Dual chamber pacing in hypertrophic obstructive cardiomyopathy: beneficial effect of atrioventricular junction ablation for optimal left ventricular capture and filling.

Clinical improvement with dual chamber pacing has largely been reported in patients suffering from hypertrophic obstructive cardiomyopathy and mainly attributed to the reduction of the subaortic pressure gradient. To be effective, pacing must induce a permanent and complete capture of the LV. In two patients of our collective, symptoms (angina and dyspnea NYHA Class III and/or syncopes) persisted or relapsed despite pacing. This was related to the inability to obtain full LV capture due to a too-short native PR interval. RF ablation of the AV junction was therefore performed in both patients, resulting in permanent AV block in one and prolonged PR interval up 310 ms in the second. Pacing was thereafter associated with an immediate and significant clinical improvement related to permanent LV capture, whatever the patient's activity. After RF ablation, the AV delay was set up to induce the best LV filling, as assessed by Doppler analysis of mitral flow. Our observations suggest that RF ablation or modification of the AV junction can be a successful procedure in some patients with residual or recurrent symptoms, when the latter result from a loss of capture or from the inability to program an AV delay that does not compromise the active component to LV filling. Doppler echocardiography is a simple and effective mean to assess the hemodynamic effect of AV interval modulation in this setting.