Transesophageal Atrial Pacing Research Articles

Evaluation of transesophageal atrial pacing in the prone and lateral positions

Objective: To develop recommendations for positioning the second-generation pacing esophageal stethoscope for transesophageal atrial pacing in patients positioned prone (P), right lateral decubitus (RLD), and left lateral decubitus (LLD). Design: Prospective; patients assigned consecutively. Setting: Tertiary and university hospitals. Participants: Thirty (10 in each position group) adult patients undergoing surgery. Interventions: The optimal depths of insertions (DOI) where pacing current threshold was minimal (THmin) were determined first when supine, then after positioning. Measurements and Main Results: Transesophageal atrial pacing was successful in all patients supine and after positioning. The optimal DOI varied from 2 cm less deep to 4 cm deeper in positioned patients compared with supine patients. Patients positioned P required equal or up to 8 mA greater current outputs to achieve transesophageal atrial pacing; LLD and RLD patients may require up to 8 mA greater or lesser current compared with supine patients. Conclusion: Transesophageal atrial pacing can be used safely and effectively in patients positioned P, RLD, and LLD. Recommendations are presented for positioning the pacing esophageal stethoscope. Emphasis is given to using the lowest DOIs and smallest currents to reduce the chance of transesophageal ventricular pacing. Copyright © 2001 by W.B. Saunders Company

Radiofrequency transmission to monitoring devices in the operating room: a simulation study.

We evaluated radiofrequency (RF) transmission to various monitoring devices using circuits that simulated potentially hazardous conditions for patients in the operating room. Right heart ejection fraction (REF) pulmonary artery catheters, transesophageal atrial pacing stethoscopes, and temperature-sensing esophageal stethoscopes were subjected to RF transmission from an electrosurgery unit. Peak voltage and spark intensity were measured in circuits between the electrocautery dispersive pad and conductive elements of the various medical devices. All monitoring devices with an exposed conductive surface were found to have induced voltages and even spark generation. The ranking for peak voltage from least to most was as follows: disrupted esophageal stethoscope (620 volts), the transesophageal pacemaker (640 volts), and the REF pulmonary artery catheter (PAC) (680 volts). Peak voltage measurements of the REF PAC significantly decreased from 388 +/- 23 to 142 +/- 22 volts (P < 0.0001, Student's t-tests) in a fluid medium compared to air. In a fluid medium, peak voltage significantly decreased from 142 +/- 22 to 85 +/- 15 volts (P < 0.0001, Student's t-tests) when the REF PAC was connected to the cardiopulmonary monitor.

Paroxysmal tachycardia in children and teenagers with normal sinus rhythm and without heart disease.

The purpose of this study was to evaluate the value of esophageal programmed stimulation in children and teenagers with normal sinus rhythm ECG and normal noninvasive studies, having palpitations and syncope, and no documented tachycardias. Paroxysmal tachycardias are frequent in children and are often related to accessory connection. These tachycardias are sometimes difficult to prove. Transesophageal atrial pacing was performed at rest and during infusion of isoproterenol in 31 children or adolescents aged 9-19 years (16 +/- 3 years) with normal sinus rhythm ECG and suspected or documented episodes of paroxysmal tachycardia. Sustained tachycardia was induced in 27 patients, at rest in 13 patients, and after isoproterenol in 14 remaining patients. Atrioventricular nodal reentrant tachycardia was found as the main cause of paroxysmal tachycardia (22 cases). Six patients were followed by a vagal reaction and dizziness. These patients had spontaneous tachycardia with syncope. In three other patients, atrial fibrillation was also induced. Concealed accessory pathway reentrant tachycardia was identified in three patients. In two patients, a regular wide tachycardia with right bundle branch block morphology was induced; the diagnosis of verapamil-sensitive ventricular tachycardia was made in a second study by intracardiac study. In conclusion, atrioventricular nodal reentrant tachycardia was found as the main cause of symptoms in children with normal sinus rhythm ECG. Syncope is frequently associated and provoked by a vagal reaction. This diagnosis could be underestimated in adolescents frequently considered as hysterical because noninvasive studies are negative.

Correction of sinus node parameters with rhythm after (transesophageal) atrial pacing increases its value in patients with sick sinus syndrome

Correction of sinus node parameters with rhythm after (transesophageal) atrial pacing increases its value in patients with sick sinus syndrome

Correction of sinus node parameters with rhythm after (transesophageal) atrial pacing increases its value in patients with sick sinus syndrome

Correction of sinus node parameters with rhythm after (transesophageal) atrial pacing increases its value in patients with sick sinus syndrome

Clinical significance of pharmacological provocation during diagnostic transesophageal atrial pacing in patients with heart palpitation”

Clinical significance of pharmacological provocation during diagnostic transesophageal atrial pacing in patients with heart palpitation”

Ibutilide versus transesophageal atrial pacing for atrial flutter treatment

Ibutilide versus transesophageal atrial pacing for atrial flutter treatment

Clinical significance of pharmacological provocation during diagnostic transesophageal atrial pacing in patients with „heart palpitation”

Clinical significance of pharmacological provocation during diagnostic transesophageal atrial pacing in patients with „heart palpitation”

Ibutilide versus transesophageal atrial pacing for atrial flutter treatment

Ibutilide versus transesophageal atrial pacing for atrial flutter treatment

A rapid stress-testing protocol for the detection of coronary artery disease: Comparison of two-stage transesophageal atrial pacing stress echocardiography with dobutamine stress echocardiography

OBJECTIVESWe compared a new two-stage transesophageal atrial pacing stress echocardiography (TAPSE) protocol with a standard dobutamine stress echocardiography (DSE) protocol.BACKGROUNDTransesophageal atrial pacing stress echocardiography has been proposed as an efficient alternative to DSE.METHODSTwo-stage TAPSE (85% and 100% of age-predicted maximum heart rate) and DSE (5 to 40 μg/kg/min at 3-min stages with or without atropine) were both performed, in random sequence, in each patient of a study group of 36 patients. Regional wall-motion analysis, patient acceptance (1 = low, 5 = high), hemodynamics and duration for performing and interpreting tests were compared.RESULTSTransesophageal atrial pacing stress echocardiography was successful in 35 of the 36 patients (feasibility 97%). More TAPSE than DSE studies were called “ischemic” (37% vs. 14%; p = 0.005). Peak heart rate was higher with TAPSE (144 ± 18 vs. 129 ± 15 beats/min, p = 0.0001). Peak cardiac index (4.6 ± 2.1 vs. 5.1 ± 1.9 liters/min/m2, p = 0.14), patient acceptance score (4.2 ± 0.7 vs. 3.8 ± 1.3, p = 0.17) and study duration (14.2 ± 9.3 vs. 13.3 ± 3.3 min, p = 0.59) were similar. Recovery time (7.1 ± 7.6 vs. 16.2 ± 15.9 min, p = 0.0003) and interpretation time (9.1 ± 2.8 vs. 13.5 ± 4.4 min, p = 0.0001) were shorter for TAPSE than for DSE.CONCLUSIONSTwo-stage TAPSE permits rapid evaluation of cardiac patients. Peak cardiac index and patient acceptance scores were similar for TAPSE and DSE. Ischemia was detected more often with TAPSE; this result was attributed to the higher peak heart rate obtained with this protocol.

Hemodynamically optimized temporary cardiac pacing after surgery for congenital heart defects.

Disturbance of normal AV synchrony and dyssynchronous ventricular contraction may be deleterious in patients with otherwise compromised hemodynamics. This study evaluated the effect of hemodynamically optimized temporary dual chamber pacing in patients after surgery for congenital heart disease. Pacing was performed in 23 children aged 5 days to 7.7 years (median 7.3 months) with various postoperative dysrhythmias, low cardiac output, and/or high inotropic support and optimized to achieve the highest systolic and mean arterial pressures. The following four pacing modes were used: (1) AV synchronous or AV sequential pacing with individually optimized AV delay in 11 patients with first- to third-degree AV block; (2) AV sequential pacing using transesophageal atrial pacing in combination with a temporary DDD pacemaker for atrial tracking and ventricular pacing in three patients with third-degree AV block and junctional ectopic tachycardia, respectively, who had poor signal and exit block on atrial epicardial pacing wires; (3) R wave synchronized atrial pacing in eight patients with junctional ectopic tachycardia and impaired antegrade AV conduction precluding the use of atrial overdrive pacing; (4) Atrio-biventricular sequential pacing in two patients. Pressures measured during optimized pacing were compared to baseline values at underlying rhythm (13 patients with first-degree AV block or junctional ectopic tachycardia) or during pacing modes commonly used in the given clinical situation: AAI pacing (1 patient with slow junctional rhythm and first-degree AV block during atrial pacing), VVI pacing (2 patients with third-degree AV block and exit block and poor sensing on epicardial atrial pacing wires) and dual-chamber pacing with AV delays set to 100 ms (atrial tracking) or 150 ms (AV sequential pacing) in 7 patients with second- to third-degree AV block and functional atrial pacing wires. Optimized pacing led to a significant increase in arterial systolic (mean) pressure from 71.5 +/- 12.5 (52.3 +/- 9.0) to 80.5 +/- 12.2 (59.7 +/- 9.1) mmHg (P < 0.001 for both) and a decrease in central venous (left atrial) pressure from 12.3 +/- 3.4 (10.5 +/- 3.2) to 11.0 +/- 3.0 (9.2 +/- 2.7) mmHg (P < 0.001 and < 0.005, respectively). In conclusion, several techniques of individually optimized temporary dual chamber pacing leading to optimal AV synchrony and/or synchronous ventricular contraction were successfully used to improve hemodynamics in patients with heart failure and selected dysrhythmias after congenital heart surgery.

Transthoracic stress echocardiography with transesophageal atrial pacing for bedside evaluation of inducible myocardial ischemia in patients with new-onset chest pain

To date, there are no data on the feasibility and accuracy of bedside pacing stress echocardiography in patients admitted to the hospital with new-onset chest pain or unstable angina. We evaluated the feasibility of pacing stress echocardiography and examined its correlation with myocardial perfusion stress scintigraphy (rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion single-photon emission computerized tomography) performed within 24 hours of the pacing stress echocardiography test. We studied 70 consecutive patients after acute myocardial infarction had been excluded. The bedside pacing stress echocardiography test was performed with 10Fr transesophageal pacing catheters. We found pacing stress echocardiography to be feasible and safe (3% minor adverse event rate) at the patients’ bedside. Target heart rate of >85% of the age-predicted heart rate was achieved in 96% of patients, and the mean rate-pressure product was 22,644 ± 4,520 beats/min/mm Hg. The mean duration of the bedside pacing stress echocardiography test including technical preparations and image interpretation was 41 ± 7 minutes. Pacing stress echocardiography and myocardial perfusion stress scintigraphy correlated well for identification or exclusion of inducible myocardial ischemia in 63 of 70 patients (90%) (κ 0.81, p <0.001). The extent of inducible myocardial ischemia by vascular territories correlated with myocardial perfusion stress scintigraphy in 52 of 70 patients (74%) (κ 0.6, p <0.001). We conclude that bedside pacing stress echocardiography is feasible and safe, and highly correlates with myocardial perfusion stress scintigraphy for identifying inducible myocardial ischemia in patients with new onset of chest pain or unstable angina.

Transesophageal atrial pacing reduces phenylephrine needed for blood pressure support during carotid endarterectomy

Objective To determine whether transesophageal atrial pacing reduces phenylephrine requirement for blood pressure support during general anesthesia for carotid endarterectomy.Design Prospective randomized clinical study.Setting University hospital.Participants Thirty-six patients undergoing elective carotid endarterectomy under general anesthesia.Interventions Adults of either sex (n = 36) received general anesthesia using a standardized anesthetic regimen for elective carotid endarterectomy. Phenylephrine requirements were measured in patients having carotid endarterectomy and randomized to phenylephrine infusion (group 1, 19 patients) or phenylephrine infusion plus transesophageal atrial pacing (group 2, 17 patients) to maintain systolic blood pressure within ±20% of baseline systolic blood pressure.Measurements and Main Results Measurements included (1) the amount of phenylephrine required in each group, (2) the variance of systolic blood pressure outside the desired range, and (3) the occurrence of postoperative electrocardiogram or myocardial enzyme changes suggesting myocardial ischemia. The average requirement for phenylephrine was less for group 2 (0.28 ± 0.16 μ/kg/min) than for group 1 patients (0.46 ± 0.23 μ/kg/min) (p = 0.02 by t-test).Conclusions Under controlled conditions of general anesthesia for carotid endarterectomy, transesophageal atrial pacing reduced by 40% the amount of phenylephrine needed for blood pressure support and helped in the treatment of disadvantageous sinus bradycardia.

Transesophageal atrial pacing reduces phenylephrine needed for blood pressure support during carotid endarterectomy

To determine whether transesophageal atrial pacing reduces phenylephrine requirement for blood pressure support during general anesthesia for carotid endarterectomy. Prospective randomized clinical study. University hospital. Thirty-six patients undergoing elective carotid endarterectomy under general anesthesia. Adults of either sex (n = 36) received general anesthesia using a standardized anesthetic regimen for elective carotid endarterectomy. Phenylephrine requirements were measured in patients having carotid endarterectomy and randomized to phenylephrine infusion (group 1, 19 patients) or phenylephrine infusion plus transesophageal atrial pacing (group 2, 17 patients) to maintain systolic blood pressure within +/-20% of baseline systolic blood pressure. Measurements included (1) the amount of phenylephrine required in each group, (2) the variance of systolic blood pressure outside the desired range, and (3) the occurrence of postoperative electrocardiogram or myocardial enzyme changes suggesting myocardial ischemia. The average requirement for phenylephrine was less for group 2 (0.28+/-0.16 microg/kg/min) than for group 1 patients (0.46+/-0.23 microg/kg/min) (p = 0.02 by t-test). Under controlled conditions of general anesthesia for carotid endarterectomy, transesophageal atrial pacing reduced by 40% the amount of phenylephrine needed for blood pressure support and helped in the treatment of disadvantageous sinus bradycardia.

The sensitivity of transesophageal pacing for screening in atrial tachycardias

Transesophageal atrial pacing and recording performed in 128 patients for palpitations or tachycardia was retrospectively evaluated and compared to the same procedure in 77 routinely evaluated patients after a catheter ablation procedure. The sensitivity and specificity of the described protocol was 74 and 90% respectively. The procedure was well tolerated and a majority of patients could be completely evaluated according to the protocol. The outcome of the first time investigation influenced the subsequent choice of therapy in the studied population. The results suggest that transesophageal pacing is a valuable tool for evaluation of atrial tachycardias with specificity, sensitivity and tolerability comparable to other noninvasive methods used in cardiology.

Evaluation of transesophageal atrial pacing in the prone and lateral position

Objective: To develop recommendations for positioning the second-generation pacing esophageal stethoscope for transesophageal atrial pacing in patients positioned prone (P), right lateral decubitus (RLD), and left lateral decubitus (LLD). Design: Prospective; patients assigned consecutively. Setting: Tertiary and university hospitals. Participants: Thirty (10 in each position group) adult patients undergoing surgery. Interventions: The optimal depths of insertions (DOI) where pacing current threshold was minimal (THmin) were determined first when supine, then after positioning. Measurements and Main Results: Transesophageal atrial pacing was successful in all patients supine and after positioning. The optimal DOI varied from 2 cm less deep to 4 cm deeper in positioned patients compared with supine patients. Patients positioned P required equal or up to 8 mA greater current outputs to achieve transesophageal atrial pacing; LLD and RLD patients may require up to 8 mA greater or lesser current compared with supine patients. Conclusion: Transesophageal atrial pacing can be used safely and effectively in patients positioned P, RLD, and LLD. Recommendations are presented for positioning the pacing esophageal stethoscope. Emphasis is given to using the lowest DOIs and smallest currents to reduce the chance of transesophageal ventricular pacing. Copyright © 2001 by W.B. Saunders Company

Effects of heart rate on arterial compliance in men.

1. Arterial compliance is a major determinant of left ventricular afterload. In keeping with earlier experimental data obtained in isolated arterial segments, it has recently been shown in the rat that arterial compliance decreases with an increase in heart rate (HR) induced by atrial pacing. 2. To elucidate the potential relevance of this effect in humans, we investigated nine male volunteers (age 20-30 years; mean 26 years). Systemic arterial compliance (SAC) was measured with the diastolic area method and carotid-to-femoral and femoral-to-dorsalis pedis pulse wave velocities (PWV) were measured to determine regional changes in compliance. Heart rate was first lowered with intravenous metoprolol to 56 +/- 2 b.p.m. and then increased by transoesophageal atrial pacing to 80 and 100 b.p.m. 3. Increasing HR from 56 +/- 2 to 80 b.p.m. by pacing increased mean arterial pressure (MAP) from 78 +/- 2 to 98 +/- 1 mmHg (P < 0.001) and then to 102 +/- 2 mmHg (P = NS). Systemic arterial compliance fell from 0.48 +/- 0.06 to 0.33 +/- 0.04 arbitrary compliance units (ACU; P < 0.01), carotid-to-femoral PWV increased from 6.1 +/- 0.3 to 6.8 +/- 0.4 m/s (P < 0.001) and femoral-to-dorsalis pedis PWV increased from 8.9 +/- 0.4 to 10.1 +/- 0.5 m/s (P < 0.001). Pacing at 100 b.p.m did not change MAP, but did lead to a further decrease in SAC (to 0.24 +/- 0.03 ACU; P < 0.05) and further increases in carotid-to-femoral (7.3 +/- 0.4 m/s; P = NS) and femoral-to-dorsalis pedis PWV (11.3 +/- 0.4 m/s; P < 0.001). 4. We conclude that systemic, central and peripheral compliances decrease in vivo with an increase in HR induced by atrial pacing.

Nonexercise stress transthoracic echocardiography: transesophageal atrial pacing versus dobutamine stress

ObjectivesTo compare transesophageal atrial pacing stress echocardiography with dobutamine stress echocardiography for feasibility, safety, duration, patient acceptance and concordance in inducing wall motion abnormalities.BackgroundTransesophageal atrial pacing is an effective method of increasing heart rate and has been used in the assessment of coronary artery disease.MethodsBoth tests were performed in sequence on the same patients in random order. Transesophageal atrial pacing stress echocardiography began at a heart rate of 10 beats/min above the baseline value and was increased by 20 beats/min every two min until 85% of the age-predicted maximum heart rate or another end point was reached. Dobutamine echocardiography was performed using three-min stages and a maximum dose of 40 μg/kg per min. Atropine (total dose ≤2 mg) was administered at the start of the 40 μg/kg per min stage if needed to augment heart rate or during pacing if Wenckebach heart block occurred.ResultsTransesophageal atrial pacing stress echocardiography was feasible in 100 of 104 patients (96%); the duration (8.6 ± 3.6 min) was significantly shorter than that of dobutamine stress echocardiography (15.1 ± 3.9 min) (p = 0.0001). With transesophageal atrial pacing stress echocardiography, the recovery period was shorter, symptoms and dysrhythmias were fewer, hypertension and hypotension were less common and target heart rate was more frequently achieved. No complications occurred with either test. Patient acceptance was satisfactory. Agreement between results of both tests was good for segmental wall motion scoring with a 16-segment model, scores 1 to 5 (kappa: rest, 0.79; peak, 0.57) and test interpretation (normal, ischemia, infarction or resting wall motion abnormality with ischemia) (kappa: 0.77).ConclusionsTransesophageal atrial pacing stress echocardiography is a feasible, well-tolerated alternative to dobutamine stress echocardiography. It can be performed rapidly and shows good agreement with dobutamine stress echocardiography in the induction of myocardial ischemia.

Transesophageal electroconversion of atrial reentrant tachycardias early or late following surgery for congenital heart disease

Atrial reentrant tachycardias (ART) are a potentially life-threatening complication in survivors of congenital heart disease surgery. From July 1993 to December 1997, temporary transesophageal pacing was used to convert 29 tachycardia episodes in 19 patients. At the time of the first tachycardia episode, patients' ages were 1 month to 26 years (mean 9.8 yrs). Time from operation to onset of first tachycardia episode ranged from 1 day to 19 years. Onset was within the first 2 weeks postoperatively in 6 patients and occurred later in 13 patients (1 to 19 years after operation). Postoperative pacemaker implantation had been performed in 2 pts; 17 of 19 pts were receiving antiarrhythmic medication. After placing a quadripolar transesophageal catheter, atrial and ventricular signals were recorded and atrial stimulation performed. Atrial cycle length of tachycardia ranged from 160-380 ms with 1:1 to 4:1 AV conduction. Temporary transesophageal pacing was performed following an algorithm starting with 4 extrastimuli (20 ms below atrial cycle length of tachycardia). Tachycardia terminated in 27 of 29 cases (93%) without complications. In 3 cases, conversion was achieved by pacing after amiodarone 5 mg/kg i.v. After tachycardia conversion, sinus- or pacemaker rhythm was present in 20 cases. In 9 cases atrial fibrillation was recorded; spontaneous conversion to sinus rhythm occurred after a maximum of 3 min (7 cases) or persisted and required direct current cardioversion (2 cases). In conclusion, transesophageal atrial pacing is an effective, relatively noninvasive method for conversion of atrial reentrant tachycardias after operation for congenital heart disease.

Myocardial ischaemia un-masked by transesophageal atrial pacing combined with two-dimensional transthoracic echocardiography in a pediatric patient: a case report

We describe a case of a child operated on for an anomalous origin of the left coronary artery from the pulmonary artery and proximal hypoplasia of the anomalous coronary, in whom residual inducible myocardial ischaemia was detected by means of transesophageal atrial pacing combined with transthoracic echocardiography.