Second look diagnosis: dual sinus nodes rhythm in heart transplant patient

Gabriela Strey
Med J Aust 2023; 219 (4): 152-152. || doi: 10.5694/mja2.52045
Published online: 21 August 2023

A 76‐year‐old woman presented to our regional hospital with coronavirus disease 2019 (COVID‐19)‐related symptoms. Her past medical history was significant for an orthotopic heart transplant in 2007 (no records available). An electrocardiogram showed sinus rhythm 65 beats per minute, but we noted increased atrial activity with two distinct p waves on the rhythm strip (Figure, A and B): the preserved recipient and the donor sinoatrial node activity, which is typical for biatrial heart transplants.1,2 Only the transplanted sinoatrial nodal activity is able to conduct to the ventricles, as the surgical anastomosis creates an electrical block that prevents transmission to the ventricles (Figure, B).



  • Gabriela Strey

  • Wide Bay Hospital and Health Service South, Hervey Bay Hospital, Hervey Bay, QLD

Patient consent

The patient gave written consent for publication.


The author thanks all medical teams and staff involved in the care of this patient, and Angela Ratsch for her helpful comments on the preparation of this manuscript.

Competing interests:

No relevant disclosures.

  • 1. Beukian S, Mahmood K, Anyanwu A, et al. A tale of 2 nodes after orthotopic heart transplant. JACC Case Rep 2020; 2: 1849‐1851.
  • 2. Thajudeen A, Stecker EC, Shehata M, et al. Arrhythmias after heart transplantation: mechanisms and management. J Am Heart Assoc 2012; 1: e001461.


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