International Journal of Cardiology 171 (2014) e37–e38
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Outcome of patients after alcohol septal ablation with permanent pacemaker implanted for periprocedural complete heart block Josef Veselka a,⁎, Jan Krejčí b, Pavol Tomašov a, Václav Durdil a, Lucie Riedlbauchová a, Jakub Honěk a, Tomáš Honěk b, David Zemánek a a b
Department of Cardiology, 2nd Medical School, Charles University, University Hospital Motol, Prague, Czech Republic 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Center, St. Anne´s Hospital, Masaryk University, Brno, Czech Republic
a r t i c l e
i n f o
Article history: Received 9 September 2013 Accepted 30 November 2013 Available online 7 December 2013 Keywords: Hypertrophic cardiomyopathy Ablation Prognosis
Highly symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) irresponsive to medical therapy are treated with surgical myectomy, dual-chamber pacing or alcohol septal ablation (ASA) [1]. Based on single-center studies or national registries it seems that both short- and long-term outcomes of ASA are acceptable [2]. The most frequent major complication associated with ASA is the mostly self-terminating complete heart block (CHB) that occurs in 20–50% of patients and requires permanent pacemaker implantation in 9–20% of all ASA patients [2,3]. Accordingly, this retrospective study was undertaken to evaluate the long-term outcome of patients who underwent early permanent pacemaker implantation due to post-ASA CHB. Details of the ASA technique have been published previously [3]. A permanent pacemaker was implanted in patients with persistent CHB or in patients with recurrent CHB occurring N24 h after ASA. All patients underwent dual-chamber pacemaker implantation with the right ventricular lead implanted at the apex. Biventricular pacing has not been used in these patients. All patients underwent clinical examination at 3–6 months after ASA and then every year. Written informed consent was given by each patient and the local ethics committee approved the study protocol. Alcohol septal ablation was performed in 167 consecutive, highly symptomatic, non-paced patients with HOCM (59 ± 12 years, 53%
⁎ Corresponding author. Tel.: +420 224434900; fax: +420 224434920. E-mail address: [email protected] (J. Veselka). 0167-5273/$ – see front matter © 2013 Elsevier Ireland. Ltd All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.11.119
females, baseline pressure gradient 68 ± 42 mm Hg, baseline NYHA class 2.9 ± 0.4), of whom 17 (10%) suffered from periprocedural CHB requiring early post-ASA pacemaker implantation (pacemaker group). Pacemakers were implanted 3–15 days after ASA. All patients, except for one, suffered from CHB during the hospital stay. The baseline characteristics of post-ASA paced and non-paced patients are listed in Table 1. The total in-hospital mortality was 0.6%; one non-paced patient died of pulmonary embolism. There were no adverse events related to pacemaker implantation. No patients were lost from follow-up. The median follow-up period was 4.7 years (IQR 2–7.2 years, 845 patient–years). Paced and nonpaced patients were followed-up for 4 years (IQR 2.5–8.3 years) and 4.8 years (IQR 2.1–7.2 years), respectively. There had been 18 deaths (2 vs. 16 deaths) at the conclusion of the study period, including the aforementioned in-hospital death (10.8% of total population). The incidence per 100 person–year follow-up of all-cause mortality was 2.22 deaths per 100 person–years of follow-up (95% CI, 0.27–8.01) and 2.12 (95% CI, 0.27–8.01) in paced and non-paced patients, respectively. Ten patients (6%) underwent a repeated interventional septum reduction procedure (three in paced and seven in non-paced group). Eight non-paced patients (4.8%) underwent ICD implantation during the study period, three of them (2% of all patients) had appropriate discharges. A comparison of the clinical and echocardiographic characteristics of paced and non-paced patients at follow-up is presented in Table 2. Among the patients with an implanted pacemaker, 11 (65%) restored AV conduction during follow-up (up to 6 months in all these patients). Ten patients (59%) were on sinus rhythm, one patient (6%) had atrial fibrillation and six patients (35%) were paced at follow-up. Accordingly, the long-term permanent pacemaker dependency was 4% from all ASA patients. In the non-paced group, three patients (2%) underwent late pacemaker implantation (12–53 months after ASA) for sick sinus syndrome or advanced heart block. Relief of dyspnea was significant in both groups (p b 0.01) (Table 2). There was no significant difference between NYHA functional class at the most recent examination (1.7 ± 0.8 vs. 1.6 ± 0.8; p = 0.71). Also the left ventricular pressure gradient at rest decreased in both groups significantly (69 ± 43 vs. 21 ± 26 mm Hg in non-paced group; 62 ± 39 vs.15 ± 13 mm Hg in paced group; p b 0.01 for both). There was no significant difference in the left ventricular pressure gradient at the most recent examination between both groups (p = 0.28). Survival free of all-cause mortality in paced and non-paced patients at 1,
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J. Veselka et al. / International Journal of Cardiology 171 (2014) e37–e38
Table 1 Clinical and echocardiographic characteristics at baseline.
Age, years Women, % Dyspnea, NYHA class Angina, CCS class Episodes of syncope, % Left ventricular outflow gradient, mm Hg Left ventricular diameter, mm Left ventricular ejection fraction, % Basal septal thickness, mm Left atrium diameter, mm
Baseline non-paced pts.
Baseline paced pts.
P value
59 ± 12 52 2.9 ± 0.4 1.8 ± 1.1 13 69 ± 43
59 ± 11 65 2.9 ± 0.3 2.3 ± 0.9 12 62 ± 39
0.97 0.44 0.89 0.09 1.00 0.46
42 77 21 47
43 73 20 47
0.48 0.17 0.26 0.54
± ± ± ±
5 9 4 6
± ± ± ±
6 10 2 4
Table 2 Clinical and echocardiographic characteristics at follow-up.
Age, years Dyspnea, NYHA class Angina, CCS class Episodes of syncope, % Left ventricular outflow gradient, mm Hg Left ventricular diameter, mm Left ventricular ejection fraction, % Basal septal thickness, mm Left atrium diameter, mm
Follow-up non-paced pts.
Follow-up paced pts.
P value
64 ± 12 1.7 ± 0.8 0.5 ± 0.7 3 21 ± 26 47 ± 5 73 ± 10 14 ± 4 48 ± 6
65 ± 11 1.6 ± 0.8 0.5 ± 0.5 12 15 ± 13 48 ± 5 71 ± 13 13 ± 3 48 ± 4
0.84 0.60 0.95 0.15 0.31 0.08 0.74 0.41 0.75
5 and 10 years was 100% vs. 96.4% (95% CI, 93.2–99.5%), 100% vs. 91.8% (95% CI, 87–96.8%), and 80% (95% CI, 45–100%) vs. 80.9% (95% CI, 69.3–92.5%) (p = 0.85), respectively (Fig. 1). To our knowledge, this is the first study focused on the long-term outcome of patients with an implanted permanent pacemaker for early post-ASA CHB. The results of the present study demonstrate that
Fig. 1. Survival free of all-cause mortality for patients with and without pacemaker implanted early after ASA.
in non-paced patients undergoing the first ASA procedure, a permanent pacemaker was implanted in 10% of cases and there were no significant differences in i) long-term survival, ii) outflow pressure gradient at the most recent examination and iii) NYHA functional class at the most recent examination between patients with and without a post-ASA implanted pacemaker for procedure-related CHB. Moreover, two thirds of patients with a permanent pacemaker recovered AV conduction early after pacemaker implantation. Although this study reports the results of a registry over 15 years, it still included only 167 pre-ASA nonpaced patients, which subsequently resulted in a limited number of patients with periprocedural CHB requiring pacemaker implantation. Therefore, we are aware that the reported results need further validation. References [1] Gersh BJ, Maron BJ, Bonow RO, et al. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy. Circulation 2011;124:e783–831. [2] Fifer MA, Sigwart U. Hypertrophic obstructive cardiomyopathy: alcohol septal ablation. Eur Heart J 2012;32:1059–64. [3] Veselka J. Alcohol septal ablation for hypertrophic obstructive cardiomyopathy: a review of the literature. Med Sci Monit 2007;13:RA62–8.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Outcome of patients after alcohol septal ablation with permanent pacemaker implanted for periprocedural complete heart block Josef Veselka a,⁎, Jan Krejčí b, Pavol Tomašov a, Václav Durdil a, Lucie Riedlbauchová a, Jakub Honěk a, Tomáš Honěk b, David Zemánek a a b
Department of Cardiology, 2nd Medical School, Charles University, University Hospital Motol, Prague, Czech Republic 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Center, St. Anne´s Hospital, Masaryk University, Brno, Czech Republic
a r t i c l e
i n f o
Article history: Received 9 September 2013 Accepted 30 November 2013 Available online 7 December 2013 Keywords: Hypertrophic cardiomyopathy Ablation Prognosis
Highly symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) irresponsive to medical therapy are treated with surgical myectomy, dual-chamber pacing or alcohol septal ablation (ASA) [1]. Based on single-center studies or national registries it seems that both short- and long-term outcomes of ASA are acceptable [2]. The most frequent major complication associated with ASA is the mostly self-terminating complete heart block (CHB) that occurs in 20–50% of patients and requires permanent pacemaker implantation in 9–20% of all ASA patients [2,3]. Accordingly, this retrospective study was undertaken to evaluate the long-term outcome of patients who underwent early permanent pacemaker implantation due to post-ASA CHB. Details of the ASA technique have been published previously [3]. A permanent pacemaker was implanted in patients with persistent CHB or in patients with recurrent CHB occurring N24 h after ASA. All patients underwent dual-chamber pacemaker implantation with the right ventricular lead implanted at the apex. Biventricular pacing has not been used in these patients. All patients underwent clinical examination at 3–6 months after ASA and then every year. Written informed consent was given by each patient and the local ethics committee approved the study protocol. Alcohol septal ablation was performed in 167 consecutive, highly symptomatic, non-paced patients with HOCM (59 ± 12 years, 53%
⁎ Corresponding author. Tel.: +420 224434900; fax: +420 224434920. E-mail address: [email protected] (J. Veselka). 0167-5273/$ – see front matter © 2013 Elsevier Ireland. Ltd All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.11.119
females, baseline pressure gradient 68 ± 42 mm Hg, baseline NYHA class 2.9 ± 0.4), of whom 17 (10%) suffered from periprocedural CHB requiring early post-ASA pacemaker implantation (pacemaker group). Pacemakers were implanted 3–15 days after ASA. All patients, except for one, suffered from CHB during the hospital stay. The baseline characteristics of post-ASA paced and non-paced patients are listed in Table 1. The total in-hospital mortality was 0.6%; one non-paced patient died of pulmonary embolism. There were no adverse events related to pacemaker implantation. No patients were lost from follow-up. The median follow-up period was 4.7 years (IQR 2–7.2 years, 845 patient–years). Paced and nonpaced patients were followed-up for 4 years (IQR 2.5–8.3 years) and 4.8 years (IQR 2.1–7.2 years), respectively. There had been 18 deaths (2 vs. 16 deaths) at the conclusion of the study period, including the aforementioned in-hospital death (10.8% of total population). The incidence per 100 person–year follow-up of all-cause mortality was 2.22 deaths per 100 person–years of follow-up (95% CI, 0.27–8.01) and 2.12 (95% CI, 0.27–8.01) in paced and non-paced patients, respectively. Ten patients (6%) underwent a repeated interventional septum reduction procedure (three in paced and seven in non-paced group). Eight non-paced patients (4.8%) underwent ICD implantation during the study period, three of them (2% of all patients) had appropriate discharges. A comparison of the clinical and echocardiographic characteristics of paced and non-paced patients at follow-up is presented in Table 2. Among the patients with an implanted pacemaker, 11 (65%) restored AV conduction during follow-up (up to 6 months in all these patients). Ten patients (59%) were on sinus rhythm, one patient (6%) had atrial fibrillation and six patients (35%) were paced at follow-up. Accordingly, the long-term permanent pacemaker dependency was 4% from all ASA patients. In the non-paced group, three patients (2%) underwent late pacemaker implantation (12–53 months after ASA) for sick sinus syndrome or advanced heart block. Relief of dyspnea was significant in both groups (p b 0.01) (Table 2). There was no significant difference between NYHA functional class at the most recent examination (1.7 ± 0.8 vs. 1.6 ± 0.8; p = 0.71). Also the left ventricular pressure gradient at rest decreased in both groups significantly (69 ± 43 vs. 21 ± 26 mm Hg in non-paced group; 62 ± 39 vs.15 ± 13 mm Hg in paced group; p b 0.01 for both). There was no significant difference in the left ventricular pressure gradient at the most recent examination between both groups (p = 0.28). Survival free of all-cause mortality in paced and non-paced patients at 1,
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J. Veselka et al. / International Journal of Cardiology 171 (2014) e37–e38
Table 1 Clinical and echocardiographic characteristics at baseline.
Age, years Women, % Dyspnea, NYHA class Angina, CCS class Episodes of syncope, % Left ventricular outflow gradient, mm Hg Left ventricular diameter, mm Left ventricular ejection fraction, % Basal septal thickness, mm Left atrium diameter, mm
Baseline non-paced pts.
Baseline paced pts.
P value
59 ± 12 52 2.9 ± 0.4 1.8 ± 1.1 13 69 ± 43
59 ± 11 65 2.9 ± 0.3 2.3 ± 0.9 12 62 ± 39
0.97 0.44 0.89 0.09 1.00 0.46
42 77 21 47
43 73 20 47
0.48 0.17 0.26 0.54
± ± ± ±
5 9 4 6
± ± ± ±
6 10 2 4
Table 2 Clinical and echocardiographic characteristics at follow-up.
Age, years Dyspnea, NYHA class Angina, CCS class Episodes of syncope, % Left ventricular outflow gradient, mm Hg Left ventricular diameter, mm Left ventricular ejection fraction, % Basal septal thickness, mm Left atrium diameter, mm
Follow-up non-paced pts.
Follow-up paced pts.
P value
64 ± 12 1.7 ± 0.8 0.5 ± 0.7 3 21 ± 26 47 ± 5 73 ± 10 14 ± 4 48 ± 6
65 ± 11 1.6 ± 0.8 0.5 ± 0.5 12 15 ± 13 48 ± 5 71 ± 13 13 ± 3 48 ± 4
0.84 0.60 0.95 0.15 0.31 0.08 0.74 0.41 0.75
5 and 10 years was 100% vs. 96.4% (95% CI, 93.2–99.5%), 100% vs. 91.8% (95% CI, 87–96.8%), and 80% (95% CI, 45–100%) vs. 80.9% (95% CI, 69.3–92.5%) (p = 0.85), respectively (Fig. 1). To our knowledge, this is the first study focused on the long-term outcome of patients with an implanted permanent pacemaker for early post-ASA CHB. The results of the present study demonstrate that
Fig. 1. Survival free of all-cause mortality for patients with and without pacemaker implanted early after ASA.
in non-paced patients undergoing the first ASA procedure, a permanent pacemaker was implanted in 10% of cases and there were no significant differences in i) long-term survival, ii) outflow pressure gradient at the most recent examination and iii) NYHA functional class at the most recent examination between patients with and without a post-ASA implanted pacemaker for procedure-related CHB. Moreover, two thirds of patients with a permanent pacemaker recovered AV conduction early after pacemaker implantation. Although this study reports the results of a registry over 15 years, it still included only 167 pre-ASA nonpaced patients, which subsequently resulted in a limited number of patients with periprocedural CHB requiring pacemaker implantation. Therefore, we are aware that the reported results need further validation. References [1] Gersh BJ, Maron BJ, Bonow RO, et al. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy. Circulation 2011;124:e783–831. [2] Fifer MA, Sigwart U. Hypertrophic obstructive cardiomyopathy: alcohol septal ablation. Eur Heart J 2012;32:1059–64. [3] Veselka J. Alcohol septal ablation for hypertrophic obstructive cardiomyopathy: a review of the literature. Med Sci Monit 2007;13:RA62–8.
