisting normal sinus rhythm and atrial fibrillation 18 years after heart transplant.

Atrial fibrillation is an important cardiogenic cause of embolic phenomenon to the brain leading to stroke and long-term disability. Recognition of atrial fibrillation is of cardinal importance in the workup of stroke and transient ischemic attack (to prevent future strokes) by the timely institution of anticoagulation therapy. We describe a patient with history of standard orthotopic heart transplant (st.OHT) who had no clinical or electrocardiographic signs of atrial fibrillation. He presented with a transient ischemic attack (TIA) and subsequently was found to have two distinct left atrial appendages (LAA) in two different rhythms based on transesophageal echocardiography (TEE) and pulse wave (PW) Doppler. The donor LAA was in normal sinus rhythm (NSR) and recipient LAA in atrial fibrillation (AF). This was an extremely rare but important diagnosis in our patient, which led to the institution of anticoagulation therapy rather than aspirin and dipyridamole as described in neurological literature. We discuss different types of heart transplant techniques and their causatum on postoperative atrial tachycardias. Significance of TEE in the scenario of TIA and follow-up in heart transplant patients is also canvassed.