Immediately following a heart transplant, a patient has two P waves followed by one QRS...

After aheart transplant, the native atrial tissue may continue to generateP waves, even though the donor heart generates its own rhythm. This results in the appearance oftwo P waveson ECG — one from the native sinoatrial node and one from the donor atrium. This is anormal findingpost-transplant and doesnot require intervention.

“Dual P waves seen post-transplant are common due to retained native atrial activity. The QRS response from donor conduction confirms proper graft function.”

(Referenced from CCRN Pediatric – Direct Care: Cardiovascular, Post-Transplant Electrophysiology Monitoring)