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Although a surgical anastomosis between the donor Introduction Atrial arrhythmias commonly occur following lung transplantation. Atrial fibrillation is the most common arrhythmia in the first weeks andmonths following transplantation, while atrial tachycardia (AT) or atrial flutter (AFL) is the most common atrial arrhythmia in the late follow-up period. Right atrial circuits, including cavotricuspid isthmus–dependent flutter, are reported to be the most common mechanism of postoperative AT/AFL, while tachycardia originating within the donor cuff of atrial tissue and late establishment of a single donor-to-recipient electrical connection across the graft anastomosis remains an unusual mechanism of atrial arrhythmias following lung transplantation. We describe an adult lung transplant recipient who presented with a left-sided AFL that involved 2 discrete electrical connections between the donor pulmonary vein (PV) graft and recipient left atrium (LA). pulmonary vein cuff and recipient left atrium should represent the ultimate form of antral pulmonary vein isolation, late-appearing electrical conduction across the donor-to-recipient anastomosis, between tissues from different hosts, occurs rarely and can result in a reentrant mechanism of AT. Case report A 53-year-old woman with a history of alpha-1 antitrypsin deficiency–related emphysema underwent bilateral lung transplantation 7 years prior to arrhythmia presentation. At transplant, the donor PV cuffs were anastomosed to separate recipient atriotomies for the right and left PVs. She presented with symptomatic atypical AFL that recurred despite cardioversion and antiarrhythmic medication trials, and she was referred for a catheter ablation. The 12-lead electrocardiogram during tachycardia demonstrated flutter waves with a right inferior axis, consistent with a left atrial origin. In the electrophysiology lab, the patient arrived in tachycardia, which had an atrial cycle length of 220–240 ms. A decapolar catheter was introduced into the coronary sinus (CS), with the earliest activation in the distal electrodes, demonstrating an eccentric

Atypical flutter following lung transplantation involving recipient-to-donor tissue connections