Transient Complete Heart Block after Alcohol Septal Ablation

HomeCirculation: Cardiovascular InterventionsVol. 13, No. 8Transient Complete Heart Block After Alcohol Septal Ablation Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBTransient Complete Heart Block After Alcohol Septal AblationIncidence of Recurrence and Need for Permanent Pacemaker Bassim El-Sabawi, MD, Rick A. Nishimura, MD, Yong-Mei Cha, MD, David J. Bradley, MD, PhD, Kyle W. Klarich, MD, Charanjit S. Rihal, MD and Mackram F. Eleid, MD Bassim El-SabawiBassim El-Sabawi Department of Medicine, Mayo Clinic, Rochester, MN (B.E.-S.). Search for more papers by this author , Rick A. NishimuraRick A. Nishimura Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (R.A.N., Y.-M.C., D.J.B., K.W.K., C.S.R., M.F.E.). Search for more papers by this author , Yong-Mei ChaYong-Mei Cha Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (R.A.N., Y.-M.C., D.J.B., K.W.K., C.S.R., M.F.E.). Search for more papers by this author , David J. BradleyDavid J. Bradley Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (R.A.N., Y.-M.C., D.J.B., K.W.K., C.S.R., M.F.E.). Search for more papers by this author , Kyle W. KlarichKyle W. Klarich Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (R.A.N., Y.-M.C., D.J.B., K.W.K., C.S.R., M.F.E.). Search for more papers by this author , Charanjit S. RihalCharanjit S. Rihal Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (R.A.N., Y.-M.C., D.J.B., K.W.K., C.S.R., M.F.E.). Search for more papers by this author and Mackram F. EleidMackram F. Eleid Correspondence to: Mackram F. Eleid, MD, Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Email E-mail Address: [email protected] https://orcid.org/0000-0001-6082-5379 Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (R.A.N., Y.-M.C., D.J.B., K.W.K., C.S.R., M.F.E.). Search for more papers by this author Originally published6 Aug 2020https://doi.org/10.1161/CIRCINTERVENTIONS.120.009202Circulation: Cardiovascular Interventions. 2020;13:e009202The most common complication of alcohol septal ablation (ASA) is conduction disturbances, including complete heart block (CHB) which often necessitates permanent pacemaker (PPM) implantation.1 Although CHB may occur up to several weeks after ASA, the majority present shortly after alcohol injection and are initially transient.2 The incidence of CHB recurrence in patients with transient CHB is unclear and as a result, the determination of their need for PPM is challenging. This study aimed to evaluate the temporal incidence of CHB recurrence in patients with transient CHB after ASA to better understand their optimal postprocedural management.This study was approved by the Mayo Clinic Institutional Review Board. The supporting data for these findings are available from the corresponding author upon reasonable request. Consecutive patients that underwent ASA for hypertrophic cardiomyopathy during 2003 to April 2019 at Mayo Clinic were reviewed retrospectively. ASA was performed using previously described catheter techniques.1,2 Continuous telemetry monitoring was performed during ASA and continued for at least 48 hours with daily 12-lead ECG. Patients that developed early transient CHB were assessed for recurrence of CHB and need for PPM. Transient CHB was defined as episodes >10 seconds occurring within 24 hours of ASA with recovery of atrioventricular conduction. Univariate analysis was performed to assess characteristics associated with CHB recurrence using the χ2 or Fisher exact test and 2-sample unpaired t test as appropriate. Variables analyzed included age, sex, septal thickness, pre-/post-ASA left ventricular outflow tract gradient, volume of alcohol injected, number of septal perforators ablated, and pre-/post-ASA conduction abnormalities.A total of 243 patients had ASA performed, including 152 (62.6%) females. Mean age was 68.0±12.0 years. Mean maximal septal thickness was 19.0±3.9 mm and 48 (19.7%) had preexisting PPM or implantable cardioverter-defibrillator. Pre-ASA conduction abnormalities included first degree atrioventricular block in 62 (25.5%), right bundle branch block in 30 (12.3%), or left bundle branch block in 20 (8.2%). ASA was performed with mean total ethanol of 1.7±0.6 mL. CHB occurred in 59 (24.3%) patients, including 34 (14.0%) who developed early transient CHB (32 intraprocedure; 2 postprocedure). New PPM was placed in 46 (18.9%; 23.5% of patients without prior device). Of those with transient CHB, 15/34 (44.1%) developed recurrence. Recurrent CHB occurred within 24 hours of ASA in 5/34 (14.7%), 8/34 (23.5%) between 24 and 48 hours, 1/34 (2.9%) between 48 and 72 hours, and 1/34 (2.9%) after 72 hours (Figure). The latter case occurred at 2 weeks in a patient with pre-ASA first degree atrioventricular block and right bundle branch block. Both patients with postprocedure transient CHB did not develop recurrence.Download figureDownload PowerPointFigure. Complete heart block (CHB) after alcohol septal ablation.A, Incidence of CHB (n=243). B, Temporal incidence of CHB recurrence in patients with early transient CHB (n=34).Twenty-two (64.7%) patients with transient CHB underwent PPM placement, including all with recurrent CHB and 7 without due to concern of late recurrence. Of the 7 that underwent PPM implantation prophylactically, 6 had documented PPM interrogation (median, 351 days [interquartile range, 41–1822]) with 5 showing no ventricular pacing need and 1 requiring intermittent pacing for atrial fibrillation with slow rate. Of the variables analyzed, only decreased post-ASA left ventricular outflow tract gradient (mean 7.3±14.0 versus 32.6±39.2 mm Hg; P=0.02) was significantly associated with CHB recurrence. No patients with transient CHB died at last follow-up (median, 316 days [interquartile range, 252–930]). Medications at discharge included beta blocker in 29/34 (85.3%), nondihydropyridine calcium channel blocker in 8/34 (23.5%), amiodarone in 6/34 (17.6%), and none on disopyramide.This study demonstrates that nearly half of patients with early transient CHB after ASA developed a recurrent episode; however, this risk appears to be low if recurrence did not develop within 72-hour post-ASA. The incidence of CHB recurring after 72 hours in patients with transient CHB (2.9%) was higher than that of new CHB presenting after 72 hours in patients without early CHB (0.8%) based on a recent analysis from our center.2 Limitations of this study include the retrospective/single center design and small sample size. Furthermore, the study population primarily included suboptimal candidates for septal myectomy with increased age and conduction abnormalities that are at elevated risk for CHB.2,3 Nevertheless, these data suggest that deferment of PPM implantation and continued close observation may be considered as an alternative management strategy in patients with ASA complicated by transient CHB and no recurrence within 72-hours.Sources of FundingNone.DisclosuresNone.FootnotesFor Sources of Funding and Disclosures see page 2.Correspondence to: Mackram F. Eleid, MD, Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Email eleid.[email protected]eduReferences1. Sorajja PValeti UNishimura RAOmmen SRRihal CSGersh BJHodge DOSchaff HVHolmes DR. Outcome of alcohol septal ablation for obstructive hypertrophic cardiomyopathy. Circulation. 2008; 118:131–139. doi: 10.1161/CIRCULATIONAHA.107.738740LinkGoogle Scholar2. El-Sabawi BNishimura RABarsness GWCha YMGeske JBEleid MF. Temporal occurrence of arrhythmic complications after alcohol septal ablation. Circ Cardiovasc Interv. 2020; 13:e008540. doi: 10.1161/CIRCINTERVENTIONS.119.008540LinkGoogle Scholar3. Veselka JLawrenz TStellbrink CZemanek DBranny MJanuska JGroch LDimitrow PKrejci JDabrowski Met al. Low incidence of procedure-related major adverse cardiac events after alcohol septal ablation for symptomatic hypertrophic obstructive cardiomyopathy. Can J Cardiol. 2013; 29:1415–1421. doi: 10.1016/j.cjca.2013.04.027CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails August 2020Vol 13, Issue 8 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.120.009202PMID: 32757660 Originally publishedAugust 6, 2020 Keywordsheart blockcardiomyopathiesarrhythmiaalcoholsrecurrencePDF download Advertisement SubjectsCatheter-Based Coronary and Valvular InterventionsHypertrophy