Transesophageal Electrophysiological Study Research Articles

Late cure after radiofrequency catheter ablation in a pediatric patient

A 12-year-old female with the Wolff-Parkinson-White syndrome underwent an electrophysiologic study followed by radiofrequency catheter ablation of the left-lateral accessory pathway. After several unsuccessful attempts, the procedure was stopped because of early recurrence of accessory pathway conduction. Twenty-four hours after the procedure, the patient was found without ventricular pre-excitation pattern on the electrocardiogram. During a 12-month follow-up, the Wolff-Parkinson-White pattern was no longer present. A transesophageal electrophysiologic study showed no further tachycardia induction and the patient is still asymptomatic. This report raises the issue that ablation-induced lesions may evolve considerably during the first few days after ablation, leading to either recurrent accessory pathway conduction or long-lasting complete cure.

Intérêt respectif de deux techniques d'étude électrophysiologique chez un sujet à cœur apparemment sain

Electrophysiologic study (EPS) frequently is required to assess the prognosis of asymptomatic Wolff-Parkinson-White syndrome (WPW) or to prove the nature of no documented tachycardia. EPS usually is performed by intracardiac route and hospitalization is required. Similar data are given by an EPS performed by oesophageal route during a consultation. The purpose of the study was to evaluate the cost of both techniques in France. Transesophageal EPS was performed during a consultation in 100 patients with asymptomatic WPW syndrome and 100 patients with no heart disease, complaining of no documented tachycardias with abrupt beginning and end, suggesting a paroxysmal junctional re-entrant tachycardia (PJRT). The cost of transesophageal study including isoproterenol infusion is 127.75 euros. The cost of intracardiac EPS is at least 1460 euros, cost of hospitalization during only one day. Results In patients with WPW syndrome, 15 had a potentially malignant form with the induction of a tachycardia conducted through the accessory pathway at a high rate (> 240/min in control state, > 300/min with isoproterenol); radiofrequency catheter ablation was indicated in a second time. In the group with no documented tachycardia, PJRT was induced in 30 patients and indication of ablation was discussed. In other 155 patients with either a benign form of WPW syndrome or with a tachycardia unrelated to a PJRT, hospitalization was not required; in these patients, intracardiac study performed during one day of hospitalization would have costed 226,300 Euros. The cost for the esophageal EPS and a similar diagnosis was 19,801 Euros, with a save money of 206,499 Euros. In 45 patients in whom hospitalization was indicated in a second time to perform catheter ablation of the arrhythmia, the cost related to esophageal EPS was 5749 Euros. In the total group, considering the final diagnosis and the need of hospitalization in 45 patients, the save money related to the use of esophageal EPS was 206,499 E–5749 E = 200,750 euros. Conclusions We should take into account the cost studies, when various techniques could be used for a similar diagnosis. There are important differences in the cost of diagnostic methods and it is easy to decrease this cost.

Intérêt de la stimulation œsophagienne dans les syndromes de préexcitation ventriculaire du grand enfant

Introduction. – In case of an accessory pathway, children are exposed to severe cardiac events including sudden death. Radiofrequency ablation is a standardized procedure, which can be applied to a significant number of children although complications can still potentially occur. In this context, transesophageal evaluation of the accessory pathway evaluation can be discussed. Materials and methods. – Among 140 procedures performed in 19 years, 70 were done for accessory pathway evaluation. The preexcitation was overt in 59 children older than 5 years, which form the basis in this study. Results. – Anterograde refractory period was determined in 88% cases and was found < 220 ms in 12 cases justifying an ablation procedure. Conversely, in case of a long refractory period (> 250 ms), the ablation procedure was not performed in 8 asymptomatic cases and was postponed in 11/20 mildly symptomatic children. Transesophageal electrophysiologic study seems legitimate in asymptomatic or mildly symptomatic children. Conclusion. – This technique is probably less useful in case of an overt preexcitation and recurrent reciprocating tachycardia requiring long-term antiarrythmic treatment. In this case, endocavitary electrophysiological study eventually followed by an ablation procedure seems the best option.

Incidence of Atrial Fibrillation in Agonistic Athletes with Palpitations of Unknown Origin

Vigorous physical exertion may be correlated to a greater incidence of atrial fibrillation (AF). Aim of the study: to evaluate the incidence of AF in agonistic athletes with palpitations of unknown origin. We evaluated 37 athletes (27 m, 28 ± 12 yrs) with palpitations of unknown origin. We performed ECG to exclude ventricular pre-excitation, echocardiography to exclude structural heart disease and transesophageal electrophysiological study (TEES) to evaluate the induction of arrhythmias. 16 pts (43%) were agonistic athletes (A, 13 m, 23 ± 10 yrs), 21 practiced regular physical activities (B, 14 m, 32 ± 12 yrs). In group A, TEES was negative in 50%, AF was induced in 4 pts (25%), atrio-ventricular nodal reentrant tachycardia (AVNRT), unsustained ventricular tachycardia of the right ventricle outflow tract, common atrial flutter (afl) and focal atrial tachycardia (FAT) in 1 pt (6.25%). In group B, TEES was negative in 13 pts (62%), AF was induced in 2 pts (9.5%), AVNRT in 4 (19%) and afl in 2 (9.5%). Among the athletes in which AF was induced (4 pts), 1 stopped agonistic activity. 1) In athletes with palpitations of unknown origin, sustained AF is inducible in 37% of cases during TEES; 2) the inducibility for AF is higher (although not significantly, p=0.2) in agonistic athletes (25%) than in patients practising non agonistic physical activity (9.5%); 3) TEES is useful in the evaluation of athletes with palpitations of unknown origin.

Apport de l'étude électrophysiologique par voie transœsophagienne dans le diagnostic étiologique des tachycardies à QRS larges

Introduction – A wide-QRS complex tachycardia is suggestive of a ventricular tachycardia (VT). Its diagnosis requires an intracardiac electrophysiological study. That study is sometimes difficult to indicate in old or very young patients. The purpose of the study was to evaluate the interest of a rapid and noninvasive study by transesophageal route for the evaluation of the nature of a wide-QRS complex tachycardia. Patients and methods – Forty patients, aged from 16 to 85 years, without bundle branch block (BBB) in sinus rhythm, were admitted for documented wide-QRS tachycardia. Transesophageal electrophysiologic study (EPS) using one and two extrastimuli was performed in control state and after infusion of 20/30 μg of Isoproterenol ®. Intracardiac EPS was performed in a second time in 38 of them. Results – The study was negative six patients; intracardiac EPS remained negative in four of them, induced a VT in one and a Mahaim-reentrant supraventricular tachycardia in another one. Clinical tachycardia was induced in remaining patients: in 27 of them, the diagnosis of SVT with aberrancy was assessed; in other patients, the diagnosis of VT was assessed; The VT was a verapamil-sensitive VT or a bundle branch reentry ( n=7). The diagnosis was confirmed by intracardiac study. Conclusion – Esophageal EPS was a means to reproduce the clinical tachycardia in 34 of 40 patients and to evaluate the mechanism of wide-QRS tachycardia in 33 of 34 patients; this technique easy to perform should be indicated in patients in whom intracardiac study is debatable to avoid to diagnose by excess a VT or in the opposite to miss this diagnosis.

Transesophageal electrophysiological study — simple and effective diagnostic tool in children

Transesophageal electrophysiological study — simple and effective diagnostic tool in children

Transesophageal electrophysiological study — simple and effective diagnostic tool in children

Transesophageal electrophysiological study — simple and effective diagnostic tool in children

Do anesthetic agents change diagnostic value of transesophageal electrophysiological study?

Do anesthetic agents change diagnostic value of transesophageal electrophysiological study?

Do anesthetic agents change diagnostic value of transesophageal electrophysiological study?

Do anesthetic agents change diagnostic value of transesophageal electrophysiological study?

Overdrive atrial stimulation during transesophageal electrophysiological study: usefulness of post-pacing VA interval analysis in differentiating supraventricular tachycardias with 1:1 atrio-ventricular relationship

We evaluated the feasibility and usefulness of overdrive atrial pacing to identify the relationship between atrial and ventricular activation in supraventricular tachycardias with a stable 1:1 atrio-ventricular (AV) conduction ratio during a transesophageal electrophysiological investigation. Overdrive atrial stimulation was performed in 42 consecutive patients (11 males and 31 females; mean age 49±17 years) during AV junctional reentrant tachycardia, orthodromic AV reentrant tachycardia and ectopic atrial tachycardia (22, 13 and seven subjects, respectively). Trains of 12 stimuli at a constant rate were introduced starting at a cycle length 10 ms shorter than the tachycardia cycle length; stimulation was repeated with a 10-ms decrement in pacing cycle length at each step until tachycardia terminated and/or second-degree AV block occurred. The difference between the VA interval duration at baseline and in the first post-pacing tachycardia beat was measured at each step and provided identification of the AV relationship. At least one post-pacing VA interval was evaluable in 90% of the cases and measured 2±4 and 1±3 ms in AV junctional and AV reentrant tachycardia groups, respectively, and 83±42 ms in the ectopic atrial tachycardia group ( P<0.0000001 ectopic atrial tachycardia group vs. others). When three or more post-pacing VA intervals were obtained during the same tachycardia, a curve was constructed by plotting their values against the corresponding pacing cycle lengths. A curve could be constructed in 36% of the cases and was flat in all patients with AV junctional and AV reentry, while it was completely irregular in the ectopic atrial tachycardia group ( P<0.003). The analysis of post-pacing VA interval behaviour in response to overdrive atrial stimulation provides a rapid and reliable differentiation between supraventricular tachycardias with 1:1 AV conduction ratio during a transesophageal electrophysiological study.

AV node reentry tachycardia in infants.

The purpose of this study was to determine the frequency of atrioventricular (AV) node reentry tachycardia in infants undergoing transesophageal electrophysiological study for paroxysmal tachycardia. The records of all 52 infants < 1-year-old with structurally normal hearts who underwent transesophageal study for paroxysmal tachycardia over a 3-year period were reviewed. Those with a diagnosis of AV node reentry tachycardia underwent complete data review, and follow-up of > 12 months was obtained. Six of 52 infants had a diagnosis of the common type of AV node reentry tachycardia. Tachycardia was diagnosed at a mean age of 2.1 months (range 1 day to 10 months), and 3 of 6 underwent transesophageal study within the first month. Although no patient had structural heart disease, three patients had significant noncardiac disease. Follow-up of 15-38 months (mean 24 +/- 7.8) revealed recurrences in 2 of 6 patients. The mean tachycardia cycle length was 240 ms (range 200-310 ms), and the transesophageal ventriculoatrial intervals ranged from < 30 to 55 ms. All patients had a inducible reentrant tachycardia with a ventriculoatrial interval that remained constant even when tachycardia cycle length increased following verapamil or adenosine administration, or decreased following isoproterenol infusion. Five of 6 had evidence for discontinuous AV node conduction curves. In our patients the substrate for AV node reentry tachycardia was present early in life, and AV node reentry tachycardia can be a clinical problem even in the newborn period.

Diagnostic Value of Synchronized Transesophageal Atrial Pacing

Synchronized transesophageal atrial pacing (single and double extrastimuli) was used in 137 patients with various tachycardias inducible by atrial pacing during transesophageal electrophysiological study (EPS). This pacing mode in five patients initiated atrioventricular tachycardias with ipsilateral bundle branch block not seen when using other pacing modes. During the tachycardia, single or double extrastimuli caused ipsilateral bundle branch block disappearance in two patients with atrioventricular tachycardia, and changed AV activation ratio in one patient with atrioventricular junctional reentrant tachycardia. This pacing mode causes very little discomfort, what is important in children, and enhances diagnostic abilities of transesophageal EPS. So, this pacing mode should be used routinely as one of the steps of transesophageal EPS.