Long-term pacing in heart transplant recipients is usually unnecessary. 
The indications for and timing of permanent pacing were reviewed in all 17 of 154 adult heart transplant recipients at this center who have had permanent pacemakers implanted.  Resting 12-lead ECGs recorded during routine follow-up were examined.  A prospective study of pacing requirement was then undertaken.  Holter monitoring was performed before and after reprogramming the pacemakers to VVI mode at 50 beats/min.  Exercise responses in various pacing modes were then assessed in seven patients with rate responsive pacemakers using a standard Bruce protocol treadmill test.  The indication for pacing was sinus node dysfunction in 59% (10/17) and atrioventricular (AV) block in 41% (7/17).  The majority of pacemakers were implanted between seven and 21 days after transplantation.  There was a progressive reduction in the frequency of pacing on 12-lead ECGs with time after transplantation.  There was a progressive reduction in the frequency of pacing on 12-lead ECGs with time after transplantation.  Eight of 14 patients with empirically selected programming paced during Holter monitoring.  After reprogramming to 50 beats/min VVI mode only three of 14 patients, all with sinus node dysfunction, paced.  Rate responsive pacing made no difference to exercise time.  The requirement for long-term pacing in cardiac transplant recipients is small (3/154) and is limited to patients with sinus node dysfunction.  Rate responsive pacing did not increase exercise tolerance.