Stratification of Arrhythmic Risk Using Remote Patient Monitoring in a Heart Transplant Recipient with Coronary Allograft Vasculopathy

INTRODUCTION: Criteria for ICD implantation in heart transplant recipients remain poorly defined. During the COVID-19 pandemic, remote patient monitoring (RPM) has been increasingly used to minimize the patient risk of infection. In addition, RPM also offers monitoring of heart rhythm and thus may have a potential to improve arrhythmic risk stratification. We present a case of heart transplant recipient in whom the decision for ICD implantation was based on RPM data. CASE REPORT: We performed elective heart transplantation in 66-year old male patient with nonischemic cardiomyopathy. The transplantation procedure was uneventful; however, on the first postoperative day we performed coronary angiography due to hypokinesia of inferior left ventricular wall. We found 1-vessel disease with stenosis of proximal RCA, which was resolved using 1 drug-eluting stent (DES). Discharge echocardiography showed normal graft function without segmental wall motion abnormalities. At the routine 12-month follow-up visit the patient was asymptomatic, but we found an increase in serum troponin and performed coronary angiography, which showed allograft vasculopathy with significant stenosis of mid LAD, which was resolved with 1 DES. As the echocardiography did not show any decline in the graft function and no ventricular arrhythmias were observed, we did not opt for immediate ICD implantation; instead, we enrolled the patient in our institution's heart transplant RPM program. The RPM program allows for remote monitoring of patient's blood pressure, weight, SpO2 and ECG, which are reviewed by heart transplant nurse on daily basis. After 2 months of RPM we first observed premature ventricular complexes with increasingly more frequent trigeminy episodes being recorded in the course of the following 4 weeks. Repeated coronary angiography showed no progression of vasculopathy and graft function was normal. However, considering the high risk for sudden cardiac death in this patient due to the combination of vasculopathy and significant ventricular ectopy we opted for the implantation of ICD. SUMMARY: RPM offers relevant and timely medical data that may facilitate the management of heart transplant recipients. Future trials are warranted to investigate whether such approach may also improve the arrhythmic risk stratification in this patient population.