ELECTROPHYSIOLOGY

Sensitivity of Transesophageal Electrophysiologic Study in Children with Supraventricular Tachycardia on Electrocardiography ¨ ¨ M.D.,* ALPER AKIN, M.D.,* SEMA OZER, M.D.,* TEVF˙IK KARAGOZ, ˙ ¨ ¨ HAYRETTIN HAKAN AYKAN, M.D.,* MUSTAFA GULGUN, M.D.,* ¨ ¨ SUHEYLA OZKUTLU, M.D.,* DURSUN ALEHAN, M.D.,* and ALPAY C ¸ EL˙IKER, M.D.† From the *Department of Pediatric Cardiology, Hacettepe University Faculty of Medicine, Ihsan Do˘gramacı Childrens Hospital, Ankara, Turkey; and †Department of Pediatric Cardiology, Acıbadem University Faculty of Medicine, ˙Istanbul, Turkey

Introduction: The aim of this study was to evaluate the inducibility of tachycardia by transesophageal electrophysiologic study (TEEPS) in patients with documented supraventricular tachycardia (SVT) on electrocardiography and to investigate the accuracy of TEEPS records by comparing with intracardiac electrophysiologic study (IEPS). Material and Methods: The TEEPS records of patients having documented electrocardiography during SVT were reviewed. The results of TEEPS in 43 of 85 patients were compared with results of IEPS for compatibility of diagnosis. Results: A total 85 patients, 46 male and 39 female, mean weight 35.1 kg (36–87), aged 1 month– 17 years, were included. Tachycardia was induced by TEEPS in 79 of 85 patients with documented electrocardiography (sensitivity 92.9%). IEPS for diagnosis or ablation was conducted in 40 patients having inducible tachycardia and three of six who had no inducible tachycardia by TEEPS. Tachycardia was induced by IEPS in 39 of 40 (97.5%) patients who had inducible tachycardia and two of three who had no inducible tachycardia by TEEPS. Mechanisms of tachycardias were similar in 97.5% of patients (37/39) who had inducible tachycardia in TEEPS and IEPS. One of the patients with atrioventricular reentry tachycardia by TEEPS was diagnosed as atrioventricular nodal reentry tachycardia (AVNRT) and the other one was diagnosed as atypical AVNRT and atrial tachycardia by IEPS. Conclusion: The rates of inducibility and mechanisms of tachycardias by TEEPS in children having documented SVT were similar with those obtained from IEPS. (PACE 2014; 37:1002–1008) transesophageal electrophysiologic study, intracardiac electrophysiologic study, electrocardiography, tachycardia, children Introduction Recent advances in electrophysiology have improved our understanding of arrhythmia mechanisms in patients with abnormal heart rhythm. Tachycardia attacks are generally transient, shortlived, and infrequent. Evaluation of childhood tachycardias is particularly difficult, especially in young infants who are unable to articulate their symptoms. A surface electrocardiogram (ECG) obtained when a patient is symptomatic is important for making a diagnosis. However, shortThere is no financial support and conflict of interest. ¨ Address for reprints: Sema Ozer M.D., Department of Pediatric Cardiology, Hacettepe University Faculty of Medicine, Ihsan Do˘gramacı Childrens Hospital, 06100 Samanpazari, Ankara, Turkey. Fax: 90 312 3090220; e-mail: [email protected] Received November 13, 2012; revised December 30, 2013; accepted January 5, 2014. doi: 10.1111/pace.12371 ©2014 Wiley Periodicals, Inc.

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lasting transient tachycardias pose a diagnostic challenge. Even the value of using a Holter recording device or a long-term cardiac event recorder is limited by variations in the frequency of tachycardia.1,2 A transesophageal electrophysiologic study (TEEPS) is a minimally invasive modality that is used for diagnosing and treating arrhythmias such as supraventricular tachycardia (SVT), as well as to determine the presence of recurrence in treated arrhythmias. Being a less invasive method than intracardiac electrophysiologic study (IEPS) that can also demonstrate SVT mechanisms by eliciting tachycardia other than during an SVT attack, TEEPS has cemented its place in management algorithms as one of the preferred initial tests for diagnosing SVT in children.3 The aim of this study was to evaluate the inducibility of only SVT by TEEPS in patients with ECG-documented tachycardia, and to validate the TEEPS diagnoses by comparing findings with those of IEPS. PACE, Vol. 37

TEEPS IN CHILDREN WITH DOCUMENTED TACHYCARDIA

Material and Methods Patient Selection This retrospective study was undertaken in our Pediatric Cardiology Department. The medical records of all patients aged 0–18 years who underwent TEEPS between January 2007 and June 2012 were systematically reviewed and those with tachycardia confirmed by ECG prior to the procedure were identified. In our study, TEEPS indications were applied as follows: suggestive signs or symptoms of arrhythmia such as tachycardia or syncope, mechanism of SVT, cardioversion, risk identification in Wolff-Parkinson-White (WPW) syndrome, antiarrhythmic drug effectiveness, evaluation after ablation treatment, and evaluation of sinus node functions. Only patients with documented SVT before TEEPS procedure were included in this study. The equipments used for electrophysiologic study were not ready to use in our laboratory and were provided by companies on the day of procedure. Thus, we performed TEEPS before ablation in patients with documented SVT to decide which procedure (radioablation or cryoablation) will be applied to them. TEEPS procedure has been carried out as soon as possible if early ablation treatment is necessary because of impairment of medical treatment or recurrent tachycardia despite drugs. The appointment for TEEPS was given to patients controlled by drugs and considered elective ablation procedures. Information regarding the stimulation method used to induce tachycardia during TEEPS, ventricle-atrium (VA) conduction time, rate of tachycardia induced, and how the tachycardia terminated was obtained for each patient from the medical records. Patients who were subjected to further evaluation based on results of TEEPS were identified, and the results of IEPS performed prior to ablation therapy were compared with the results of TEEPS for compatibility of diagnoses. TEEPS Procedure In our department, the standard protocol for TEEPS requires discontinuation of antiarrhythmic treatment at least five half-lives prior to the procedure, and all procedures are performed after at least a 4-hour fast. TEEPS and IEPS procedures are both performed in the cardiac catheterization and intracardiac electrophysiology laboratories of the Department of Pediatric Cardiology. For agitated/anxious patients, sedation is first achieved using midazolam (0.1 mg/kg) followed by intravenous ketamine (1 mg/kg), if

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necessary. We do not use general anesthesia for sedation in TEEPS procedure. TEEPS procedures are performed using either 6-Fr catheters for children weighing less than 15 kg or 7-Fr catheters for heavier patients. The stimulator and recorder electrodes on these quadripolar catheters are spaced 5 mm, 10 mm, or 15 mm apart. A catheter is introduced transnasally into the esophagus using 1% lidocaine cream for lubrication, either under fluoroscopy or using Benson’s formula. In our routine, we do not use x-rays to adjust the quadripolar catheter used in TEEPS procedure. After inserting the quadripolar catheter nasally, we check the A and V signals from the atrium to correct whether the catheter is in an appropriate position or not. If we cannot detect adequate signals, we rarely need to use fluoroscopy. Once the point of maximal reception of atrial signals is determined, a FIAB Programmable Cardiac Stimulator 8817 (FIAB SpA, Vicchio, Italy) is used to deliver 5–45-mA currents for a period of 5–20 ms. We usually use 15–20 mA as an output and pulse with 15–20 ms in the TEEPS procedure. If we cannot achieve stable capture with present currents, we rarely need to increase the level of the current output. Electrocardiography readings are recorded using an EP MedSystems device normally used for IEPS, but adapted for TEEPS (EP MedSystems, Inc./St. Jude Medical, St. Paul, MN, USA). Stimulation is initiated using the lowest current setting (usually 10 mA) for a period of 10 ms, at a rate 10–20% above the baseline heart rate. Anterograde conduction and refractory characteristics were determined during atrial pacing. The current and period of the stimulus is gradually increased to determine the stimulus threshold. Programmed stimulation is then applied with stimulus current strength and duration set at 50% more than threshold level. In our institution, stimulation protocols dictate the use of single and double extrastimuli as well as rapid atrial pacing in the baseline state. In the event of failure to induce tachycardia under baseline conditions, the pacing protocol is repeated following infusion of atropine (0.04 mg/kg). If this fails, the protocol is repeated once more after administration of isoproterenol (0.02– 0.1 µg/kg/min up to maximum of 4 µg/min). Tachycardias that do not cease spontaneously are terminated by either applying short stimulation (burst) or by overdrive pacing if valsalva maneuver or ice to the face is useless. If overdrive pacing also fails to terminate a tachycardia, intravenous adenosine or verapamil are administered as needed. For all induced tachycardias, VA interval is measured from the onset of the QRS complex up

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to the rapid deflection of the atrial component of esophageal ECG. SVT is classified as atrioventricular nodal reentry tachycardia (AVNRT) in patients without preexcitation if they were reentrant with a 1:1 ventricular-atrial relationship and a VA interval < 70 ms. A diagnosis of atrioventricular reentry tachycardia (AVRT) is made in the presence of a regular rhythm with no evidence of atrioventricular dissociation, and a VA interval ≥ 70 ms.3 Ectopic atrial tachycardia (AT) was determined as one of the basic forms of primary atrial tachycardias in which the primary electrophysiologic abnormality was happened completely within the atria and a nonsinus atrial focus showed enhanced automaticity, resulting in an improper rapid atrial rate.3 IEPS Procedure The average time of IEPS after TEEPS was 4.6 months (3 days–2 years). The indications of IEPS were applied as follows: history of syncope or sudden death in patients with WPW, antegrade effective refractory period (ERP) less than 250 ms in a patient with WPW, ventricular dysfunction due to SVT, tachycardia-induced cardiomyopathy, arrhythmia resistant to medical treatment, recurrent arrhythmia, inadaptability to medical treatment, and evaluation before ablation treatment. IEPS was performed for all patients who undergone treatment of radiofrequency ablation just before the procedure. Antiarrhythmic medications were stopped at least 5 days prior to each IEPS and informed consent was acquired from parents of patients. Midazolam (0.1 mg/kg) or/and ketamine (1 mg/kg) were used for sedation for all patients. We did not need general anesthesia for patients during IEPS stage. We used general anesthesia for patients only during treatment of ablation. For intracardiac electrophysiological studies, the IEPS procedure involves initial percutaneous placement of three or four quadripolar electrodes strategically placed to stimulate the right atrium, His-bundle, apex of the right ventricle, and the coronary sinus. This is followed by programmed stimulation of the lateral right atrium using the same protocol applied during TEEPS. Anterograde conduction and refractory features were identified using premature extrastimuli. Once tachycardia is induced, atrial mapping of the right atrium and coronary sinus is performed. In patients with preexcitation, the anterograde ERP of an accessory connection was defined as the longest atrial coupling interval near the accessory pathway which fails to conduct with preexcitation. The existence of transient bundle branch block during tachycardia in patients with orthodromic reciprocating tachycardia guided localization of the accessory

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pathway. If there was prolongation of tachycardia cycle length or VA interval during bundle branch block, it showed evidence of the accessory connection located ipsilaterally. Otherwise, if there was no change in VA interval during bundle branch block, it was considered that the accessory connection was located on the contralateral side or septal. Bundle branch block typically occurred during the onset of tachycardia.3 Multiple accessory connections were considered if one of the following signs was present: changes in delta wave polarity, multiple pathways of retrograde atrial activation or evidence of mismatch of anterograde preexcitation, and the site of retrograde atrial activation during orthodromic reciprocating tachycardia.3 Statistical Analysis Statistical analyses were made using the Statistical Package for the Social Sciences program (version 15.0; IBM Corp., Armonk, NY, USA). Normality of distribution was evaluated using the Shapiro-Wilk test. Comparisons of categorical variables were made using Fisher’s exact test. For numerical variables, two-group comparisons were made using the Mann-Whitney U test. Values for numerical variables are given as mean ± standard deviation or mean. Categorical variables were depicted as number and percentage (%). A P value of less than 0.05 was considered indicative of statistical significance. Results A total of 85 patients (46 male and 39 female) with confirmed SVT on ECG who underwent TEEPS procedure were included in the study. Mean age at which TEEPS was performed was 9.4 years (30 days–17 years), with a mean weight of 35.1 kg (3.6–87 kg). TEEPS was performed for patients with documented tachycardias at the admission to our hospital or in 2 months. Sedation for the TEEPS procedure was achieved by midazolam alone in 54 patients whereas nine patients required additional use of ketamine to achieve sufficient sedation. The remaining 25 patients did not require any premedication prior to the procedure. Mean tachycardia rate during the TEEPS procedures was 218/min ± 27 (range 150–280). Mean VA period was measured 81 ± 35 ms (range 20–210 ms) and a mean Wenckebach point was measured 268 ± 35 ms (range 220–440 ms). Of the 79 patients with a positive result following TEEPS, 61 patients’ use of atropine and/or isoproterenol was not required to induce tachycardia, while in 18 patients tachycardia was elicited following administration of atropine and/or isoproterenol.

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TEEPS IN CHILDREN WITH DOCUMENTED TACHYCARDIA

Figure 1. This figure shows inducibility of supraventricular tachycardia (SVT) by transesophageal electrophysiologic study (TEEPS) and intracardiac electrophysiologic study (IEPS) as well as accuracy of diagnosis by TEEPS compared with IEPS.

Neither patient age nor duration between TEEPS and IEPS were found to have a significant effect on the likelihood of tachycardia being induced. None of the patients in our study developed any complications related to TEEPS. TEEPS was successful in inducing tachycardia in 79 of the 85 (92.9%) patients (Fig. 1). The distribution of post-TEEPS diagnosis was AVNRT in 41 patients, AVRT in 37 patients, and AT in one patient. TEEPS was performed in eight patients aged 0–2 years. They diagnosed AVRT and medical treatment was started. Since tachycardia was controlled with medical treatment, IEPS for these patients was not performed. Comparison of

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inducibility of tachycardia by TEEPS and IEPS have been summarized in Table I. Although the tachycardia induced by TEEPS terminated spontaneously in seven of the 79 patients, overdrive pacing was successful in terminating the induced tachycardia in 70 of the remaining 72 patients. The other two patients had SVT which was terminated by administering adenosine. None of the patients in the study required cardioversion. Overall, IEPS was performed in 43 patients (40 patients with TEEPS-induced tachycardia and three patients without induced tachycardia on TEEPS). The mean duration between the TEEPS and IEPS procedures was 4.6 months (0–24 months). There was no statistical significance

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Table I. Comparison of Tachycardia Inducibility with TEEPS and IEPS IEPS (n: 43) Tachy- Tachycardia cardia Could Not Induced be Induced TEEPS (n: 43)

Tachycardia induced Tachycardia could not be induced

39

1

2

1

IEPS = intracardiac electrophysiologic study; TEEPS = transesophageal electrophysiologic study.

between the TEEPS and IEPS groups in terms of age, gender, and body weight. Tachycardia was elicited by IEPS in 39 of the 40 patients (97.5%) with TEEPS-induced tachycardia. In 37 of these 39 patients (95%), diagnosis of tachycardia induced by IEPS was compatible with that induced during TEEPS. IEPS elicited findings consistent with typical AVNRT in an 8-year-old male and atypical AVNRT plus AT in a 13-year-old patient despite prior diagnosis of AVRT following TEEPS. IEPS was successful in inducing tachycardia in two of the three patients in whom TEEPS failed to elicit tachycardia, whereas in one patient tachycardia could not be induced. Numbers and results of TEEPS and IEPS procedures have been shown in Figure 1. Of the 41 patients with tachycardia induced by IEPS, 24 had AVNRT, 16 had AVRT, and one had AVNRT + AT. Two patients had preprocedural ECG findings consistent with preexcitation (WPW); in both of them TEEPS was successful in inducing tachycardia. Both patients were considered highrisk since they had ERPs of less than 250 ms. IEPS was planned but neither of them has undergone IEPS yet. Four patients who developed AVRT following TEEPS, but did not have preexcitation on pre-TEEPS ECG, were found to have preexcitation on baseline ECGs obtained before the IEPS procedures. A tentative diagnosis of intermittent WPW was made in these patients. Discussion The main finding of this study is that compared with intracardiac electrophysiologic studies, transesophageal electrophysiologic studies are highly accurate in diagnosing and charac-

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terizing various types of SVT in pediatric patients. Tachycardia mechanisms, as diagnosed by the two techniques, were concordant in 56 of 57 patients. In patients with tachycardia utilizing concealed accessory connections, transesophageal study correctly localized accessory connections in 12 patients in whom transient bundle branch block occurred during SVT. Very few studies have evaluated the results of both TEEPS and IEPS in children with SVT detected on superficial ECG. In a study by Pehrson et al.4 on patients aged between 13 years and 74 years, TEEPS findings of 45 patients with tachycardia recorded on ECG were compared with 11 patients who complained of palpitations but did not have any positive findings on ECG. The tachycardia induction rate by TEEPS in the ECG-positive group was higher than in the ECG negative group (87% vs 73%). In the same study, of the 31 patients in whom tachycardia was induced during TEEPS, IEPS was also successful in eliciting tachycardia in 30 patients (96.8%). IEPS induced tachycardia in one of three patients in whom tachycardia could not be induced by TEEPS. On the other hand, in one patient, IEPS could not elicit tachycardia despite TEEPS having induced tachycardia previously.4 In another study, Brembilla-Perrot et al.14 showed that TEEPS was a semi-invasive and effective alternative method to IEPS in terms of inducibility of tachycardia and determination of mechanism of SVT. Although a SVT was detected by 24-hour Holter monitorization in 45 of 140 children with clinically diagnosed SVT, the characteristics of tachycardia were not determined in the majority of patients with SVT by using only ECG records and they used TEEPS procedure for evaluation of the characteristics of tachycardia. They also reported that SVT was induced in all patients and mechanism of SVT was revealed for each case in their investigation. In our study, SVT records on surface ECG were not enough to light the characteristics of tachycardia, in agreeing with previous reports. Our study differs from the Pehrson et al.4 study in that our cohort was comprised exclusively of children, and of the 40 patients with TEEPS-induced tachycardia, tachycardia was also induced by IEPS in 39 patients (97.5%). IEPS failed to elicit tachycardia in only one patient with tachycardia detected during TEEPS. Nevertheless, the tachycardia induction rates obtained with TEEPS and IEPS on our patients with ECGdocumented tachycardia were comparable to those reported in the Pehrson et al.4 study. In ¨ another study by Ozer et al.5 on patients with symptoms suggestive of arrhythmia aged between 26 days and 26 years, evaluated prior to 2007, the

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TEEPS IN CHILDREN WITH DOCUMENTED TACHYCARDIA

reported tachycardia induction rate with TEEPS was 36% (32/89). In the same study, TEEPS was also successful in inducing tachycardia in 12 of 22 patients (54%) with tachycardia detected by either Holter or superficial ECG.5 Although tachycardia inducibility with TEEPS was higher in patients with documented arrhythmia (54%), the rate was lower than the tachycardia-induction rate of 89.1% observed in our study. Tachycardia induction rates and information regarding tachycardia mechanisms obtained with TEEPS have been shown to correlate well with findings of subsequent invasive electrophysiologic studies.4,6 Inducibility of tachycardia ranges from 73% to 98.5% in patients with clinical supraventricular reentrant tachycardia.4,7,8 In their study, Samson et al.3 reviewed the records of 57 pediatric patients undergoing both transesophageal and intracardiac electrophysiologic studies and tachycardia mechanisms showed concordance in 56 of ¨ the 57 patients (98%). In another study by Ozer et al.5 153 TEEPS procedures were performed on 147 patients. However, tachycardia could only be induced in 72 patients allowing for identification of tachycardia mechanism. Moreover, Erdo˘gan et al.9 reported on a positive predictive value of 91% for TEEPS in the determination of SVT mechanisms. Pongiglione et al.2 also reported on a successful tachycardia induction rate of 71% (20/28) with TEEPS. Twenty-three of the 28 patients in this study had normal findings on a standard ECG, whereas the remaining five had a short PR interval or signs consistent with ventricular preexcitation. The diagnostic concordance of TEEPS and IEPS in our study with regard to the induction of tachycardia was as high as in previous reports in the literature (95%), with disconcordance between the two modalities mainly occurring with AVRT and AVNRT.1,4,10,11 In the Pehrson et al.4 study, the regular tachycardia diagnosed by IEPS was compatible with TEEPS diagnosis in 25 of 28 patients (89%). Finally, characteristics of conduction and refractory properties of anterograde accessory connection determined during transesophageal study were highly correlated with those determined during intracardiac study.3 In two of the remaining patients, AVRT observed on TEEPS was eventually confirmed to be AVNRT by IEPS, whereas in one patient a TEEPS diagnosis of AVNRT was changed to AVRT after IEPS evaluation. In a similar study by Ko et al.1 on 10 patients who underwent both the TEEPS and IEPS procedures, one patient who was diagnosed with AVNRT after TEEPS was later diagnosed with AVRT following IEPS. The two disconcordant cases in our study that were diagnosed as having AVRT during TEEPS were eventually

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identified as having AVNRT. One of the patients in fact had atypical AVNRT and AT, with two different tachycardia mechanisms distinguished by IEPS evaluation. Tritto et al.12 reported on a patient with narrow QRS tachycardia in whom both AVNRT and AT were detected by TEEPS. Since the ECG findings of both arrhythmias are quite similar, authors highlighted the importance of TEEPS in distinguishing between the two tachycardias. In a study by Blaufox et al.13 on 27 patients with TEEPS-induced tachycardia aged between 9 months and 22 months, none of the factors evaluated (age at presentation, age at TEEPS procedure, duration between initial diagnosis, and TEEPS procedure) were found to increase the likelihood of tachycardia being induced during TEEPS. In our study, neither patient age nor duration between TEEPS and IEPS were found to have a significant effect on the likelihood of tachycardia being induced. In the study by Pehrson et al.4 on 47 patients with ECG-documented tachycardia in whom TEEPS elicited an arrhythmia, investigators most frequently used incremental pacing to induced tachycardia, followed by single extrastimulus, double extrastimulus, atropine followed by double extrastimulus and atropine followed by single extrastimulus, and spontaneously in order of decreasing frequency. On the other hand, authors reported on a spontaneous tachycardia termination rate of 24%, with the tachycardia in 94% of the remaining patients terminating following overdrive pacing. Incremental stimulus was also the most frequently utilized method for induction of tachycardia in our study, with overdrive pacing terminating SVT in 97.2% of cases, a rate consistent with other reports in the literature. In another study, Brembilla-Perrot et al.14 compared the efficacy of incremental atrial stimulation and short burst pacing with an atrial stimulation program utilizing single or double extrastimulation for inducing tachycardia. A tachycardia induction rate of 100% was observed in the programmed atrial stimulation group compared to a rate of 70% in the other group. The evidence regarding the superiority of either atropine or isoproterenol to the other remains inconclusive. The general approach in our department is to use atropine in older children with suspected AVNRT, whereas isoproterenol is preferred in younger children and babies, especially if WPW syndrome is suspected. For a select group of patients, and those in whom tachycardia could not be induced by a single drug, a combination of both medications has been utilized. In our study, atropine and isoproterenol

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were administered in sequence in six patients with ECG-documented tachycardia in whom tachycardia could not be initially induced by TEEPS. The tachycardia induction rate in our study using either one of the drugs was 24%. Brembilla-Perrot et al.15 reported the need of using isoproterenol during TEEPS to induce SVT in 59 of 140 (42.1%). Similarly, Ko et al.1 reported that stimulation of tachycardia was required the use of isoproterenol in 10 of 47 patients (%21) in TEEPS. Rhodes et al.16 reported on a low false negative rate with the TEEPS procedure, especially with concurrent use of isoproterenol. With regard to atropine, Pehrson et al.4 used the drug to help induce tachycardia during TEEPS in 20% of their patients. None of the patients in our study developed any complications related to TEEPS. The TEEPS procedure has not been directly associated with any complications, and available reports in the literature have shown the primary risk to be linked with sedation rather than with the procedure itself.3,13 It is recommended that all precautions

against potential complications should be taken when inducing sedation and that sedation should be supervised by experienced personnel. In our study, we managed to demonstrate a reasonably high tachycardia inducibility rate of 92.9% with the TEEPS procedure in children with superficial ECG-documented tachycardia and that the information provided by TEEPS regarding tachycardia mechanisms correlated quite well with findings on IEPS (95% concordance). However, it would seem that a diagnosis of AVRT following TEEPS warrants further investigation to rule out the presence of atypical AVNRT. In conclusion, we think that TEEPS is a semi-invasive and effective method to evaluate the characteristics of SVT on surface ECG before ablation treatment. Thus, TEEPS procedure in children with SVT should be considered a similar alternate method to IEPS to avoid from possible complications due to invasive IEPS. In addition, overdrive pacing seems a safe and useful method to terminate SVT in children.

References 1. Ko JK, Ryu SJ, Ban JE, Kim YH, Park IS. Use of transesophageal atrial pacing for documentation of arrhythmias suspected in infants and children. Jpn Heart J 2004; 45:63–72. 2. Pongiglione G, Saul JP, Dunnigan A, Strasburger JF, Benson DW Jr. Role of transesophageal pacing in evaluation of palpitations in children and adolescents. Am J Cardiol 1988; 62:566–570. 3. Samson RA, Deal BJ, Strasburger JF, Benson DW Jr. Comparison of transesophageal and intracardiac electrophysiologic studies in characterization of supraventricular tachycardia in pediatric patients. J Am Coll Cardiol 1995; 26:159–163. 4. Pehrson SM, Blomstrom-Lundqvist C, Ljungstrom ¨ ¨ E, Blomstrom ¨ P. 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. Clin Cardiol 1994; 17:528–534. ¨ 5. Ozer S, Celiker A, Karagoz ¨ T, Melek E. Transesophageal electrophysiologic study in children and young patients. Turk J Pediatr 2007; 49:45–51. 6. Volkmann H, Kuhnert H, Dannberg G. Electrophysiological ¨ evaluation of tachycardias using transesophageal pacing and recording. Pacing Clin Electrophysiol 1990; 13:2044–2047. 7. Gallagher JJ, Smith WM, Kerr CR, Kasell J, Cook L, Reiter M, Sterba R, et al. Esophageal pacing: A diagnostic and therapeutic tool. Circulation 1982; 65:336–341. 8. Guarnerio M, Furlanello F, Vergara G, Inama G, Del Greco M, Accardi R, Dallago M. Electropharmacological testing by transoesophageal atrial pacing in inducible supraventricular tachyarrhythmias: A good approach for selection of long-term antiarrhythmic therapy. Eur Heart J 1992; 13:763–769.

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9. Erdo˘gan I, Ozer S, Karagoz ¨ T, Sahin M, Celiker A. Clinical importance of transesophageal electrophysiologic study in the management of supraventricular tachycardia in children.Turk J Pediatr 2009; 51:578–581. 10. Benson DW, Dunnigan A, Sterba R, Benditt DG. Atrial pacing from the esophagus in the diagnosis and management of palpitations. J Pediatr 1983; 102:40–46. 11. Ko JK, Deal BJ, Strasburger JF, Benson DW Jr. Supraventricular tachycardia mechanisms and their age distribution in pediatric patients. Am J Cardiol 1992; 69:1028–1032. 12. Tritto M, Calabrese P, Massari V, Tricarico G. Intra-atrial and atrioventricular nodal reentrant tachycardia in the same subject diagnosed at transesophageal electrophysiologic study. Cardiologia 1994; 39:137–141. 13. Blaufox AD, Warsy I, D’Souza M, Kanter R. Transesophageal electrophysiological evaluation of children with a history of supraventricular tachycardia in infancy. Pediatr Cardiol 2011; 32:1110–1114. 14. Brembilla-Perrot B, Spatz F, Khaldi E, Terrier de la Chaise A, Le Van D, Pernot C. Value of esophageal pacing in evaluation of supraventricular tachycardia. Am J Cardiol 1990; 65:322–330. 15. Brembilla-Perrot B, Moulin-Zinsch A, Sellal JM, Schwartz J, Olivier A, Zinzius PY, De Chillou C, et al. Impact of transesophageal electrophysiologic study to elucidate the mechanism of arrhythmia on children with supraventricular tachycardia and no preexcitation. Pediatr Cardiol 2013; 34:1695–1702. 16. Rhodes LA, Walsh EP, Saul JP. Programmed atrial stimulation via the esophagus for management of supraventricular arrhythmias in infants and children. Am J Cardiol 1994; 74:353–356.

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Sensitivity of transesophageal electrophysiologic study in children with supraventricular tachycardia on electrocardiography.

The aim of this study was to evaluate the inducibility of tachycardia by transesophageal electrophysiologic study (TEEPS) in patients with documented ...
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