Termination of atrial reentrant tachycardias by using transesophageal atrial pacing

Atrial reentrant tachycardia (ART) is not an uncommon complication in patients after surgery for congenital heart defects, particularly after extensive atrial procedures with sutures lines or baffeling maneuvers. Primary atrial flutter is a rare dysrhythmia in newborns. Two issues of ART or atrial flutter can be addressed by the esophageal approach: First, ART (often with 2:1 A-V conduction) may be difficult to detect on the surface ECG as the P waves usually do not show the typical flutter morphology or are hidden in the T wave. Recordings over the esophageal lead clearly determine the underlying rhythm. Second, termination of ART by pacing the atria can easily be performed by using an esophageal electrode. We performed 62 conversions of ART in 39 pts. (median age 12.5 years), among them 7 newborns with typical atrial flutter. The pacing algorithm started with 4 extrastimuli and pacing intervals 20 msec shorter than the atrial cycle length of tachycardia. Conversion was achieved in 50/62 (81%) cases; in 12 of 62 (19%) cases conversion was performed externally as the transesophageal approach was insufficient to restore sinus rhythm. Intravenous infusion of amiodarone prior to atrial pacing seems to be helpful in some patients for termination of ART. We recommend transesophageal atrial pacing as a first step of acute management of atrial flutter and other forms of ART in neonates, infants, and children because it is a minimal invasive procedure with high success rates.