Impact of Preoperative Right Heart Structural Abnormalities on Atrial Arrhythmias Following Lung Transplantation: A Stratified Cohort Study

Objective To determine whether preoperative right heart structural abnormalities (RHSA) drive new-onset atrial arrhythmias (AA) after lung transplantation and modify the prognostic impact of AA on all-cause mortality. Methods In this dual-center retrospective cohort, 503 adult recipients who underwent allogeneic lung transplantation between 2017 and 2024 were stratified by preoperative echocardiography into RHSA and non-RHSA groups. The primary exposure was new-onset AA within 30 postoperative days; the primary outcome was all-cause mortality. Firth-corrected penalized logistic regression on 50 multiply imputed datasets identified independent risk factors for AA. A multivariable Cox model with an RHSA × AA interaction term assessed effect modification by right heart phenotype. Results Postoperative AA occurred in 30.2% of recipients and was independently predicted by recipient age and left ventricular hypertrophy (LVH), whereas RHSA was not an independent risk factor. The AA-associated hazard of all-cause mortality was numerically greater in the RHSA subgroup (HR, 2.80; 95% CI, 1.62–4.84; P <.001) than in the non-RHSA subgroup (HR, 1.55; 95% CI, 1.14–2.10; P=.005); the RHSA × AA interaction term was not statistically significant (P = .158). Conclusions Postoperative AA is driven predominantly by age and LVH, not by RHSA. Effect modification by RHSA was not formally established in this cohort, although RHSA may be a potential effect modifier. These findings are hypothesis-generating; a right heart phenotype-based rhythm-control strategy requires prospective validation.