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Abstracts: Transesophageal Electrophysiolology: Diagnosis and Treatment of Arrhythmias
Clinical Abstracts on Transesophageal Electrophysiology
For more information See:
http://www.cardiocommand.com/research_electrophysiology.html
A gastroesophageal electrode for electrophysiological
studies. McEneaney DJ, Escalona O, Anderson JA, Adgey AA. Regional
Medical Cardiology Centre, Royal Victoria Hospital, Belfast. Pacing Clin Electrophysiol
1999 Mar;22(3):487-99. A novel gastroesophageal electrode has been developed
capable of atrial and ventricular pacing. We performed electrophysiological
studies using the gastroesophageal electrode (Esothoracic) and compared the
results with the standard endocardial approach. The flexible polythene gastroesophageal
electrode was passed into the stomach under light sedation. Five ring electrodes,
now positioned in the lower esophagus were used for bipolar atrial pacing and
recording. Ventricular pacing was performed using a cathodic point source on
the gastroesophageal electrode tip; the indifferent electrode (anode) was a
high impedance chest pad. Parameters of sinus and AV nodal function were obtained
by atrial pacing. Programmed ventricular stimulation was performed using a standard
protocol. These electrophysiological parameters were subsequently determined
using the endocardial approach. There was close correlation between measurements
of sinus and AV node function using the two approaches in 48 subjects: sinus
node recovery time (SNRT) r2 = 0.70, corrected sinus node recovery time (CSNRT)
r2 = 0.87, AV Wenckebach cycle length (AVWCL) r2 = 0.97. The degree of agreement
between the two approaches was estimated by the mean difference delta and standard
deviation of the difference sigma (SNRT delta = 40 ms, sigma = 257 ms; CSNRT
sigma = 14 ms, delta = 164 ms; AVWCL sigma = 7 ms, delta = 16 ms). Programmed
ventricular stimulation was performed in 15 of 48 subjects with known or suspected
ventricular tachyarrhythmias. Seven had ventricular tachycardia induced using
both esothoracic and endocardial programmed ventricular stimulation. One subject
was noninducible using esothoracic programmed ventricular stimulation, but inducible
at endocardial electrophysiological studies. Another subject was inducible at
esothoracic electrophysiological studies, but noninducible using endocardial
programmed ventricular stimulation. Six subjects were noninducible using both
endocardial and esothoracic programmed ventricular stimulation. The gastroesophageal
electrode permits reliable atrial and ventricular pacing without transvenous
catheterization or fluoroscopy. Electrophysiological parameters determined using
this electrode are similar to those obtained using endocardial stimulation.
Supraventricular paroxysmal reentry tachycardia.
Empirical and guided therapy. Piccolo E, Bonso A, Raviele A, Delise P. Divisione
di Cardiologia, Ospedale Umberto I, Mestre-Venezia. Cardiologia
1991 Aug;36(8 Suppl):87-97. The empirical therapy of reentrant supraventricular
tachycardias (A-V and junctional tachycardia) is based on a preliminary diagnosis through
standard ECG to evaluate, whenever possible, the relationship between P wave and QRS. In
order to distinguish atrial tachycardias from other types, we must employ vagal manoeuvres
or drugs. Often we use methods of recording and stimulation such as Holter monitoring and
transesophageal technique which can provide useful information about the
electrophysiological mechanisms and therefore can better guide our choice of drugs. The
decision of undertaking pharmacologic treatment takes into account frequency, duration and
tolerability of the crises and the patient's compliance. The most commonly used drugs are
verapamil, diltiazem, propafenone, flecainide, sotalol and amiodarone. The percentage of
success at 1 year ranges from 30 to 60%. Particularly in the Wolff-Parkinson-White (WPW)
therapy must follow an accurate evaluation of the electrophysiological pattern through
effort test, drugs test, transesophageal (ETS) or endocavitary (EPS) electrophysiological
study. Indeed therapy aims not only at reducing arrhythmic relapses, but also preventing
the potential risk of either death or severe damage. The useful drugs must have the
property of acting at the same time upon at least one branch of the A-V circuit, on the
atrium reducing its vulnerability and finally modifying the conductive anterograde
capacity of the Kent bundle. They are quinidine, procainamide, propafenone (group I)
sotalol and amiodarone (group III). The limitations of the empirical therapy are a high
percentage of relapses and the difficulty in foreseeing the pro-arrhythmic effects. The
guided by serial electrophysiologic testing implies artificial induction of spontaneous
arrhythmia by repeating the test after acute or chronic assumption of drugs. Is this way
it can be evaluated the efficacy as well as the tolerability of an antiarrhythmic drug
which later will be taken for chronic prophylaxis. The percentage of inducibility of
clinical arrhythmias is next to 100% both for EPS and TES. The number of patients for whom
we can find an effective pharmacologic regimen through acute testing ranges from 30 to
100%, but is influenced by several factors such as aggressiveness of therapeutic protocol
and type and dosage of drugs. The predictive value is high as it approaches 100% for a
positive acute test. The elective indications for serial electrophysiologic study are:
failure of empirical therapy; disabling and very frequent arrhythmias; arrhythmias
provoking major disturbances (lipothymia, syncope, hypotension, shock); symptomatic WPW.
Comparative study of auricular stimulation by
transesophageal and endocavitary approach for evaluating sinus and atrioventricular node
function. Cebron JP, Brugada J, Gallay P, Puech P. Arch Mal Coeur Vaiss 1987
Feb;80(2):170-5. The purpose of this study was to find out whether non-invasive
transoesophageal pacing could effectively replace right intra-atrial pacing for the
indirect evaluation of sinus node and atrioventricular (AV) node function. In a population
of 17 patients the corrected sinus node recovery time (CSRT), the atrio-sinu-atrial
conduction time (ASACT) and Wenckebach's point (W) were calculated by intracavitary
pacing, then by transoesophageal pacing. There was no significant difference between the
two methods in pre-pacing sinus cycle. With right intra-atrial pacing, mean CSRT value was
365 +/- 54 ms (with 5 values greater than 520 ms), mean ASACT value was 229 +/- 29 ms
(with 8 values greater than 220 ms), and W occurred at a mean cycle length of 425 +/- 29
ms. With transoesophageal pacing, mean CSRT value was 406 +/- 87 ms (with 5 values greater
than 520 ms), mean ASACT value was 222 +/- 17 ms (with 8 values greater than 220 ms), and
W occurred at a mean cycle length of 408 +/- 26 ms. The two methods correlated very
closely for CSRT and W (r = 0.97) and relatively well for ASACT (r = 0.84). The number of
CSRT and ASACT values regarded as prolonged was the same with the two methods; 4% of
recorded (i.e. maximal) CSRT values occurred with the same length of pacing cycle. There
was no statistically significant difference between the two methods in the calculation of
CSRT and ASACT, but W occurred at a slightly shorter cycle (p less than 0.05) with
transoesophageal pacing. Thus, transoesophageal pacing is a non-invasive, easy to perform
method for indirect exploration of sinus node and AV node function in patients who do not
require subnodal conduction studies.
Diagnostic and therapeutic use of transesophageal
atrial pacing in children. Janousek J. Center of Pediatric Cardiology and Cardiac
Surgery, Prague. Int J Cardiol 1989 Oct;25(1):7-14. Transesophageal atrial pacing was used
in 29 consecutive patients aged 1 day to 16.5 years (mean 8.04 years) to replace the
following procedures: intracardiac electrophysiologic study in patients with selected
arrhythmias (21 patients), intracardiac overdrive or synchronized direct current
cardioversion of supraventricular tachyarrhythmias or drug administration in patients with
acute reciprocating supraventricular tachycardia (9 patients). Atrial capture was achieved
without discomfort in 27 patients (93.1%). The diagnostic or therapeutic goal of the
procedure was achieved in 26 children (89.7%). Transesophageal atrial pacing may replace
intracardiac pacing procedures, direct current cardioversion and drug administration in
patients with selected cardiac arrhythmias and has proved appropriate as a first
diagnostic or therapeutic step.
The study of acute clinical electrophysiological effects of propafenone on
paroxysmal supraventricular tachycardia using transesophageal atrial pacing
technique. Li Q, Wang Z, Peng D. Department of Cardiology, Second Affiliated Hospital, Hunan Medical University, Changsha.
Hunan I Ko Ta Hsueh Hsueh Pao 1997;22(2):123-6. Trans-esophagus atrial pacing (TEAP) was employed to evaluate the
acute electrophysiological effects of propafenone administrated intravenously in 50 patients with
SVT. Forty three of the subjects are patients with atrial ventricular reciprocating
tachycardia (AVRT). Seven of them were involved in atrioventricular nodal reentry tachycardia (AVNRT). The results indicate
that propafenone exerts an obvious inhibitory effect on both the dual atrioventricular node pathways and the
accessory pathways, with the latter one being markedly affected. In addition, propafenone can deter the
antegrade and retrograde conduction and prolong the refractory period of the accessory pathways. Still
more, it results in preceding of the Wenchebach and 2 to 1 block point of the atrioventricular node
conduction. All these promise the potential terminating effect on tachycardia. Propafenone has
little effects on sinus node. Prolongation of sinus node recovery time (SNRT) to 3600 ms following drug
administration was observed in only one patient who has a history of sinus bradycardia.
The role of an electropharmacological transesophageal test in the
prevention of paroxysmal atrial fibrillation. Experience with flecainide. De Sisti A, Matteucci C, Patrissi T, Accogli S, Di Lorenzo M, Sasdelli M, Ciolli A, Lo Sardo G, Palamara A.
Divisione di Cardiologia, Ospedale Sandro Pertini, Roma. G Ital Cardiol 1998 Dec;28(12):1391-9.
BACKGROUND: The management of patients with paroxysmal atrial fibrillation (AF) is unsuccessful, because AF recurs in
about 50% of patients despite an antiarrhythmic treatment. Usefulness of non-pharmacological strategies is available in a limited
subset of patients and it does not present a global solution to the problem. At present, treatment with antiarrhythmic
agents is the only available tool in patients with AF recurrence. The aim of this study was to assess the
predictive value of the electropharmacological transesophageal (TE) test in the management of patients
with paroxysmal AF treated by flecainide. METHODS: In 32 patients, ranging in age from 38 to 70 years
(mean: 59 +/- 12 years), with documented episodes of paroxysmal AF (mean: 5.6 +/- 3.7 episodes/last
year), we performed an electrophysiological transesophageal (TE) test following pharmacological wash-out. An aggressive protocol was used: step A: 10 sec atrial burst at Wenckebach point + 10 bpm,
200 and 250 bpm; step B: 10 sec atrial bursts at 300, 400, 500 and 600 bpm; step C: 8 sec increasing
rate burst from 200 to 800 bpm. Induction of sustained AF (> 1 min) was considered the end-point.
Patients were treated with flecainide 100 mg bid and a second TE test was performed at the steady-state,
with an identical induction protocol and end-point. Based on the response of the second
test, patients were divided into responders (R Group: non-inducible AF) and non-responders (NR Group: inducible,
sustained AF). Patients were followed-up by periodical controls and contacted by telephone to confirm
their clinical status. RESULTS: Sustained AF was induced in 30 patients (94%) at the first TE study. Eight
of them dropped-out at the time of the second TE test (6 patients for lack of consent, 1 patient for
side-effects and another one for proarrhythmic effects). In the mean follow-up of 15 +/- 6
months, among patients who underwent a second TE test, AF recurrence was documented in 2 out of 14 patients from
the R Group and in 7 out of 10 patients from the NR Group (p < 0.01). There were 4 AF episodes in the R Group and 19 in the NR
Group (p < 0.001). We did not find significant statistical differences between the two groups in terms of age, sex, body weight, AF
episodes/past year, P-wave duration, left atrial dimension, structural heart disease, AF duration at the first TE test and follow-up
duration. In five patients from the NR Group with induced AF lasting > 5 min, the percentage of recurrence was 100% and there
were 16 AF episodes. Global percentage of patients with recurrence was 37%. CONCLUSIONS:
Flecainide is effective in reducing the incidence of AF and results are similar to other antiarrhythmic agents
generally used. The electropharmacological TE test might be a useful tool to predict the response to an
antiarrhythmic treatment.
Study of sinus function and nodal conduction using
transesophageal recordings. Le Heuzey JY, Khaznadar G, Guize L, Carcone P,
Weissenburger J, Lavergne T, Ourbak P, Valty J. Arch Mal Coeur Vaiss 1987 Jan;80(1):28-35.
Transoesophageal pacing is mainly used for treatment of supraventricular tachycardias and
assessment of refractory periods of accessory pathways. It has been proposed for the study
of sinus node function and A-V nodal conduction. The aim of this study was to know if
transoesophageal pacing could modify the vago-sympathetic tone, therefore the results of
the tests, knowing it can be discomfortable and that endodigestive procedures can induce
vagal responses. Furthermore, the stimulation is elicited near the left atrium, and not in
the right atrium as during endocavitary tests. We have compared in 20 patients (age 68 +/-
12) the results obtained by both endocavitary and transoesophageal pacing (tension 21.2
+/- 4.5 V, duration 16 msec, interelectrode spacing 30 mm). We measured sino-atrial
conduction time (SACT), sinus node recovery time (SNRT), Wenckebach's point and nodal
refractory periods. After introduction of the oesophageal lead we observed a significant
(p < 0.01) but slight and transitory tachycardia. The results of A-V nodal conduction
parameters were not significantly different and were significantly correlated (r = 0.94
for Wenckebach's point and effective refractory period). For the sinus node function,
there was no significant difference between the parameters if the oesophago-atrial delay
(mean 104.4 +/- 25.9 msec) is taken into account. The correlation is poor for sino-atrial
conduction time (corrected SACT, r = 0.55), tighter for sinus node recovery time (maximal
corrected SNRT, r = 0.92).
Transesophageal stimulation in the treatment of
atrial flutter and tachysystole. Factor influencing immediate results.Girardot C,
Diebold H, Morelon P, Dentan G, Fraison M, Eicher JC, Bouhey J, Louis P. Hopital du
Bocage, Dijon. Arch Mal Coeur Vaiss 1988 Nov;81(11):1379-84. The effectiveness and safety
of transoesophageal atrial pacing in the treatment of atrial flutter and tachycardia have
been well demonstrated. The purpose of this study was to determine the factors that could
influence the results of this method at the end of the procedure. Seventy-seven
transoesophageal atrial pacings were performed in 62 unselected consecutive patients with
either flutter or atrial tachycardia. The following parameters could be evaluated in 55
patients: date of onset of the arrhythmia, echocardiographic diameter of the left atrium,
maximum amplitude of oesophageal atrial potentials, voltage and frequency of stimuli in
the last stage of pacing. Our results can be summarized as follows: In both flutter and
atrial tachycardia taken globally, conversion to sinus rhythm was obtained in 37% of the
cases, and conversion to atrial fibrillation in 46.7% of the cases. The failure rate was
19.4%; all failures were due to lack of atrial capture during pacing. The main factor or
transoesophageal atrial capture is voltage. Patients must be able to tolerate the voltage
needed for capture. In the case of flutter, when capture was achieved a normal-sized left
atrium and a high maximum amplitude of oesophageal atrial potentials were factors
indicating that conversion to sinus rhythm could be expected. This, however, did not apply
to atrial tachycardia. -- Whatever the type of tachyarrhythmia, the more recent its onset
the easier its reduction.
Diagnostic transesophageal atrial stimulation as a
sinus node function test. I. Normal values and comparison with right atrial stimulation.
Volkmann H, Paliege R. Z Gesamte Inn Med 1981 May 1;36(9):287-94. For the non-invasive
functional analysis of the sinus node diagnostic transoesophageal atrial stimulations were
performed. By means of transoesophageal premature individual stimulation we succeeded in a
calculation of the so-called sinuatrial conduction time in 112 of 118 normal persons
(ESACT = 103 +/- 23.5 ms). In comparison to the results in right-atrial stimulation the
transoesophageally established times were 20 to 30 ms longer. By means of transoesophageal
atrial stimulation with higher frequency in 64 healthy test persons the recreation time of
the sinus node was determined in 64 healthy test persons (ESNRT = 968 +/- 218 ms). Taking
into consideration the double standard deviation in an upper limit of 1,400 ms was the
result which corresponds to the limit in intraatrial stimulation. In the direct comparison
of the transoesophageal and right-atrial stimulation technique in patients with and
without syndrome of the sinus node for the sinuatrial conduction time (r = 0.81, n = 51)
as well as for the recreation time of the sinus node (r = 0.90, n = 36) relatively good
correspondences were found. In the transoesophageal stimulation, however, the larger
distance of the place of stimulation from the marginal area of the sinus node, the
conduction of the impulse over the left to the right atrium as well as a possible vagal
irritation are to be taken into consideration.
Diagnostic transesophageal atrial stimulation for
sinus node function testing. II. Results in patients with and without sinus node syndrome.
Volkmann H, Paliege R. Z Gesamte Inn Med 1981 Feb 15;36(4):93-102. By means of
transoesophageal atrial stimulation of higher frequency in patients with sinus node
syndromes (n = 78) in about 60% of the cases a prolonged sinus node recovery time could be
proved. After the end of the stimulation secondary stops appeared in about half of the
patients, so that in 81% of the cases at least one pathological result was established. By
means of premature individual transoesophageal stimulation (n = 99) in 2/3 of the patients
with sinus node syndrome we contrived to perform a calculation of the sinuatrial
conduction time. Half of all calculable values were above the normal. In 1/3 of the
examined persons pathological stimulation patterns were found. Altogether 90% of the
patients showed at least one pathological result, when apart from prolonged sinus node
recovery times and sinuatrial conduction times at the same time secondary stops after
serial stimulation with higher frequency and abnormal behaviour patterns of the
post-extrasystolic stops after individual stimulation were taken into consideration. In
patients with different cardiovascular diseases without clinical or electrocardiographic
reference to a sinus node dysfunction in 25% of the cases at least one pathological result
was found, in which case cannot be clarified, whether latent functional sinus node
disturbances or falsely positive results are in question or not. Altogether the
non-invasive transoesophageal stimulation technique leads to on principle diagnostic
evidences of the same value as the up to now usual stimulation of the right atrium.
Methodical problems which arise from the stimulation of the right atrium in
transoesophageal approach are to be taken into consideration in the interpretation of the
results.
Esophageal approach in rythmology. Diagnostic and
therapeutic applications. Moustaghfir A, van de Walle JP, Deharo JC, Djiane P,
Touze JE. Service de Pathologie Cardio-vasculaire, HIA Laveran, Marseille Armees. Ann
Cardiol Angeiol (Paris) 1996 Nov;45(9):539-44. The oesophageal route is a simple
technique, which is easy to perform. It allows precise assessment of supraventricular
arrhythmias without using the endocavitary route. There is a perfect correlation between
the two methods for the study of sinus function and the Wenckebach point. This technique
makes a considerable contribution to the diagnosis of junctional tachycardia and the
evaluation of Wolff-Parkinson-White syndrome. It can reduce approximately 65% of flutters
and 50% of atrial tachyarrythmias. It can also be used to monitor antiarrhythmic treatment
or in the assessment of radiofrequency resection, especially in nodal tachycardias and
left atrioventricular accessory pathways. Its limitations concern the sometimes painful
nature of the investigation and the impossibility of recording the electrical activity of
the His bundle.
Programmed atrial stimulation via the esophagus for
management of supraventricular arrhythmias in infants and children. Rhodes LA,
Walsh EP, Saul JP. Children's Hospital, Harvard Medical School. Am J Cardiol 1994 Aug
15;74(4):353-6. This report describes the use of programmed atrial stimulation via
the esophagus to predict the clinical efficacy of various management strategies for
supraventricular arrhythmias in infants and children. A total of 203 transesophageal
electrophysiologic studies were performed in 132 patients. Therapies evaluated included
medications from each antiarrhythmic class, the Valsalva maneuver, follow-up of
radiofrequency ablation, and no therapy. The transesophageal technique appeared to be
adequate for inducing tachycardia, yielding a low false-negative rate. Overall, the
predictive value of a negative study was high (89%), and increased to 96% when stimulation
was performed in the presence of isoproterenol. However, the positive predictive value was
significantly lower both with (72%, p < 0.00001) and without (60%, p < 0.0001)
isoproterenol. These results were due in part to a very low positive predictive value when
evaluating either digoxin and/or beta-blocker therapy, 62% vs 82% for the remaining
studies. When clinical tachycardia cannot be induced with therapy, transesophageal
techniques can be used to predict freedom from many supraventricular tachycardias for most
therapies in children. However, induction of tachycardia may not predict treatment
failure. Transesophageal pacing to evaluate arrhythmia therapy may be most useful when
managing either severe symptoms, multiple recurrences, or the results of radiofrequency
ablation.
The diagnosis and
management of supraventricular tachycardia by transesophageal cardiac stimulation and
recording. Harte MT, Teo KK, Horgan JH. Saint Laurence's Hospital, Dublin,
Ireland. Chest 1988; 93(2):339-44. Twenty-two consecutive patients underwent esophageal
stimulation and recording for the diagnosis and management of supraventricular
tachycardia. In 13 of these patients, the resting electrocardiogram was normal and in nine
it showed pre-excitation. Of the 13 patients with a normal resting electrocardiogram,
supraventricular tachycardia was initiated in all. Seven patients had a
ventricular-to-atrial interval greater than 70 ms during supraventricular tachycardia
suggesting the presence of a concealed accessory pathway, and six patients had a
ventricular-to-atrial interval less than 70 ms during supraventricular tachycardia
suggesting reentry within the atrioventricular node. Supraventricular tachycardia was
initiated in four of nine patients with pre-excitation on the resting electrocardiogram
and the accessory pathway was confirmed by a ventricular-to-atrial interval of greater
than 70 ms during supraventricular tachycardia in these four patients. Atrial fibrillation
was initiated in eight of the nine patients with pre-excitation on the resting
electrocardiogram and the shortest R-R interval during atrial fibrillation was measured.
The response to therapy was assessed in seven of these nine patients by further
measurement of the shortest R-R interval during atrial fibrillation following treatment.
Esophageal stimulation and recording provides a simple noninvasive procedure which can be
utilized as a screening technique to identify patients with intranodal reentry and those
with reentry utilizing an accessory pathway. Sequential assessment of the response to
therapy, especially in those patients with pre-excitation, is of considerable value in
treatment.
Role of transesophageal pacing in evaluation of
palpitations in children and adolescents. Pongiglione G, Saul JP, Dunnigan A,
Strasburger JF, Benson DW Jr. Children's Memorial Hospital, Chicago. Am J Cardiol 1988 Sep
15;62(9):566-70. Transesophageal atrial pacing was used to evaluate the cause of
palpitations in 28 patients ages 3 to 18 years (mean 11). Palpitations were defined as the
sustained (seconds to minutes) sensation of rapid heart beating. Each patient had had
greater than 2 episodes of palpitations. No patient had other evidence of heart disease.
Standard electrocardiogram was normal (23 of 28 patients), demonstrated ventricular
preexcitation (3 of 28 patients) or demonstrated short PR interval (2 of 28 patients). In
selected patients, ambulatory monitoring (11 patients) or exercise testing (3 patients)
was performed but failed to demonstrate a cause of palpitations. In an effort to initiate
tachycardia, a similar transesophageal atrial pacing protocol was performed in each
patient. The protocol consisted of: (1) single extrastimuli at progressively closer
intervals during sinus rhythm and after an 8-beat pacing train at greater than or equal to
1 cycle lengths and (2) incremental atrial pacing to the point of second-degree
atrioventricular block. If this pacing regimen failed to initiate tachycardia, it was
repeated during isoproterenol infusion (0.02, 0.05 and 0.1 micrograms/kg/min) and then
following intravenous atropine (0.04 mg/kg) administration. During the study, tachycardia
was initiated in 20 of 28 patients (71%) (14 of 15 patients greater than 10 years, 6 of 13
patients less than or equal to 10 years; p < 0.01, Fisher's exact test).
Electrophysiologic characteristics of induced tachycardia suggested reentry within the
atrioventricular node (8 of 20 patients) or orthodromic reciprocating tachycardia (12 of
20 patients). In 3 of 12 patients with orthodromic reciprocating tachycardia, a transition
to atrial fibrillation was observed.
Clinical value of transesophageal atrial
stimulation and recording in patients with arrhythmia-related symptoms or documented
supraventricular tachycardia--correlation to clinical history and invasive studies.
Pehrson SM, Blomstrom-Lundqvist C, Ljungstrom E, Blomstrom P. University Hospital, Lund,
Sweden. Clin Cardiol 1994 Oct;17(10):528-34. The main objective of the present study was
to evaluate the clinical applicability of transesophageal atrial stimulation (TAS) and
recording with regard to inducibility of supraventricular tachycardia (SVT) in patients
with either an ECG-documented paroxysmal SVT or a clinical history of palpitations
suggesting this disease. A further objective was to assess the inducibility of SVT and to
compare the inducibility by TAS with that obtained by an invasive electrophysiologic study
(EPS). A total of 64 patients (aged 13-74 years) with ECG-documented paroxysmal SVT (n =
50) or only a history of palpitations (n = 14) was referred for TAS. Preexcitation was
present in 35 patients. The study protocol included single and double extrastimuli
delivered at a basic paced interval of 500 ms, and incremental atrial stimulation until a
cycle length of 275 ms or a second-degree AV block appeared. In 10 patients atropine
intravenously was required for induction. The same protocol was used in 34 of the patients
who also underwent invasive EPS. TAS was completed in 56 of 64 patients (88%). In this
group SVT was induced during TAS in 84% (47/56). Of patients with ECG-documented
tachycardia, clinical tachycardia was induced in 90% (35/39) with ECG-documented regular
paroxysmal SVT and in 67% of patients (4/6) with ECG-documented atrial fibrillation. In
patients without ECG-documented tachycardia, clinically relevant arrhythmia was induced in
73% (8/11). In 30 of 32 patients (94%) with an inducible tachycardia during invasive EPS,
it was also possible to induce the tachycardia by TAS.
Transesophageal study of infant supraventricular
tachycardia: electrophysiologic characteristics. Benson DW Jr, Dunnigan A,
Benditt DG, Pritzker MR, Thompson TR. Am J Cardiol 1983 Nov 1;52(8):1002-6. Programmed
electrical stimulation of the heart to initiate and terminate tachycardia and analysis of
the temporal relation between ventricular and atrial activation during tachycardia have
been useful in the evaluation of supraventricular tachycardia (SVT). Such techniques have
rarely been applied to evaluate infants with SVT. We used a silicone rubber-coated bipolar
electrode catheter (15 or 22 mm interelectrode spacing), positioned in the esophagus, for
electrical stimulation of the heart and recording of electrograms for the evaluation of 14
infants aged 1 to 84 days with SVT. Three infants had electrocardiographic features of
Wolff-Parkinson-White syndrome, and no infant had other manifestations of congenital heart
disease. Tachycardia cycle lengths ranged from 180 to 295 ms and ventriculoatrial
intervals recorded from the esophagus were 80 to 220 ms. In 12 infants, transesophageal
atrial stimulation was used to terminate and initiate SVT using stimuli of 9.9 ms and 10
to 20 mA. Initiation and termination of SVT by electrical stimulation suggest that SVT in
infants is due to reentry, and the presence of ventriculoatrial intervals greater than 70
ms further suggests that accessory atrioventricular connections (usually concealed)
constitute a portion of the reentry circuit.
Evaluation of electrophysiological diagnosis of concealed accessory pathway
(CAP) during transesophageal atrial pacing. Li Q, Wang Z, Zhou S. Cardiology Division, Second Affiliated Hospital, Hunan Medical University,
Changsha. Hunan I Ko Ta Hsueh Hsueh Pao 1997;22(1):49-52. CAP were diagnosed by TEAP using RPE intervals in 55 cases of paroxysmal supraventricular tachycardia (PSVT). There were
no obvious CAP manifestations of ECG in those cases, the mean RPE interval during tachycardia was 140 +/- 29 ms, and the
lower limit of x +/- 2 s was 82 ms. Among them, the VA intervals were measured by electrocardiophysiological examination in 21
cases. The mean value was 130 +/- 25 ms, and the lower limit of x +/- 2 s was 80 ms. The results suggest that RPE over 82 ms
may be an important diagnostic threshold cut off point of atrioventricular reciprocation.
Standard of transesophageal atrial pacing to diagnose dual atrioventricular
node pathway. Fu H, Lang EP. Hua Hsi I Ko Ta Hsueh Hsueh Pao 1989 Mar;20(1):99-102.
In order to assess the diagnostic methods of dual atrioventricular node pathway (DAVNP), we performed transesophageal atrial
pacing in 58 patients with palpitation. These patients were classified into two groups, group A comprising 40 patients
without broken A-V conduction curve during pacing, compared with group B of 18 patients with broken
A-V conduction curve. In our study, both atypical Wenckebach cycle and 3:2 A-V conduction during the
increment atrial pacing (IAP) had no significant difference between the two groups (P greater than 0.05). The maximum increments of SR interval in Wenckebach cycle of group
A and B during pacing (Wenckebach delta SRmax) were 83.59 +/- 20.92 ms and 125.00 +/- 32.52 ms respectively (P less than
0.001) and at the cut-off point of Wenckebach delta SRmax at 120 ms the specificity and positive
predicative value were very high (96.88% and 90.91%), but sensitivity was not so high (71.43%). The
minimum increments of RS interval (delta RSmin) in a greater change of SR interval showed a significant
difference between the two groups and the specificity and positive predicative value were also high, but
the sensitivity was not so high, either (78.57%). We conclude that the diagnostic value of both
Wenckebach delta SRmax and delta RSmin, when the SR interval is of greater change during pacing to
the DAVNP, is rather significant. As the sensitivity is very low, isolated atypical Wenckebach
phenomenon is not as reliable a diagnostic criterion to the DAVNP as previously supposed.
Transesophageal versus
intracardiac atrial stimulation in assessing anterograde conduction properties of the
accessory pathway in Wolff-Parkinson-White syndrome. Favale S, Minafra F, Massari
V, Tritto M, Rizzon P.Univ of Bari, Italy. Int J Cardiol 1991 Feb;30(2):209-14.
Electrophysiologic intracardiac and noninvasive transesophageal testing, used to evaluate
parameters of anterograde conduction across the accessory pathway, the refractory period
and shortest atrial cycle length with 1:1 conduction over the pathway, were compared to
assess the reliability of the noninvasive technique in identifying patients with
Wolff-Parkinson-White syndrome, at risk of rapid ventricular response during atrial
fibrillation when this arrhythmia is not inducible. Sixteen patients with
Wolff-Parkinson-White syndrome were submitted both to invasive and transesophageal atrial
stimulation. We evaluated both the functional and effective refractory periods of the
accessory pathway, using the same drive cycle length, and the shortest cycle length with
1:1 atrioventricular conduction over the accessory pathway. There were no differences
between the parameters obtained by intracardiac atrial stimulation and by transesophageal
atrial stimulation. The two approaches correlated well: mean functional refractory periods
of the accessory pathway were 285 +/- 42 msec and 289 +/- 32 msec, respectively (NS, r =
0.88); mean effective refractory periods of the accessory pathway were 267 +/- 41 msec and
271 +/- 32 msec, respectively (NS, r = 0.89); mean shortest cycle lengths with 1:1
conduction over the accessory pathway were 255 +/- 48 msec and 255 +/- 44 msec,
respectively (NS, r = 0.94). These data demonstrate the reliability of transesophageal
atrial stimulation in estimating the parameters for anterograde conduction across an
accessory pathway. These results, and the already documented ability of transesophageal
atrial stimulation to induce atrial fibrillation, suggest this noninvasive technique
should be taken as a first approach in screening patients with Wolff-Parkinson-White
syndrome.
Transesophageal versus intracardiac atrial
stimulation in assessing electrophysiologic parameters of the sinus and AV nodes and of
the atrial myocardium. Blomstrom-Lundqvist C, Edvardsson N. Sahlgren's Hospital,
Gothenburg, Sweden. Pacing Clin Electrophysiol 1987 Sep;10(5):1081-95.
Electrophysiological parameters of the sinus and AV nodes and of the atrial myocardium
were assessed with both transesophageal atrial stimulation (TAS) and intracardiac atrial
stimulation (ICS) in the same patient during the same study. The study group was comprised
of nine men and seven women, aged 45 to 79 years, referred for the evaluation of syncope
of possible arrhythmogenic origin. Twelve patients were included for analysis. Autonomic
inhibition (AI) was obtained in five patients. The most striking result was the
significantly longer AERP with TAS (mean 286 +/- 9 ms) than with ICS (mean 244 +/- 12 ms;
p than 0.02). After AI, the AERP was even more prolonged with TAS (mean 332 +/- 20 ms)
than with ICS (mean 237 +/- 8 ms; p less than 0.01). Intraatrial and AV nodal conduction
times assessed at multiple paced cycle lengths were significantly shorter with TAS than
with ICS. There was no difference between TAS and ICS with regard to AVERP, Wenckebach
periodicity and H-V intervals. Although a tendency towards shorter sinus node recovery
time (SNRT) and sinoatrial conduction time (SACT) was observed with TAS, the difference
was not statistically significant. Possible mechanisms of the differences are discussed.
It seemed clear that the site of origin of an atrial impulse can have definite effects
upon excitability and conduction properties of atrial and AV nodal fibers. Enhanced
sympathetic activity during TAS was also suggested. The electrophysiological properties
inherent in the TAS technique warrant further elucidation.
Transesophageal electrocardiography and atrial pacing in acute cardiac
care: diagnostic and therapeutic value. Twidale N, Roberts-Thomson P, Tonkin AM.
Department of Medicine, Flinders Medical Centre, Bedford Park, SA. Aust N Z J Med 1989 Feb;19(1):11-5.
The utility of transesophageal electrocardiography using a bipolar 'pill electrode' was assessed in 17 consecutive
patients with tachycardia presenting to our casualty department. Standard 12-lead electrocardiography
showed regular narrow QRS tachycardia in 12 patients, and five patients had wide QRS tachycardia. Esophageal atrial electrogram recordings were obtained in 14 patients
(82%), and these were helpful in determining the mechanism of tachycardia in 11 patients (78%). Of these 11, seven patients
fulfilled criteria for atrioventricular junctional (AVJ) tachycardia based on measurement of the minimum interval between the
onset of ventricular depolarisation and earliest atrial (esophageal) activity. One of these patients had presented with a wide QRS
tachycardia. The other four patients were diagnosed as having ventricular tachycardia (VT) following diagnosis of AV
dissociation. Atrial overdrive pacing, via the pill electrode, successfully reverted four of the nine patients (44%) with narrow QRS
tachycardia but no patient with VT. Esophageal recording during tachycardia is a simple, relatively non-invasive technique
which is helpful in suggesting the mechanism of tachycardia both in patients with narrow and wide QRS
tachycardia, and may have a therapeutic role in patients with AVJ tachycardia.
Induction of supraventricular tachycardia
(paroxysmal junctional tachycardia and atrial tachycardia) by esophageal stimulation.
Brembilla-Perrot B, Spatz F, Khaldi E, Terrier de la Chaise A, Suty-Selton C, Le Van D,
Cherrier F, Pernot C. CHU Brabois, Vandoeuvre. Arch Mal Coeur Vaiss 1998;83(11):1695-702.
Transesophageal stimulation is tending to replace endocavitary electrophysiological
studies in the investigation and treatment of supraventricular tachyarrhythmias. The aim
of this study was to determine the sensitivity of this technique in the evaluation of
paroxysmal junctional tachycardia (PJT) and atrial tachycardia (AT). Fifty-eight patients
with these arrhythmias (PJT, n = 23; AT, n = 35) were investigated under basal conditions
and then during Isoproterenol infusions with a protocol using incremental atrial
stimulation and programmed atrial stimulation delivering one and two extra-stimuli on two
paced rhythms (400-600 ms). It was possible to induce the arrhythmia in the 23 patients
with PJT either under basal conditions (n = 16) or during Isoproterenol (n = 7). A
reentrant mechanism was suggested in 22 patients by the following findings: position of
the auriculogramme with respect to the ventriculogramme, presence or absence of a delaying
branch block, situation and morphology of the P wave in lead V1 compared with atrial
activation recorded by the esophageal catheter. Atrial tachycardia was induced in 26
patients (74 %), 19 under basal conditions, 6 with Isoproterenol and once after carotid
sinus massage. As a conclusion, we can say that the sensitivity of transesophageal
stimulation is the same as for endocavitary stimulation.
Transesophageal study in the diagnostic evaluation
of pre-excitation. Favale S, Pitzalis MV, Totaro P, Di Biase M, Rizzon P.
Universita degli Studi, Bari. Cardiologia 1991 Aug;36(8 Suppl):75-80. Electrophysiologic
non-invasive transesophageal testing is compared to intracardiac study in the management
of patients with Wolff-Parkinson-White (WPW) syndrome. Transesophageal study can be
reliably used to identify the participation of the accessory pathway in reciprocating
supraventricular tachycardia and to determine the anterograde conduction properties of the
accessory pathway. Using the shortest pre-excited interval during induced atrial
fibrillation, or programmed and continuous atrial transesophageal stimulation can markedly
reduce the need of intracardiac evaluation. The greater safety and economy of
transesophageal compared to the intracardiac technique justify its wider use in
preliminary screening of all WPW patients, unless ablative treatment has been clinically
indicated, and in evaluating long-term drug protection against a potential deleterious
ventricular response during atrial tachyarrhythmias.
Evaluation of the informative value and safety of
the transesophageal atrial electric stimulation test in patients with unstable stenocardia
and myocardial infarction (data of 24-hour ECG monitoring). Merkulova IN,
Khakimov AG, Chikvashvili DI, Karpov I. Kardiologiia 1987 Oct;27(10):69-74. Kardiologiia
1987 Oct;27(10):69-74. The effect of the transesophageal pacing test (TEPT) on the
occurrence of ventricular arrhythmias and ischemic episodes was examined on the basis of
24-hour ECG monitoring in patients with unstable angina (UA) and myocardial infarction
(MI). It is demonstrated that TEPT is a relatively safe test for UA and MI patients (to be
performed on day 10-14), which does not provoke severe arrhythmias during and after the
testing, but for short paroxysms of ventricular tachycardia seen in 2-4% of the cases.
Both painful and painless ST displacements were recorded during the test; ST elevation was
only noted in MI patients. The time of ECG baseline recovery was longer in painful
ischemic episodes, as compared to painless ones. The TEPT test is a valuable instrument
for detecting latent atrioventricular conductivity disorders in UA and MI patients.
Use of esophageal investigation in the mid-term
outcome after radiofrequency ablation of intranodal reentrant tachycardia. Deharo
JC, Moustaghfir A, Macaluso G, Le Tallec L, Djiane P. Service de cardiologie, hopital
Sainte-Marguerite, CHU Marseille. Arch Mal Coeur Vaiss 1996 Nov;89(11):1375-9. The aim of
this prospective study was to assess the medium term results of radio-frequency ablation
of intranodal tachycardias by transoesophageal stimulation and recordings.
Transoesophageal stimulation was performed on average 9 months after ablation. The
anterograde Wenckebach point, the presence of dual nodal conduction and inducibility of
nodal tachycardias were determined under basal conditions and after isoproterenol. The
follow-up period after ablation was 16.1 +/- 10.2 months. At the time of the oesophageal
investigation 25 patients were asymptomatic and 5 had a recurrence of palpitations. The
investigation was carried out without complications in all patients and lasted 34.8 +/- 14
minutes. The anterograde Wenckebach point was 340 +/- 78.2 ms and was unchanged compared
with the value recorded by endocavitary left atrial stimulation before ablation (332 +/-
63.2 ms). Dual nodal conduction was observed in 19 patients. Nodal tachycardia was
inducible in only 2 of the 5 patients with palpitations. Of the asymptomatic patients, 3
had inducible nodal tachycardias after isoproterenol. The authors conclude that
oesophageal electrophysiological studies are a simple means of assessing the medium-term
results of radiofrequency ablation of intranodal tachycardias. In those patients with a
recurrence of symptoms but without documented arrhythmias, failure of radiofrequency
ablation may be identified. In addition, the possibility of inducing nodal tachycardias in
asymptomatic patients may be detected.
The diagnostic and treatment characteristics of
cardiac arrhythmias in patients with the premature ventricular excitation syndrome.
Lipnitskii TN, Otkalenko IuK, Randin AG, Stepaniuk AV. Vrach Delo 1991 Oct;(10):83-6.
Studied were 24 patients with the syndrome of premature excitation of the ventricles. In
18 of them transesophageal |
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