食管心房调搏诱发室性心动过速5例分析

１４２０例病人经食管心房调搏检查诱发室速９例（６．３４‰）。其中５例经心房起搏或程控早搏刺激诱发持续性室速，且均符合分支型室速。食管心房调搏检查均发现有房室分离及室性融合波，２例经心房电刺激终止，３例不能终止，经静推维拉帕料而终止，剂量３－２０ｍｇ。食管心房调搏检查对分支型室速有一定的临床意义。     

食管心房调搏12830例分析

目的探讨经食管心房调搏(trans-esophageal atrial pacing,TEAP)对心律失常的诊断价值。方法对我院26年来临床有反复心悸、头晕、短暂晕厥症状的12 830例患者的食管心房调搏检查结果进行分析,了解不同心律失常的发生情况。结果心律失常的诱发率为61.23%,室上性心动过速的诱发率(50.35%)明显高于室速(1.23%);两者比较,差异有统计学意义(P<0.05)。经食管心房调搏超速抑制成功终止99.83%的室上速,失败占0.15%(患者自行要求终止,未列入统计范畴)。两者比较,差异有统计学意义(P<0.05)。全部患者在检查中均未出现严重并发症。结论经食管心房调搏诱发和抑制室上速是有效的无创性方法,可为临床进一步治疗提供可靠依据,值得大力推广与广泛应用。     

食管心房调搏诱发与终止房室折返性心动过速的研究

目的探讨经食管心房调搏诱发与终止房室折返性心动过速的价值。方法选择255例有心动过速发作史,并且既往心电图证实有阵发性室上性心动过速(PSVT)的患者行食管心房调搏检查。结果在被检的255例患者中诱发房室折返性心动过速229例,占89.8%(其中顺向型217例,占94.8%,逆向型12例,占5.2%)。诱发成功的最佳刺激方法为程序期前刺激法(S1S2、S1S2S3),诱发率为88.2%。诱发的必备条件是旁路有效不应期长于房室结有效不应期。在诱发房室折返性心动过速的229例中215例经电刺激成功终止,转复为窦性心律,成功率为93.9%,其中64例采用短阵快速刺激一次性成功终止,转复成功率达100%。结论食管心房调搏能有效地诱发与终止房室折返性心动过速,诱发顺向型房室折返性心动过速的关键因素是旁路不应期大于房室结有效不应期,终止发作的最有效的刺激方法为短阵快速刺激。本法可作为急诊终止阵发性室上性心动过速的首选方法。     

食管心房调搏诱发终止特发性室性心动过速(附23例报告)

1998年2月至2003年4月，我们对23例特发性室性心动过速(IVT)患者，应用食管心房调搏诱发和终止室速发作过程，效果满意。现报告如下。     

食管心房调搏终止室性心动过速的初步探讨

目的：总结15例经食管心房调搏，成功终止室性心动过速的经验与体会。方法：选择15例室性心动过速病人，予以食管心房调搏，先后用分级递增和连续递增两种刺激方式予以刺激，刺激电压为25～30V，对难以终止，静脉注射异搏定，再予以经食管心房调搏。结果：单纯采用分级递增法终止了10例患的室速，2例患需加用连续递增法才能终止，另3例患经上述两种方式均未成功，给予异搏定5mg静脉注射后以分级递增法才终止了室速。结论：经食管心房起搏可以部分地成功终止持续性室性心动过速，减少直流电复律应用的必要性。     

经食管心房调搏终止室性心动过速

报道 5例经食管心房起搏成功终止室性心动过速 (简称室速 )的患者 ,探讨该方法对血流动力学相对稳定的室速的临床应用价值。全部患者心动过速发作时记录 12导联心电图资料 ,并记录食管心电图 ,证实为室速。经食管心房调搏分别用分级递增和连续递增两种刺激方式 ,刺激电压为 2 5～ 30V。结果 :3例患者使用分级递增法终止了室速 ,1例患者采用连续递增法终止 ,另 1例患者经上述两种方式均未成功 ,给予维拉帕米 5mg静脉注射后以分级递增法终止了室速。结论 :经食管心房起搏可以成功地终止部分血流动力学相对稳定的持续性室速。     

经食管心房调搏对阵发性室上速诱发与终止的临床价值

目的：研究经食管心房调搏对阵发性室上性心动过速（PSVT）诱发与终止的价值。方法：选择237例有心动过速发作史的患者进行食管心房调搏检查,如果诱发出阵发性室上速,进行12导联心电图记录后,予以短阵快速刺激或程序期前刺激终止之。另外对54例急诊PSVT患者直接予以短阵快速刺激或程序期前刺激终止之。结果：在被检的237例患者中诱发出PSVT148例,占62．4％（其中房室结双径87例,房室折返为61例）。对其202例PSVT患者均采用短阵快速刺激或程序期前刺激。PSVT即刻终止的有196例,转复成功率97％。结论：经食管心房调搏可作为PSVT筛选检查及终止的首选方法。     

经食管心房调搏诱发及终止预激综合征房室折返性心动过速的研究

目的探讨经食管心房调搏诱发和终止预激综合征阵发性房室折返性心动过速的价值.方法对30例预激综合征患者行食管心房调搏程控刺激.结果经食管心房调搏对房室折返性心动过速的诱发率,典型预激综合征A型与B型差异无显著意义(P＞0.05),典型预激综合征与詹姆斯型预激综合征差异则有非常显著意义(P＜0.05).心房刺激诱发顺向型房室折返性心动过速的关键因素是旁道有效不应期大于房室交接区有效不应期.结论典型预激综合征的类型对诱发房室折返性心动过速无明显影响;诱发的关键因素是旁道有效不应期大于房室交接区有效不应期;猝发法是终止发作的最有效方法之一,转复成功率接近100%.     

食管心房调搏对96例阵发性室上速诱发及终止作用的研究

食管心房调搏术在我国已获得广泛的开展,它对诊断和治疗阵发性室上性心动过速(室上速)的作用也有初步报道。本文旨在通过我院所见96例室上速患者用食管心房调搏进行心电生理检查的经验,对各种不同方式的电刺激在诱发和终止室上速的作用作一比较系统的分析。     

食管心房调搏超速抑制终止室上性心动过速诱发变异型心绞痛二例

据文献报道,食管心房调搏超速抑制治疗室上性心动过速(简称室上速),安全可靠,几乎无并发症[中华心血管病杂志1984;12:119.]。我们在工作中曾遇到由此所诱发的变异型心绞痛2例,特报告如下: 例1 女,65岁。脑梗塞史3年。阵发性心悸半月,发作2 h来诊。ECG(图1A)系室上速(214次/分),伴多导联T波倒置。即插入食管电极给予S_1S_1刺激(230次/分)10 s后室上速终止。此时患者左胸     

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.     

Therapeutic value of trans-esophageal electrostimulation in tachycardic arrhythmias

We were able to terminate atrial flutter in 136 of 162 patients by transesophageal rapid atrial stimulation (conversion to sinus rhythm in 75 cases, induction of atrial fibrillation in 61 cases). Atrial tachycardias were interrupted in 17 of 23 patients (sinus rhythm in 11, atrial fibrillation in 6 cases), AV reciprocating resp. AV nodal supraventricular tachycardias were terminated in 32 of 33 patients (sinus rhythm in 28 cases, atrial fibrillation in 4 cases). By transesophageal rapid ventricular and/or atrial pacing, ventricular tachycardias could be terminated in 10 of 15 patients. The success rate of transesophageal pacing is influenced by the type of tachyarrhythmia, by the type of atrial flutter and by the stimulation rate. It is not influenced by the tachycardia's cycle length. Because the success rates are comparable with invasive technique and the procedure is simpler, the non-invasive transesophageal antitachycardia pacing represents a useful method for termination of tachycardic arrhythmias.     

External cardiac programmed stimulation for noninvasive termination of sustained supraventricular and ventricular tachycardia

To examine the feasibility of using a noninvasive temporary pacemaker for termination of well-tolerated supraventricular (SVT) and ventricular tachycardia (VT), a standard external demand pacemaker was modified to allow stimulation with single or multiple extrastimuli and overdrive pacing. To evaluate the efficacy, safety and tolerance of external cardiac programmed stimulation, a standard arrhythmia termination protocol was used in 223 tachycardias in 22 patients. The technique of external cardiac programmed stimulation was used in 209 episodes of SVT in 13 patients. It terminated 95% of the episodes with success in 19 of 20 episodes of atrioventricular nodal reentrant tachycardia and 179 of 189 episodes of atrioventricular reciprocating tachycardia. Of 198 episodes of SVT terminated by the technique 168 (85%) were terminated by a single extrastimulus and 28 (14%) by double extrastimuli. Only 2 episodes of SVT required overdrive pacing for termination. External cardiac programmed stimulation did not result in atrial fibrillation or arrhythmia acceleration. Of 14 episodes of sustained monomorphic VT 5 were terminated by external cardiac programmed stimulation. One tachycardia was terminated by a single extrastimulus, 1 by double extrastimuli and 3 by overdrive pacing. Arrhythmia acceleration occurred once and was terminated by endocardial pacing. On 27 separate occasions patient evaluation of maximal discomfort included 4 ratings of mild, 10 of moderate, 11 of severe and 2 of intolerable discomfort. External cardiac programmed stimulation is effective and safe in patients with well-tolerated sustained supraventricular or ventricular arrhythmias.     

Sensitivity of an automatic external defibrillator for ventricular tachyarrhythmias in patients undergoing electrophysiologic studies

An automatic advisory external defibrillator (AED) was activated during all arrhythmias occurring at the time of 77 electrophysiologic studies in 45 patients. Sustained ventricular tachycardia (VT) occurred during 55 studies in 31 patients and nonsustained VT was induced during 10 studies in 9 patients. Ventricular fibrillation was induced 5 times in 5 patients and atrial arrhythmias with a rapid ventricular response occurred during 7 studies in 4 patients. The AED detection algorithm advised "shock" during 36 of 55 (65%) episodes of sustained VT and all 5 episodes of ventricular fibrillation. The device correctly advised "shock" for all 6 episodes of nonsustained VT that spontaneously terminated after analysis was complete. Thus, the sensitivity of the device for all ventricular arrhythmias analyzed was 47 of 66 (71%). The device recommended "shock" for all 31 episodes of rapid VT and 1 of 2 episodes of atrial fibrillation associated with systemic hypotension (32 of 33, 97%). The 19 episodes of VT for which "no shock" was advised were comparatively slow and were hemodynamically well tolerated. The device recommended "no shock" during all 21 episodes of normal sinus rhythm and all 20 episodes of rapid atrial pacing (cycle length 400 ms) analyzed. "No shock" was advised during 4 episodes of sustained narrow QRS complex supraventricular tachycardia and 4 brief episodes of nonsustained VT that terminated before analysis was complete. Thus, in this study the specificity of the AED for wide complex tachycardias was 100%.     

Long-term efficacy of antitachycardia pacing for supraventricular and ventricular tachycardias

Over a 14-year period, 53 patients received implanted pacemakers to assist in the control of recurrent tachycardias. Indications were: prevention of tachycardia in 2 patients with supraventricular tachycardia (SVT), and 4 with ventricular tachycardia (VT); termination of tachycardia (15 SVT, 20 VT); and long-term periodic programmed electrical stimulation with potential for tachycardia termination (12 VT). Pacemakers for prevention of VT were implanted in 3 patients with prolonged QT interval syndromes and 1 in whom Holter monitoring showed a significant reduction in ectopic activity during pacing. Pacers were implanted for tachycardia termination only after patients underwent a rigorous protocol aimed at achieving 100 trials of the proposed modality. Patients with tachycardia also requiring antibradycardia pacemakers received pacemakers capable of noninvasive programmed stimulation for use during follow-up. There were no tachycardia recurrences among those patients in whom pacemakers were implanted for prevention. Pacers capable of outpatient programmed stimulation were useful, and it may be desirable to expand their use. The 15 patients with pacers designed for termination of SVT were followed for a mean of 68 months. Among these, actuarial continuation of pacing efficacy was 93% at 1 year, and 78% at 5 years. The 20 patients with pacers for termination of VT were followed for a mean of 37 months. Actuarial efficacy was 78% at 1 year, and 55% at 5 years. Sudden death occurred in 4 of these patients, none clearly pacer related. Pacemakers can play a major therapeutic role in some patients with recurrent tachycardias. The role of such pacemakers in patients with VT may be expanded with the advent of combined pacer-defibrillators.(ABSTRACT TRUNCATED AT 250 WORDS)     

Use of transesophageal atrial pacing for documentation of arrhythmias suspected in infants and children

Transesophageal atrial pacing study was used to document arrhythmias in 67 infants and children age 2 months to 16 years (mean, 8.3 years), who had palpitations or symptoms suggesting tachyarrhythmias but had no electrocardiographic documentation of cardiac dysrhythmias. The transesophageal pacing and medical records were reviewed retrospectively. In 47 of 67 (70%) of the infants and children with suspected tachyarrhythmias, transesophageal atrial pacing induced various tachycardias, which may be the cause of symptoms. In 10 of 67 patients, tachycardia was induced during infusion of isoproterenol. During the study, tachycardia was initiated in 14 of 15 patients less than < 6 years-old and in 33 of 52 patients > or = 6 years-old (P < 0.05). Of these induced tachycardias, 25 of 47 were atrioventricular reciprocating tachycardia, 16 atrioventricular nodal reentrant tachycardia, and 6 idiopathic left ventricular tachycardia. Both transesophageal study and invasive electrophysiologic study were performed in 10 patients. The mechanisms of tachycardia in the invasive study and transesophageal study were identical except for one patient. In conclusion, transesophageal atrial pacing and recording was less invasive, safe and useful for documenting arrhythmias in infants and children who had symptoms suggesting tachyarrhythmias, especially in patients < 6 years of age. Evaluation of the mechanism of induced tachycardia provided useful information regarding the prognosis and therapeutic options in infants and children.     

Transesophageal low-energy cardioversion in an animal model of life-threatening tachyarrhythmias

The purpose of this study was to determine the feasibility and efficacy of terminating life-threatening ventricular tachyarrhythmia by low-energy synchronous or asynchronous shocks delivered through a transesophageal catheter that had both an anode and a cathode. Forty-three episodes of ventricular fibrillation or flutter (Vf or VF) were provoked by transesophageal asynchronous random shocks occurring during the vulnerable period of the ventricular cycle in seven dogs and seven pigs that were healthy adults. The 43 episodes of Vf or VF were terminated by the transesophageal technique. The defibrillation energy thresholds were 23.11 +/- 6.28 J (range, 5-30 J). Seven episodes of ventricular tachycardia (VT) with a cycle length of 360 msec or less (330 +/- 27 msec) were provoked by ventricular pacing stimuli during acute myocardial ischemia resulting from delayed resuscitation in two dogs and three pigs. Five of the seven VTs had a duration of 31 seconds or more, and they were all terminated by transesophageal synchronous shocks, the cardioversion thresholds being 1.71 +/- 2.25 J (range, 0.25-5 J). Fourteen episodes of idioventricular tachycardia (IVT) with a cycle length of 400 msec or more (445 +/- 33.5 msec) spontaneously occurred after the use of adrenaline and after defibrillation in four dogs and five pigs. We also succeeded in terminating seven episodes of IVT with a duration of 34 seconds or more by the same means of treating VT, although IVT is not an indication for cardioversion in the clinical setting.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ultrarapid single-capture train stimulation for termination of ventricular tachycardia

Termination of ventricular tachycardia (VT) with single programmed extrastimuli or slow underdrive competitive pacing is often possible. The usefulness of these techniques is limited because the zone in the cardiac cycle during which programmed stimuli are effective may be narrow, with significant time elapsing until termination of the VT, and the zone may vary markedly between episodes, rendering preset extrastimuli ineffective. Ultrarapid trains of stimuli beginning during the refractory period and of a duration sufficient to cause only a single capture should terminate all tachycardias whose termination zone begins just after the refractory period. To test this hypothesis, 21 patients with 371 well-tolerated episodes of VT had single programmed extrastimuli and trains of 10 bipolar stimuli at 25, 50, and 100 Hz. VT was terminated 1 or more times in 18 of the 21 patients with programmed extrastimuli or trains, or both. Forty-eight percent of 290 episodes were terminated with programmed stimulation, compared with 56% of 120 episodes with trains (difference not significant). In 98 episodes, the effects of trains and programmed stimulation could be matched (same patient, date, tachycardia morphology, rate, and drug therapy); the results were concordant (both techniques either terminated the VT or failed) in 92 and discordant in 6. With only 2 possible exceptions, the termination zone always began just after the refractory period; thus, for tachycardias terminating with single captures, the first train to achieve capture was effective, minimizing the duration of the VT.     

Transitory or permanent regular wide QRS complex tachycardia induced by atrial stimulation in patients without apparent heart disease. Significance

Objectives. - The purpose of the study was to evaluate the frequency of transitory or permanent bundle branch block (BBB) associated with a paroxysmal tachycardia induced by atrial stimulation in patients without heart disease and its significance.Methods. - Esophageal atrial stimulation was performed in 447 patients suspected to have supraventricular tachycardias (SVT). Sustained regular tachycardia was induced in all of them but three, either in control state (75%) or after administering isoproterenol. In 346 patients, only narrow complex SVTs were induced (77%); in 259 of them, the reentry occurred in the AV node and in remaining patients within a concealed accessory pathway. In 62 patients, a transitory functional BBB was recorded at the onset of the tachycardia (14%). In 33 of them, the reentry occurred in the AV node and in the remaining 29 patients within a concealed accessory pathway. In 36 patients (8%), a permanently wide QRS complex tachycardia was induced. Three patients had also inducible narrow complex SVT. Atrial pacing induced a BBB similar to the aberrancy in tachycardia in 22 patients: the reentry occurred in the AV node in 17 patients, within a concealed accessory pathway in three patients and in a Mahaim bundle in two patients. In other patients, QRS complex remained normal during atrial pacing: all 14 patients had a ventricular tachycardia (VT), either a verapamil-sensitive VT (n = 7) or catecholamine-sensitive VT (n = 4) or bundle branch reentry (n = 3). Followed from 2 to 12 years, the prognosis of these patients was excellent.Conclusion. - Transitory BBB at the onset of an SVT is noted in 14% of the population, is more frequent in patients with accessory pathway reentrant tachycardia, but is helpful for this diagnosis in only 12% of cases. A regular tachycardia with permanent left or right bundle branch morphology induced by atrial stimulation in a patient without heart disease and without BBB during atrial pacing is due to a VT even if this patient has also narrow complex tachycardias. This mechanism does not affect the excellent prognosis of this population.