title: Bradycardia and sinus arrest during percutaneous ethanol injection therapy for hepatocellular carcinoma.
abstract: 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.
  
  
  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.
authors.affiliation: University of Vienna Medical School, Vienna, Austria.
authors.forename: A
authors.initials: A
authors.lastname: Ferlitsch
authors.forename: A
authors.initials: A
authors.lastname: Kreil
authors.forename: E
authors.initials: E
authors.lastname: Bauer
authors.forename: H
authors.initials: H
authors.lastname: Schmidinger
authors.forename: M
authors.initials: M
authors.lastname: Schillinger
authors.forename: A
authors.initials: A
authors.lastname: Gangl
authors.forename: M
authors.initials: M
authors.lastname: Peck-Radosavljevic
mesh_terms: D001919:Bradycardia / Q000175:diagnosis / Q000209:etiology*; D006528:Carcinoma, Hepatocellular / Q000628:therapy*; D004305:Dose-Response Relationship, Drug; D004562:Electrocardiography; D000431:Ethanol / Q000008:administration & dosage / Q000009:adverse effects*; D006327:Heart Block / Q000175:diagnosis / Q000209:etiology*; D006801:Humans; D015552:Injections, Intralesional; D008113:Liver Neoplasms / Q000628:therapy*
chemical_list: D000431:Ethanol