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Modifications Electro-Vectorcardiogram
after Percutaneuos Transluminal Septal
Ablation in Hypertrophic Obstructive
Cardiomyopathy

Pérez Riera, Andrés R.; Fortunato de Cano, Silvia J.;
Cano, Manuel N.; Fleury Neto, Lucianoa A.P.;
Sousa, José E duardo M.R.

Instituto Dante Pazzanese de Cardiologia, São Paulo, Brasil

SUMMARY
Objectives: Evaluate the immediate and late electrocardiogram (ECG) changes and late vectorcardiogram (VCG) patterns in patients undergoing Percutaneous Transluminal Septal Ablation in Hypertrophic Obstructive Cardiomyopathy (PTSA-HOCM).
Material and Methods: We studied consecutive seven patients submitted to PTSA, from October 1998 up to now, 3 men, mean age 56.2a(38-76), mean gradient pre-PTSA 88,2mmHg (56-150mmHg).
The conventional 12 leads ECG pre PTSA, was obtained in all patients and compared to that obtained immediately after procedure.
ECG and VCG (Frank method) late changes, were analyzed at follow-up.
Results: ECG pre PTSA: All patients had sinus rhythm, six had atrial enlargement and left ventricular hypertrophy (LVH) with "strain" pattern and one had LVH without strain pattern.
ECG Immediately after PTSA: All patients had injury and ischemia in septal or anteroseptal wall.
All but one, had Right Bundle Branch Block (RBBB), one patient had complete transitory AV block (treated with temporary pacemaker). Another two developed ventricular tachycardia easily cardioverted. Two patients developed alternating and transitory bundle branch block, and the remaining presented ventricular ectopic beats, isolated, bigeminated or trigeminated.
ECG late modifications: Six patients had Right Bundle Branch Block (RBBB), isolated or associated with left divisional block and septal myocardial infarction pattern.
No patient developed Left Bundle Branch Block (LBBB).
VCG late changes: Transverse plane (TP) of QRS loop the 10-20ms instantaneous vector of QRS loop in TP was affected in all patients, indicating septal midportion or apicoanterior involvement.
Six patients showed a typical pattern of RBBB where the afferent branch was behind the X line, configuring, the so called type I or "Grishman type".
Conclusions: Although it is a relative small group of patients, we observed a great predominance of RBBB, isolated or in association with divisional block after PTSA. No patient developed LBBB in our series, differently from what we found in literature after miotomy/miomectomy, where LBBB prevails. It is interesting that two invasive options in HOCM produce different bundle branch block predominance: PTSA: RBBB and miotomy/miomectomy: LBBB.

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INTRODUCTION
   Percutaneous transluminal septal ablation in hypertrophic obstructive cardiomyopathy (PTSA-HOCM) is a relative new alternative technic used in cases with significant gradient, without good response to drugs in patients functional class III or IV.

   We wanted to analyze it from the Electro-Vectorcardiogram (ECG/VCG) point of view.

OBJETIVES
   Evaluate the immediate and late ECG changes and late VCG patterns in patients undergoing Percutaneous Transluminal Septal Ablation in Hypertrophic Obstructive Cardiomyopathy (PTSA-HOCM).

MATHERIAL AND METHODS
    We studied consecutive 8 patients (p/) submitted to PTSA, from October 1998 up to now. Conventional 12 leads ECG pre PTSA Were obtained from all patients. ECG and VCG changes were analyzed in late follow-up.

Exclusion Criteria of the procedure

1) septum with diastolic thickness inferior to 18mm.
2) hypertrophy in unusual location such as the
posterior portion of the septum, posterobasal free
wall and midventricular level: without narrowing
of the left ventricular outflow tract.
3) absence of significant gradient : lower than 50mm Hg.
4) Presence of systolic dysfunction.
5) Presence of mitral intrinsic valvulopathy.
6) Patients with good response to drugs.
7) Functional class smaller than NYHA III.
8) Patients who spontaneously choose the surgery.

RESULT
ECG pre PTSA
   All p/ had SR, and LVH. Seven of them with "strain pattern" (LVH-1) and only one without (LVH-0). Four had LAE.
(Figure 1)

ECG Immediately after PTSA:

- All patients had injury and ischemic in septal or anteroseptal wall.
- Six p/ had RBBB isolated or associated with DIVISIONAL BLOCK: LADB (two cases) and LPDB (one case).
- One p/ developed alternating and transitory bundle branch block.
- One p/ had complete transitory total block.
- One had NON SUSTAINED VENTRICULAR TACHYCARDIA (NS-VT).
(Figure 2)

ECG late modifications:

- One p/ had AF after 2y and the remainder SR.
- All had RBBB isolated or associated with DIVISIONAL BLOCK.
- No patient developed LBBB.
- Four p/ had ASI and two SI.
(Figure 3)

VCG late modifications:

- Transverse plane of QRS loop the 10-20ms instantaneous vector was affected in all of patients indicating septal midportion or apicoanterior involvement.
- All had RBBB isolated or associated with DIVISIONAL BLOCK.
- RBBB was type I of Kennedy classification or "Grishman Type": afferent limb was behind the X line.
(Figure 4)
(Figure 5)

THE HUMAN RIGHT HIS SYSTEM
(Figure 6)

IRRIGATION OF THE HUMAN RIGHT HIS SYSTEM
   Right His

1: penetrating portion.
2: ramificating portion.

Irrigation 1 and 2 portion:

a) Right coronary artery... AV node artery
b) Left anterior descending artery (LADA)... First
septal perforator branch.

IRRIGATION OF THE HUMAN RIGHT HIS SYSTEM

3: Troncular, proximal or membranous portion.
Right 4: Intramyocardial portion.
band 5: Moderator band.
6: Divisional portion

Irrigation:
3: Troncular: First septal perforator branch of LADA.
4: Intramyocardial portion: septal branches of left posterior descending artery (LPDA), second septal perforator branch of LADA and Kugel artery (circunflex branch LCx).
5: Moderator band and 6: divisonal portion.
"ramus limbi dextri" branch of second septal perforator of LADA.

IRRIGATION OF THE DIVISIONS OF LEFT BUNDLE
(Table 1)

CONCLUSION
   We observed a great predominance of RBBB, isolated or associated with divisional block after PTSA. VCG was "Grishman" type in all cases.

    No patient developed LBBB in our series differently from what we found in the literature after myectomy by transaortic approach, where produce different bundle branch block predominance: PTSA RBBB and myotomy /myectomy LBBB.

 

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
Scientific Committee
President
Dr. Armando Pacher
Technical Committee - CETIFAC
President
fgaro@fac.org.ar
fgaro@satlink.com
rbretal@fac.org.ar
rbretal@netverk.com.ar
apacher@fac.org.ar
apacher@satlink.com

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