Heart 1998;80:257–262 257 Electrocardiographic changes after alcohol septal Heart: first published as 10.1136/hrt.80.3.257 on 1 September 1998. Downloaded from ablation in hypertrophic obstructive cardiomyopathy J Kazmierczak, Z Kornacewicz-Jach, M Kisly, R Gil, A Wojtarowicz Abstract Alcohol ablation of the first large septal branch Objective—To report acute and mid-term of the left anterior descending coronary artery is electrocardiographic changes in patients a new therapeutic method of reducing outflow with hypertrophic obstructive cardiomyo- tract obstruction and improving left ventricular pathy (HOCM) after alcohol ablation of function in patients with hypertrophic obstruc- the first large septal branch of the left tive cardiomyopathy (HOCM).1–6 Alcohol sep- anterior descending coronary artery; and tal ablation induces myocardial infarction of the to relate electrocardiographic data with subaortic part of the interventricular septum, the left ventricular outflow tract pressure where the ventricular conduction system be- gradients. gins. One would therefore expect there to be Patients—Nine consecutive symptomatic significant changes in the electrocardiogram. patients with HOCM (mean (SD) age 45 We present the electrocardiographic changes in (12) years). a group of nine patients who underwent the Methods—Analysis of baseline and post- procedure. procedure ECGs and 24 hour ambulatory monitoring (up to six months). ECG data Methods were related to left ventricular outflow PATIENTS tract pressure gradients. We report nine consecutive symptomatic pa- Results—One patient developed complete tients with subaortic HOCM , in whom alcohol atrioventricular block requiring perma- septal ablation was performed. Eight had nent pacing. The PR interval was signifi- dyspnoea, five had chest pain; seven were in cantly prolonged up to third month after New York Heart Association class II and two in ablation. Immediately after the procedure class III. There were eight men and one all patients developed right bundle branch woman, mean (SD) age 45 (12) years (range 26 block. At the sixth month of follow up, to 63 years). All patients had normal coronary http://heart.bmj.com/ right bundle branch block was present in arteries. four patients. New anterior ST elevation In all patients the first septal branch of the developed immediately after ablation in left anterior descending artery was ablated. In five of the nine patients, and new Q waves six, 3 ml of alcohol was used; in the remaining in four. The QRS duration was signifi- three, 4 ml (3.3 (0.5) ml per patient). cantly prolonged immediately after abla- A reduction in the left ventricular outflow tion and during follow up. There was tract pressure gradients immediately after the procedure, measured haemodynamically, was significant but transient prolongation of on September 28, 2021 by guest. Protected copyright. QT-mean and QTc-mean intervals. QT achieved in all patients. The left ventricular dispersion, QTc dispersion, and JTc- outflow tract pressure gradient at rest was reduced from 56 (58) mm Hg (range 18 to mean interval were not aVected. JT and 108) before treatment to 12 (13) mm Hg JTc dispersions were transiently pro- (range 0 to 40, p < 0.01). The postextrasystolic longed. No serious ventricular arrhyth- gradient could be reduced from 139 (45) mm mias were recorded during Holter Hg (range 69 to 208) to 37 (34) mm Hg (range monitoring, either before or after the pro- 0 to 81, p < 0.01). During the Valsalva cedure. There were no significant correla- manoeuvre, the gradient decreased from 132 tions between the left ventricular outflow (31) mm Hg (range 89 to 180) to 25 (21) mm tract pressure gradient and QTc, QT-d, Hg (range 0 to 60, p < 0.02). Doppler QTc-d, JTc, JT-d, JTc-d, or QRS duration Department of echocardiographic measurements of the pres- Cardiology, before and after ablation. Pomeranian Medical sure gradients before and after the procedure Conclusions—Alcohol septal ablation for are given in table 1. School, Powstanców HOCM induces significant changes in the Wlkp.Str. 72, 70-111 During occlusion of the septal artery and Szczecin, Poland resting ECG in most patients, despite the alcohol injection, all patients complained of J Kazmierczak, occlusion of a relatively small artery. The mild to moderate chest pain and a feeling of Z Kornacewicz-Jach, changes include new Q waves, new bundle pressure in the thorax. Administration of 3–5 M Kisly branch block, transient anterior ST seg- mg of morphine was necessary in all patients. R Gil ment elevation, atrioventricular block, A Wojtarowicz During first 24 hours after the procedure three and transient prolongation of QT interval. of nine patients complained of chest pain or (Heart 1998;80:257–262) Correspondence to: discomfort in the thorax, requiring administra- Dr Kazmierczak. Keywords: hypertrophic obstructive cardiomyopathy; tion of up to 5 mg of morphine. Accepted for publication alcohol septal ablation; electrocardiography; QT On discharge, eight of the nine patients had 24 April 1998 interval improved subjectively while one (with an 258 Kazmierczak, Kornacewicz-Jach, Kisly, et al Table 1 Maximum left ventricular outflow tract pressure gradients (mm Hg) before chosen at diagnostic angiography, and the (baseline) and after alcohol septal ablation measured by Doppler echocardiography at rest branch was occluded by balloon inflation. The Heart: first published as 10.1136/hrt.80.3.257 on 1 September 1998. Downloaded from measurement of the left ventricular outflow Immediately After 3 After 9 After 3 After 6 Patient Baseline after days days months months tract pressure gradient was then repeated. Echocardiographic contrast injections (1–2 ml 1 291010101111 2 13 8 10 10 13 5 of Levovist, Schering, Germany) through the 390403045810balloon catheter, with simultaneous transtho- 4 108 12 30 10 18 26 racic echocardiographic recording, were used 5 65 5 45 45 49 32 6 117 13 25 15 6 8 to assess the area of the septum supplied by this 7 691035201113 artery and to relate it to the location of the 855355176–– 933251510––myocardial hypertrophy. After this, 1 ml of Mean (SD) 64 (36) 18 (13)* 28 (15)* 27 (23)† 17 (15)* 15 (10)* 98% ethanol was slowly injected through the inflated balloon into the vessel. If the reduction *p < 0.01 v baseline; †p < 0.02 v baseline. of the left ventricular outflow tract pressure Table 2 Morphological features of the electrocardiograms before (baseline) and after gradient was insuYcient, further 1 ml doses of alcohol septal ablation ethanol were injected at five minute intervals, up to maximum of 4 ml. Ten minutes after the After ablation last injection the balloon was deflated and the Baseline 1 h 3 d 7 d 9 d 3 m 6 m catheter removed. Pressures were then meas- ured again. Number 9 999977 Sinus rhythm (n/total) 9/9 8/9* 8/9* 8/9* 7/9† 6/7‡ 6/7‡ New ST elevation (n/total) 5/9 5/9 5/9 1/9 1/7 0/7 ECG ANALYSIS New Q waves (n/total) 4/9 4/9 4/9 4/9 2/7 2/7 Resting 12 lead electrocardiograms were re- RBBB (n/total) 1/9 2/9 2/9 1/9 2/9 1/7 1/7 RBBB + LAH (n/total) 0/9 6/9 4/9 5/9 4/9 3/7 3/7 corded at a paper speed of 50 mm/s before RBBB + LPH (n/total) 0/9 1/9 0/9 0/9 0/9 0/7 0/7 ablation and then after one hour, after three, Inc RBBB + LAH (n/total) 1/9 0/9 0/9 0/9 0/9 0/7 0/7 seven, and nine days, and after three and six LBBB (n/total) 1/9 0/9 1/9§ 1/9§ 1/9§ 1/7§ 1/7§ months. The following features were noted: *One patient with complete heart block; †one patient paced and one patient with junctional basic rhythm, any new ST segment elevation, rhythm, 75/min; ‡one patient paced; §a diVerent patient from at baseline. any new Q waves, atrioventricular block, and h, hours; d, days; m, months; inc RBBB, incomplete right bundle branch block; LAH, left anterior hemiblock; LBBB, left bundle branch block; LPH, left posterior hemiblock; RBBB, complete right the presence of bundle branch block. The heart bundle branch block. rate was calculated from the first four com- plexes. QRS axis in the frontal plane was calcu- implanted pacemaker) reported no change in lated according to general rules (values from his subjective symptoms. After six months, the range −90° to ±180° were also included). subjective improvement was still present in all QRS duration was measured in all leads and seven patients followed at that time. the arithmetical mean was calculated. The Serial creatine kinase activity (mean (SD)) longest PR interval was taken for analysis. For http://heart.bmj.com/ peaked at 1529 (340) IU (range 1051 to 2076) QT measurements an average of three con- at 14.0 (7.3) hours after the procedure, and secutive intervals was taken from all leads. The aspartate transaminase at 218 (71) IU (range mean QT (QT-mean) was the arithmetical 107 to 320) at 24.8 (3.3) hours. mean from all 12 leads. QTc was calculated Drug dosage was decreased twofold to four- with the formula of Bazett for each lead fold on the day before ablation and continued separately, and a mean value was taken for fur- at that level after the procedure in all patients: ther analysis (QTc-mean). For QT and QTc verapamil (120 mg/day) in seven, propranolol dispersions, the diVerence between the maxi- (90 mg/day) in one, and acebutolol (200 on September 28, 2021 by guest. Protected copyright. mum and the minimum QT and QTc intervals mg/day) in one.