Bradycardia and sinus arrest during percutaneous ethanol injection therapy for hepatocellular carcinoma

• Published in: European journal of clinical investigation 2004-03, Vol.34 (3), p.218-223
• Main Authors: Ferlitsch, A., Kreil, A., Bauer, E., Schmidinger, H., Schillinger, M., Gangl, A., Peck-Radosavljevic, M.
• Format: Article
• Language: English
• Subjects: Biological and medical sciences; Bradycardia - diagnosis; Bradycardia - etiology; Carcinoma, Hepatocellular - therapy; Cardiac dysrhythmias; Cardiology. Vascular system; Complications of tumour therapy; Dose-Response Relationship, Drug; Electrocardiography; Ethanol - administration & dosage; Ethanol - adverse effects; Gastroenterology. Liver. Pancreas. Abdomen; General aspects; Heart; Heart Block - diagnosis; Heart Block - etiology; hepatoma; Humans; Injections, Intralesional; Liver Neoplasms - therapy; Liver. Biliary tract. Portal circulation. Exocrine pancreas; Medical sciences; percutaneous ethanol instillation; Tumors
• ISSN: 0014-2972; 1365-2362
• DOI: 10.1111/j.1365-2362.2004.01321.x

Background  Percutaneous ethanol injection (PEI) is an established method in the treatment of hepatocellular carcinoma (HCC) and considered a safe procedure, with severe complications occurring rarely. Cardiac arrhythmias have not been reported to date. Aim of the study was to investigate the occurrence of dysrhythmias during PEI. Patients and methods  Twenty‐six consecutive patients with inoperable HCC were included. During ultrasound‐guided PEI with 95% ethanol, electrocardiogram (ECG) monitoring was performed before starting and continuously during PEI. Results  During PEI a significant reduction in mean heart rate (> 20%) was seen in 15 of 26 (58%) patients. In 11 of 26 patients (42%) occurrence of sinuatrial block (SAB) or atrioventricular block (AVB) was observed after a median time of 9 s (range 4–50) from the start of PEI with a median length of 24 s (range 12–480). Clinical symptoms were seen in two patients, including episodes of unconsciousness, seizure‐like symptoms in both and a respiratory arrest during PEI in one patient, requiring mechanical ventilation. In four of 12 patients with repeat interventions, dysrhythmias were reproducible during monthly performed procedures. There was a significant association between the occurrence of SAB or AVB and the amount of instilled alcohol (P = 0·03) and post‐PEI serum ethanol levels (P = 0·03). Conclusions  Bradycardia and block formation occur frequently during PEI. These symptoms could be explained by a vasovagal reaction and/or the direct effect of ethanol on the sinus node or the right atrial conduction system. Ethanol dose is an important factor for the occurrence of SAB/AVB. ECG‐monitoring seems mandatory during PEI. Prophylactic use of intravenously administered Atropine might be useful.